The right medicine for alcoholics (En)
By Markus Heilig.
Markus Heilig is a physician scientist at the National Institutes of Health. The views expressed are his own.
With about 80,000 Americans dying each year, excessive alcohol use remains the third most-preventable cause of death in the United States, topped only by smoking and obesity. Alcohol remains a stubborn killer of people in their prime. The tragedy is propagated over generations, through poverty, violence, broken families and harm to fetal brains. The consequences of excessive alcohol use are also a disaster in crass economic terms. At a quarter trillion dollars a year, alcohol-use disorders are some of the most neglected and mismanaged medical conditions.
A comparison with nicotine addiction makes this abundantly clear. Much work remains, but sustained policy efforts have reduced U.S. smoking rates from about 40 percent a few decades ago to about 20 percent. For remaining smokers, scientifically supported treatments have become widely available. Success rates of behavioral interventions are modest but over the years have been supplemented by increasingly effective medications approved by the Food and Drug Administration (FDA).
The situation is fundamentally different when it comes to alcohol-use disorders. Only about one in 10 people with alcoholism ever receives treatment. For those who do, treatment in the United States is almost synonymous with joining Alcoholics Anonymous (AA). AA was once critical for advancing a view of alcoholism as a disease rather than a moral defect, and it created an admirable fellowship of people willing to support each other. But AA was formed three-quarters of a century ago. At the time, medicine had little to offer alcoholics beyond treating the shakes of acute withdrawal. Much has happened since.
We now know that the effects of behavioral treatments for alcoholism, including AA attendance, are modest. A rigorous academic analysis by the Cochrane Collaboration states that “available . . . studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments.”AA’s own surveys have indicated that for every 100 alcoholics entering their first meeting, only about 30 will be attending and sober a year later. This is very close to the spontaneous relapse rates consistently found by research over the past four decades.
With this in mind, one would think that the arrival of relapse-preventive medications would be greeted with great enthusiasm, but nothing could be further from the truth. The first medication in this class, naltrexone, was approved by the FDA in 1994. It is by no means a panacea, but clinical research has established that it reduces the risk of heavy drinking by about 20 percent. Naltrexone is in fact twice as effective in patients with a particular genetic makeup, showing that patients with alcoholism differ in important ways and allowing a personalized medicine approach to treatment. It is also safe, well-tolerated and cheap. Another medication, acamprosate, also has FDA approval for alcoholism, while several additional drugs look promising in well-designed academic studies.