Brave New Directions in Alcohol Use Disorders: An Overview

The National Institute on Alcohol Abuse and Alcoholism estimates that approximately 18 million people in the US suffer from alcohol use disorders, and 52% of the population report current use of alcohol: 35% of the general population do not drink at all; 37% drink at low-risk levels; and 28% drink at heavy or at-risk (hazardous) levels. Heavy drinking affects an estimated 23% of individuals aged 12 and older, according to the Substance Abuse and Mental Health Services Administration.

A significant number of people who use alcohol will transition to alcohol misuse, heavy drinking, hazardous (at-risk) drinking, and alcohol dependence. Alcohol use disorders may last most of a person’s lifetime and are considered chronic. However, National Epidemiological Survey on Alcohol and Related Conditions data reveal that more than 70% of persons who meet criteria for alcohol dependence have a single episode that lasts on average 3 to 4 years. Many people who seek formal treatment go on to remain alcohol-free, and many apparently recover without formal treatment. Nevertheless, in some people the course is chronic and relapsing, with multiple treatment episodes and a consequent steady decline in health.

Historically and to some extent currently, the conventional wisdom concerning treatment is to strive for complete abstinence. Traditional treatments have heralded this approach. The alcohol-misusing patient is detoxified, abstains from drinking, gets into treatment, and seeks the support of family and primary care provider. If he or she “falls off the wagon,” the only recourse is to call the sponsor or family member [[{"type":"media","view_mode":"media_crop","fid":"25031","attributes":{"alt":"Alcohol use disorders","class":"media-image media-image-right","id":"media_crop_5190572251225","media_crop_h":"322","media_crop_image_style":"-1","media_crop_instance":"2229","media_crop_rotate":"0","media_crop_scale_h":"344","media_crop_scale_w":"200","media_crop_w":"187","media_crop_x":"69","media_crop_y":"21","style":"width: 159px; height: 274px; margin: 0px; float: right;","title":" ","typeof":"foaf:Image"}}]]and get back into treatment. This approach does not always work-many persons fail to make the proper adjustments, or just cannot stay “sober,” or abstinent. There are periods of uncontrollable drinking and destruction interspersed with periods of shaky abstinence.

The realization that treatment does not have to be an all or nothing proposition is now in the forefront of modern medical treatment. Behavioral and psychopharmacological treatments emerged in the past 5 to 10 years. Psychotherapies such as motivational techniques, cognitive-behavioral therapies, relapse prevention, 12-step facilitation, and novel computerized techniques now augment and advance the treatment of alcohol use disorder. In addition, several medications seem to be effective, including naltrexone (oral and injectable), disulfiram, acamprosate, and the anticonvulsant topiramate.

The 3 excellent Special Reports in this issue by Ismene L. Petrakis, MD; Kathleen M. Carroll, MD; and Henry R. Kranzler, MD, and Leah R. Zindel, RPh, MALS, review advancements in the treatment of alcohol use disorders. Dr Petrakis, explores the co-occurrence of alcohol use disorders and psychiatric comorbidity and reviews the available medications. Dr Carroll examines the current direction of computer-based therapies to augment the treatment of alcohol used disorders. Finally, Dr Kranzler and Ms Zindel review Dr Kranzler’s research with topiramate and provide an introduction into the nascent field of personalized medicine for alcohol use disorders.

Disclosures:

Dr Trevisan is Associate Clinical Professor in the department of psychiatry at Yale University School of Medicine, New Haven, Conn, and Acting Chief of the Mental Health Service Line at VA Connecticut Healthcare System, West Haven, Conn. He reports no conflicts of interest concerning the subject matter of this Special Report.