New research is redefining alcohol disorders
Does the treatment field have the courage to change?
by Mark L. Willenbring, MD

In the treatment community, it is common knowledge that many people with alcohol dependence never receive specialty addiction treatment, and that those who do receive treatment have the most severe form of the disorder together with substantial co-existing mental, physical, and social disability. Among treatment professionals, one common explanation is lack of access due to practical barriers such as distance or lack of insurance. Stigma also is frequently mentioned. But are those the biggest problems?

This article proposes an alternative explanation: that the type, location, and style of treatments currently available are based on outmoded views of the nature and variability of alcohol dependence and the types of treatment that should be available to address it. I also will argue that fundamental changes are needed in the configuration of services and service providers (the continuum of care) to make effective treatments sufficiently attractive, accessible, and affordable to reach more than the one in eight of those who need and currently receive specialty addiction treatment.

Although access, cost, and stigma are important, treatment avoiders are more likely to assert, “I'm not that bad yet,” or “I can handle it myself.” Accordingly, many professionals view those assertions as evidence of “denial” (i.e., that people do not realize that they are ill). I believe that explanation to be simplistic and self-serving. Like the famous cartoon character Pogo, I believe instead that “we have met the enemy, and he is us.” Unless we open ourselves to new ideas, I don't think we will make progress. In fact, we may expend precious time and resources in search of the wrong solution.
A continuum of need

In a recent National Institute on Alcohol Abuse and Alcoholism (NIAAA) Web conference titled “Alcoholism Isn't What It Used to Be: New Findings on the Nature and Course of Alcohol Use Disorders” (available at http://https://webmeeting.nih.gov/p27471408), I presented evidence that our view of alcohol use disorders (AUDs; abuse and dependence) has been distorted by focusing on people attending treatment programs. This is not uncommon in healthcare: We focus first on the people presenting for care, who have the most severe, treatment-resistant form of the disorder and who often also have other unrelated disorders that make managing any one of them more difficult. Only in time does a different picture emerge: The disorder exists in a much more varied form in the community at large, and those entering treatment do not represent the typical person who has it.

For example, at first breast cancer was identified only when a tumor became large and unavoidable; now mammograms identify tiny tumors undetectable even by careful examination. Once it was thought that schizophrenia was inevitably severe and totally disabling, requiring long-term hospitalization; but then studies of community populations revealed many milder cases in which people improved over time and were able to work and have relatively normal lives.

In the general population, there is a continuum of alcohol use and disorders ranging from abstinence to low-risk drinking, risk drinking, harmful drinking, and dependence to chronic, relapsing dependence (see Figure). There is no sharp delineation between categories; instead, they blend one into another, and category definitions involve tradeoffs between being too sensitive or missing “cases.”

Figure. Continuum of care for excessive drinking and alcohol use disorders. (Percentages represent the approximate proportion of the U.S. population age 18 and older in each category in any given year.)
For example, a diagnosis of alcohol dependence requires that three of seven DSM-IV criteria be met, but why not two, or four? Most heavy drinkers (four or more drinks per day for women, five or more for men) do not have and never develop any AUD or other adverse consequences. Most people who become dependent have milder forms of the disorder and meet only three or four DSM-IV criteria. Almost three-quarters of persons with dependence experience a single episode that lasts three or four years, after which they get and stay well. In contrast, most people in treatment programs meet six or seven criteria and have repeated episodes over the course of years to decades. Whereas most people with dependence have no observable disability (i.e., job, relationship, or legal problems) and remain quite functional even though symptomatic, most people in treatment are significantly disabled and have multiple co-existing conditions.

Thus, our understanding of AUDs and related judgments about how they should be treated are limited by our exposure to only the sickest 10%—that is, those in our treatment programs. Unfortunately, this incomplete understanding leads in turn to many false beliefs: alcoholism is inevitably a severe, chronic, progressive disorder; people are either alcoholic or not; heavy drinking always leads to bad consequences, and so forth.

If we (incorrectly) assume that non-treatment seekers are similar to seekers of care, our attempts to address the treatment gap will fail. And although almost all would agree that strategies based on the best and most current research are most likely to succeed, recent findings suggest very different directions from those to which we are accustomed. Rather than being a threat to the treatment professional, however, decisions based on these new findings can lead ultimately to a stronger, more effective, and more satisfying specialty treatment sector that complements other elements to address persons who are less severely affected.
Structural barriers

The peculiar way that treatment developed in the United States also presents a barrier to innovation. The dominant treatment paradigm, the Minnesota Model, developed outside the mainstream of professional care and initially was staffed by recovering counselors with little or no professional education. Even now, in some states, only a high school education is required. The “28-day program” was a noble initial attempt to address alcohol dependence, but it has not kept pace with advances in knowledge.

For example, only about 5% of current patients are treated with available, research-tested medications, even though they are about as effective as treatments for depression. According to recent research, we must admit that we have been attempting to treat a chronic, relapsing form of alcohol dependence in a few weeks or months. Yet, if a client doesn't achieve recovery with a run through “the program,” we have little to offer except another run through “the program.” In addition, we are only beginning to consider appropriate treatments for the large numbers of non-treatment seekers who have milder forms of the illness and are more functional than treatment-seekers.

Further, most of our clients today are overtly coerced into treatment by the criminal justice system, employers, or family members. Among treatment professionals, this situation divides loyalties (e.g., are we serving the court or the individual?) and fosters complacency, since programs need not attract clients based on understanding what customers want and providing good service. Instead, we can do what we please and our clients must accept it. At present, more than 90% of treatment programs offer group counseling and referral. If instead our clients had a choice, would we be forced to innovate?

Of course, the “up” side of the current situation is that there is a huge untapped market for the entrepreneurial among us: a new model of consumer-oriented treatment. Non-treatment seekers who have AUDs tell us that they are not coming to treatment because they are not yet so bad off they have no other choice. What if we offered them treatments that they found attractive, affordable, accessible, and effective? Since most people with AUDs never achieve a degree of severity so great that they have no choice, I propose that we offer them treatments that they will choose to receive without coercive interventions.

Before Prozac was approved for treatment of depression, very few people received treatment. Only the sickest people, who were usually hospitalized, were treated and then only by psychiatrists. In a foreshadowing of today's controversies, psychoanalysts argued that we should not use medications to treat depression, because then people would not be motivated to change (never mind that subsequent research showed that psychoanalysis was not effective for treating depression). In 1987, Prozac was approved as the first of many second-generation medication treatments, and the field changed rapidly. Now, most depression treatment occurs in primary care, about two-thirds of depression episodes are treated, and mental health specialists provide more intensive treatment for those with more severe and complex disorders. The time is right for a similar development in addressing heavy drinking and AUDs.
A broader service mix

What are the elements of an expanded continuum? From a public health perspective, we need first to address nondependent heavy drinking (risk drinking). Because 21% of U.S. adults engage in risk drinking, they account for more excess morbidity and mortality than dependent drinkers, who constitute only 4% of the population in any given year. Because they are non-dependent, risk drinkers often respond to facilitated self-change or brief counseling and advice, which could be made widely available at relatively low cost. Some harmful and dependent drinkers will respond to the same modalities, but many will need additional services.

The only way to reach so many people is through existing systems with a broad reach, such as primary medical care and general mental healthcare. (If everyone with a diagnosis of dependence showed up at specialty treatment programs, we would be quickly overwhelmed.) Since most of them have milder forms of dependence, are functional, and have more resources available to them, they may respond well to either outpatient behavioral treatment (such as 4 to 10 sessions over a few weeks) or medication with brief behavioral support, or both. In the COMBINE (Combining Medications and Behavioral Interventions) trial, for example, behavioral treatment and naltrexone plus brief behavioral treatment were equally effective.

For this continuum to work, however, the addiction specialty treatment sector needs considerable development. Intensive abstinence-oriented behavioral treatment would continue, but with greater resourcing to improve efficacy. Over time, the minimum requirements for providing specialty treatment would need to increase to approximate those for treating mental health disorders. Since no one behavioral approach has better overall outcomes than others, clients should have a choice of available, effective treatments.

Because most people in need of specialty treatment (about one-quarter of all dependent persons) have chronic, relapsing dependence as well as co-existing physical and mental disorders, specialty addiction treatment should seamlessly integrate addiction, primary medical, and psychiatric treatments. In addition, for those unable to achieve or sustain full remission, chronic care models (such as those available for other chronic illnesses) should provide intermittent or continuous treatment and management over years to decades.

New research has shown us that the disorder that we treat is more varied and complex than we had imagined. Yes, these findings challenge what has become conventional wisdom among addiction professionals. Will we view them as a threat or as an opportunity? How we respond is up to us and will determine the future of our field.

The disorder exists in a much more varied form in the community at large, and those entering treatment do not represent the typical person who has it.

Although access, cost, and stigma are important, treatment avoiders are more likely to assert, “I'm not that bad yet,” or “I can handle it myself.” Accordingly, many professionals view those assertions as evidence of “denial” (i.e., that people do not realize that they are ill). I believe that explanation to be simplistic and self-serving.