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RECOVERY OPTIONS: Finding Effective Treatment for Alcohol Dependence
By Lloyd Vacovsky
Executive Director, American Council on Alcoholism and Director of Assisted Recovery Centers of America

Finding effective treatment for alcoholism is a daunting task faced by alcohol dependent individuals and their loved ones. Adding to the confusion is the fact that treatment for alcohol dependence is currently a very controversial subject. For example, the debate continues as to whether or not alcoholism is a “disease”, and what is the most appropriate treatment. Individuals seeking treatment are confronted with the reality that outside of the traditional 12 Step or Minnesota Model programs, there are few alternatives currently available. Human beings are a diverse group of creatures, with unique needs, especially in terms of treatment for alcohol dependence and substance abuse. In general there are three basic camps or treatment approaches.

The approach embraced by the vast majority of treatment providers is the Minnesota Model. This is your basic12-Step type of program and was developed at the Hazeldon Institute in Minnesota. This model accepts alcoholism as a disease, but defines the disease as being spiritual in nature. It relies heavily on establishing (or re-establishing) spiritual values and reaching an accommodation with a “higher power”. The primary treatment tool is the group meeting. It must be noted that Alcoholics Anonymous does not consider itself a “treatment program”, but rather a group of individuals bound together by a common issue, alcohol dependence. The vast majority of treatment programs incorporate the 12-Steps as an integral part of their treatment.

The second approach to treatment regards alcoholism as a “learned behavior” rather than as a disease. As such, the focus of treatment utilizes what is known as cognitive restructuring, or cognitive behavioral therapy. Simply stated this means assisting the alcohol dependent individual to assess the various components of their life, and to work on those behaviors, which have been impacted by alcohol consumption. This is the approach often utilized by independent treatment professionals and is usually provided in a more intimate one on one setting. Albert Ellis of the Ellis Institute of New York City is widely considered the founding father of cognitive behavioral therapy.

Finally, there are those who point to the increasing body of evidence that indicates that alcoholism is indeed a disease, albeit a very complicated disease with distinct Biological, Psychological and Social components.
This group believes that treatment should be more broad-based and include such new developments as pharmacotherapy. They embrace the use of effective medications, for example Naltrexone as an important component of the treatment processes. The use of medications addresses the Biological component of the recovery process. In addition, it relies heavily upon counseling that utilizes Cognitive Behavioral Therapy to address the Psychological and Social components of recovery. This position is becoming known as the Pennsylvania Model of Recovery. The Pennsylvania Model does not require a spiritual epiphany or the acceptance of a Higher Power for recovery.

Pennsylvania Model protocols are largely based on the research and work of the University of Pennsylvania School of Medicine, Treatment Research Center, in Philadelphia, and in particular Dr. Joseph R.Volpicelli, M.D., Ph.D., also of the University of Pennsylvania. These protocols fully integrate pharmacological and psychosocial support in the recovery process. This type of integrated program is distinguished from other protocols, which generally reject the use of pharmacological agents as an aid in the recovery process.

The Pennsylvania Model is a medical model, in which a full range of empirically tested treatment options are offered to individuals who are dependent upon alcohol. The University of Pennsylvania has a 20-year history of clinical studies, which has led to the development of these protocols. The medical and scientific community has recognized the research of the University of Pennsylvania for developing important advances in the treatment of alcohol and drug dependence. For example, the University pioneered the use of the pharmacological agent Naltrexone HCI, which suppresses the craving to consume alcohol or opiates, and dramatically reduces relapse. (Archives of General Psychiatry, 49:876-880, 1992 Volpicelli etc.)

The vast majority of treatment providers in the United States incorporate the protocols of the Minnesota Model, which again has as its cornerstone the acceptance of a higher power before recovery can be achieved. This is the model that has been used to train treatment professionals for decades. As a result, the Minnesota Model has been accepted almost without question as the only effective treatment option. It is a very rigid method that does not allow individuals to stray far from established procedures. For example, individuals must work each of the twelve steps in order, and secure a “sponsor” or advisor. The utilization of any treatment technique, other than what is proscribed in the Big Book of AA is frowned upon.

While the use of medications is not specifically discouraged, neither is it encouraged. For many years, even the use of Physician prescribed anti-depressants was actively discouraged by most well meaning AA groups. The bias against the use of any medication that alters mood or the need to consume alcohol is clearly part of the AA mantra. This is largely due to the fact that many medications (especially psychotropic medications) are not understood by the general public, and in turn, by members of the AA community. As a result, this continuing bias against the use of appropriate medications has resulted in disastrous consequences for countless individuals.

While this bias against the use of safe, effective medications to assist in the recovery process has dramatically reduced their utilization. The primary culprit appears to be the lack of understanding among treatment professionals and physicians, as to the proper use of approved medications. The majority have very little experience with pharmacotherapy for the treatment of alcohol dependence. While many are generally receptive to the concept of pharmacotherapy, most have never heard of the most promising medication for the treatment of alcohol dependence, Naltrexone, ten years after its approval by the United States Food & Drug Administration.

The FDA first approved naltrexone in 1984 under the brand name Trexan for the treatment of opiate abuse. In 1994, the FDA extended its use to include alcohol dependence and was marketed by DuPont Pharma under the brand name ReVia. Since December 1997, it has been available as a generic.

While there was some initial enthusiasm for Naltrexone, most treatment providers became easily discouraged, because it did not produce immediate and positive results for all their patients. At best they reported “spotty” results. The Naltrexone seemed to work well with one individual, while being seemingly ineffective with another. We now believe that many individuals received inadequate dosage and inappropriate time of dosage, for their unique metabolism and life patterns, and in turn reported the medication ineffective. There are numerous additional factors affecting the effectiveness of Naltrexone, for example age and gender. In addition, the presence of pre-existing conditions such as clinical depression probably must be addressed with appropriate anti-depression medication. Other factors include social, relationship, legal, and employment issues, which can all directly impact the recovery process. Cognitive behavioral therapy has been shown to be very effective in helping individuals to address the numerous, recovery complex issues that they face.

Mental health professionals have long understood the need to adjust the dosage of medications prescribed for their patients. Each individual is unique, and reacts to medications uniquely. Alcohol treatment professionals who utilized Naltrexone rarely ventured outside of the Physicians Desk Reference’s (PDR) recommended guidelines. For example the PDR recommends that Naltrexone be taken in the morning. The thought behind this recommendation was that it would improve medication compliance by getting an individual in the habit of taking the Naltrexone first thing each morning. The reality is that very few people drink first thing in the morning. They need the full effect of the medication much later in the afternoon as the thought process turns to going home and “relaxing” with “a” drink.

It is increasingly clear that issues such as dosage and length of treatment can vary greatly from individual to individual, and what may be appropriate for a man, is not necessarily so for a woman. A recent article published in THE SCIENTIST 16(6): 29: March 18, 2002 entitled THE INEQUALITY OF DRUG METABOLISM describes how the same medication and dosage often have different outcomes for men and women. Our experience has shown that a 50 mg dose of Naltrexone, when combined with therapy is usually effective for older males (40 and over), and usually ineffective, even with therapy for older females (40 and over). We have found that the most effective dose for most females is a minimum of 100 mg per day or even higher. It is interesting to note that much of the initial research on Naltrexone was conducted at Veterans Administration facilities, whose subjects were mostly older males.

What most treatment professionals do not seem to comprehend is that Naltrexone is an extremely effective tool, when appropriately utilized, and that it is not a cure. The purpose of Naltrexone is to suppress the intense craving to consume alcohol, generated by alcohol compromised brain chemistry. It is not meant to solve, for example, the legal or relationship issues which are often the result of alcohol induced behavior.

The fact of the matter is that Naltrexone will dramatically affect alcohol consumption. In effect, it forces individuals to face life, on life’s terms. It forces them to deal with the consequences of their actions. Indeed, the most difficult aspect of recovery is learning how to be happy without alcohol. Most alcohol dependent individuals are not well equipped to make the successful transition to sobriety. Even though the actual physical craving to consume alcohol has been suppressed by the Naltrexone, the need to return to drinking often overwhelms them. They have become dependent upon the alcohol to deal with all their problems. Unless they start to successfully address these problems, they will almost certainly begin drinking again. When this occurs, it is simple to blame the Naltrexone for “not working”. Naltrexone does not replace treatment or counseling. Its primary purpose is to create an environment in which an alcohol dependent individual is able to begin to make progress in his or her recovery.

When a human being consumes alcohol, it sets off a chemical chain reaction within the brain that results in the release of a group of chemicals, most notably, endorphins. Endorphins assist people in dealing with stress, anxiety, self-esteem and so forth. When consumed, alcohol travels through the stomach wall into the blood system, which transports it to the brain. There, it attaches to opioid receptor sites. (Receptor sites in the brain can be compared to a message center, which receive and forward commands in response to stimuli.) The stimulated opioid receptor immediately sends a command to the opioid endogenous system located within the pleasure center of the brain, releasing a cascade of endorphins into the system. It is the release of the endorphins that generates the euphoria or sense of well being associated with alcohol consumption.

Current research also points to a genetic link, which can predispose an individual to becoming alcohol dependent. One theory is that most individuals whom become alcohol dependent have a low threshold for the release of endorphins as stimulated by alcohol consumption. When an individual with this predisposition consumes alcohol, they experience an intense feeling of euphoria that the “social drinker” does not. As an individual continues to drink alcohol over a long period of time, the brain acclimates to the artificial stimulation of the alcohol. It is thought that in this process the brain slows down, or actually shuts down the normal production and release of endorphins. At this point the individual crosses the proverbial Rubicon, or the point of no return, when their brain becomes dependent upon alcohol to feel emotionally normal or well. It should be noted that alcohol dependent individuals at this stage are not drinking to feel good, but rather so that they do not feel bad.

Historically, when an individual slipped or relapsed, the blame was placed squarely on the shoulder of that individual. It is clear that treatment providers must now also begin to accept some of the “blame”. Treatment should include the latest scientific advances and should be tailored to the individual’s unique requirements. Reliance on outdated and ineffective treatment methods has created an environment that fully expects individuals to fail, and fail again until such time that rock bottom has been reached. It is often said that once an individual has reached rock bottom that there is only one way to go, UP. The problem with that philosophy is that for many people, the ultimate rock bottom is death.

Many, (if not indeed most) alcohol dependent individuals have lost faith in themselves, and more importantly hope for the future. It is common for such individuals to have numerous attempts at sobriety, most often using 12-Step methods. They have been programmed to accept themselves as hopeless and powerless, with their chance for recovery being slim to none. It is important to recognize that alcohol dependent individuals do have control over their lives and that there is appropriate help for them to be found in the treatment community. It is up to the individual to determine what is the most appropriate treatment. It is up to the treatment community to provide options that set up individuals to succeed, rather than be expected to fail.

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