Sober N Clean

Addiction medication and sage advice could be dispensed from a physician's office.

British songstress Amy Winehouse, who croons "no, no, no" to rehab, has a lot of American company this time of year -- both in her heavy-drinking ways and her unwillingness to spend weeks in a specialized facility to get sober.

But experts say there may be new hope for rehab refuseniks like Winehouse and an estimated 5.7 million alcoholics in the United States who are not in treatment -- hope that could be as close as the family doctor.

New research and a growing arsenal of medications have set the stage for a major shift in the treatment of alcoholism, from specialized clinic to the "primary care office setting," the Journal of the American Medical Assn. reported in its Dec. 5 issue.

But if the promise of "office-based" treatment of alcoholism is to become a reality, the nation's 337,000 general-practice physicians -- and the systems within which they work -- will have to undergo some transformation themselves, addiction experts say.

Doctors must overcome their reluctance to broach the subject of drinking and learn how best to intervene when they suspect alcoholism. Medical practices may need to add staff to help counsel recovering patients. And insurance companies and federal insurance programs will need to be persuaded to reimburse patients for medication that can be costly and to pay physicians for taking on a new role in patients' care.

Several new drugs are making office-based treatment a realistic prospect. In April 2006, a monthly injectable form of the drug naltrexone won approval from the Food and Drug Administration. Marketed as Vivitrol, the new formulation of a long-available drug can be started after only four days of abstinence and appears to cause less nausea than pills taken daily -- features that make it easier for patients to start and stay on the treatment. It joined two other medications approved to curb alcohol cravings.

Evidence is growing for the effectiveness of these and other addiction medications, such as the anti-convulsive drug topiramate, which, although not FDA-approved for this purpose, is also widely prescribed off-label to help alcoholics stay away from drink. And more FDA approvals for drugs that treat alcohol dependence are on the horizon.

At the same time, studies published this year underscored the effect that a few frank words from the doctor can have on patients whose drinking appears to have become excessive.

These developments could be the "tipping point" into a new era of alcohol treatment, says Mark Willenbring, director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism. With new confidence in their powers of persuasion and new pharmaceutical tools in their black bags, primary care physicians -- who have been notoriously shy of confronting patients about their drinking habits -- may grow more willing to flag an alcohol problem, offer medication and dispense advice during routine office visits, Willenbring says.

In turn, as patients grow more confident that they can curb their drinking without the time, expense and stigma of a stay in a clinic, more will likely step forward for help.

Parallel with depression

"In many ways, we are with alcoholism where we were with depression 30 years ago," Willenbring says. As a new generation of antidepressants came to market in the early 1980s, physicians on the front lines of patient care grew more attentive to the signs of depression and more willing to treat it. Patients with protracted bouts of blue mood turned to their family doctors for help in increasing numbers.

In the process, depression was transformed from a highly stigmatized mental illness that was rarely treated before a suicide attempt or outside a psychiatric hospital to a condition for which 80% of patients turn first to a general medical practitioner.

A similar shift in the treatment of alcohol-related disorders won't happen overnight, Willenbring says. But with 19.5 million Americans thought to have alcohol-related disorders in 2006, and only 1.6 million getting specialized treatment, he says, "we have to start thinking creatively about how to provide more accessible, appealing and creative options" to encourage patients with drinking problems to get the help they need before they hit the skids.

Experts warn, however, that as general-care physicians armed with medications shoulder a greater role in treating alcohol dependence, patients and public officials must ensure that the sickest patients do not suffer in a rush to treat alcoholism more economically.

In that regard, not all experts see depression treatment as an encouraging example. Medication has worked wonders for many depressed patients. But a study published in 2001 found that only about one-quarter of depressed patients seeing a general practitioner got appropriate care. Meanwhile, insurance companies keen to reduce spending for depression care have limited patients' access to costly psychotherapy, despite studies showing that patients improve most when such therapy is paired with medication.

As anti-alcoholism drugs show gains in effectiveness, many fear that insurance companies and federally supported programs will rely largely on medications and the brisk medical management of primary-care doctors.

That, they fear, could deny alcoholics who need the extra support of intensive rehabilitation the care they need to quit.

"You'd have to be naive not to be a little concerned that that will happen," says Mitchell Karno, UCLA's alcohol treatment researcher.

Doctors, too, will have to make changes if this new era of "office-based" alcohol treatment is to become a reality, experts say -- and some aren't convinced that the changes will easily happen.

"It's a vision that has some benefits to it, but it's not a done deal at this point," says Richard Rawson, associate director of UCLA Medical School's Integrated Substance Abuse Programs.

Rawson observed one crucial obstacle when he tried to launch a pilot program in which U.S. primary care doctors would screen patients for risky or excessive alcohol use and provide "brief interventions" intended to get those with problems to quit or reduce their alcohol consumption.

In all, the prescribed screening and intervention initiative would have taken physicians 10 minutes, Rawson says. He approached five institutions in an effort to recruit support.

None bit.

"What we hear over and over again is, 'Look, we have seven minutes to do whatever it is we're going to do. To take five minutes to do screening and then another five to do a brief intervention on this one dimension of health problems is just not in the cards,' " Rawson says. "I don't think we're at a point where we can just dump it all in the laps of primary care docs."

Rawson adds that in addition to physician training, other things would also have to change to account for the new demands -- such as systems of payment, insurance reimbursement and the office structure of general care practitioners.

Another obstacle experts see: Doctors are generally wary of challenging patients in matters that involve emotionally charged personal habits such alcohol consumption as well as smoking and obesity. And patients, in any case, almost always lie about their habits.

Physicians frequently hesitate to raise the question unless a patient is showing clear evidence of alcohol-related damage -- including impaired liver function, high triglycerides or bloated red blood cells. "It's like, 'Don't ask, don't tell,' " says New York internist Dr. Steven Lamm, who has successfully treated a number of patients with medication, including the monthly injectable version of naltrexone. That's especially been the case, he adds, because of the perceived paucity of medical treatments they have to offer. "What are you going to do about it? Send them to Alcoholics Anonymous?" he says.

Change is in the air

In the new climate, such reluctance might change.

As pharmaceutical companies launch new drugs -- and new marketing campaigns for them -- doctors will grow more assertive about raising the issue, says UCLA geriatrician Dr. Alison Moore, who sits on a panel at Willenbring's NIAAA that reviews the effectiveness of alcoholism treatments.

But, Moore adds, in addition to writing prescriptions for new drugs, physicians also had better learn new scripts for how to talk to patients about their alcohol problems and where to refer them if they need more help than a pill or an injection can provide.

"They're better than nothing," Moore says of the available medications. "But I don't see them as wonder drugs." They don't work for all patients, and even when they do, patients frequently relapse, she adds.

A new era in alcohol treatment may also bring new definitions of sobriety, as well, experts say. Programs such as Alcoholics Anonymous, as well as most of those who treat alcoholism, have always drawn a clear line between sober -- completely abstaining from alcohol -- and alcoholic.

As alcohol treatment grows more accessible, however, a wider range of patients -- including those who are not alcohol-dependent, but who endanger their health by drinking to excess -- are expected to come forward for treatment. For these patients, support groups like Alcoholics Anonymous may be less relevant than newer groups such as SMART Recovery and Rational Recovery, less ubiquitous than AA, which emphasize a goal of moderation in drinking.

In January, the NIAAA will launch a print- and Web-based self-help program called "Rethinking Drinking," aimed at a wide range of drinkers, including those with what Willenbring calls "a mild form of alcohol dependence."

The emergence of these alternatives to AA is certain to reignite a long-running debate over what goals alcoholism treatment should embrace. And it will likely spark efforts to define more broadly the range of patients who have a drinking problem, as well as those who could benefit from preventive or early treatment.

UCLA's Mitchell Karno says that patients and their family doctors will likely work out their own solutions. "People will seek out the level of treatment that's going to match their need," Karno says -- whether it's eight weeks in rehab, or a pill, an encouraging word from the doc and a self-help book.

Between strict abstinence and a safer level of drinking, Karno says, "it will be up to physicians and patients to choose how they're going to negotiate that tension."

source: Los Angeles Times
melissa.healy@latimes.com