In treating alcohol use disorders, why not use evidence-based treatment?

Abstract

Alcohol use disorders are common and devastating diseases with a strong genetic component. Prevalence in the United States in adult men is about 12% (1). Besides the social and economic consequences of uncontrolled alcohol drinking, these disorders account for one in 10 deaths annually through accidents and secondary medical problems such as cirrhosis (2). Despite the importance of this category of disorders, less than a third of patients with alcohol use disorders receive any treatment, and fewer still receive evidence-based treatment. Early in the course of the disease, when treatment is most effective, symptoms are often ignored bymedical practitioners. The typical patient is only diagnosed late in the course of this progressive disease, when the symptoms become severe. Eventually a crisis develops that results in medical attention. If insurance coverage is available, the patient may be admitted to a residential program, and the patient receives medication to ease the symptoms of alcohol withdrawal. Even though Food and Drug Administration-approved medications with proven efficacy in reducing relapse are available, fewer than 10% of patients are treated with such medications (3). The typical residential program is built around “milieu” therapy and self-help groups. These treatment approaches lack efficacy, as demonstrated by controlled outcome studies. Some evidence-based psychotherapies, such as cognitive-behavioral therapy and motivational interviewing, are available (4), but none of them focus on the brain changes that produce the uncontrolled drinking. Instead, the typical treatment program stresses counseling, support, and group therapy. Patients are made comfortable with a healthy diet, educational lectures, and perhaps massage therapy and other spa-like features. Patients are advised to avoid people, places, or things that remind them of alcohol. By the end of 30 days, the patient may feel relatively well and optimistic, but the neuroplasticity, the changes in the brain that have become ingrained, have not been addressed. Thus, it is not surprising that repeated relapses to uncontrolled drinking are common.