Roughly 100,000 people in the U.S. die each year from alcohol-related causes^{1, 2}, making alcohol use the third leading cause of death³. This is not surprising given the association between alcoholism and the development of cancer of the liver, breast, mouth and throat, as well as diabetes, coronary artery disease, hypertensive disease, cerebrovascular disease and stroke, and cirrhosis of the liver; with disease susceptibility directly proportional to the amount and duration of alcohol consumption⁴. Additionally, alcohol use is a significant factor in physical and sexual assaults, domestic violence, child abuse and neglect, developmental disorders and birth defects among children of alcohol-abusing mothers, and sudden infant death syndrome¹.

Alcoholism is responsible for more than 15% of the U.S. health care budget², with approximately 40% of hospital admissions alcohol-related⁵ American Psychiatric Association, 2000. Overall, alcohol-related costs to society exceed $176 billion when including lost productivity and absenteeism, premature death, treatment cost, and criminal justice expenditure⁶. Thus it is important to understand the basis and treatment of this disease.

Alcohol dependence is a complex disease of heterogeneous origin, including genetic, environmental and cultural factors^{7, 8}. Geneticists refer to alcoholism as a "dirty phenotype"⁹, meaning that there is evidence for the existence of different subtypes of alcohol dependence which may have different etiologies. In fact, evidence suggests that multiple genes interact with environmental factors in the development of alcoholism^{7, 8}. Thus, as with other disease models, it is erroneous to consider psychosocial causes as operating independently or competing with biological causes in the development and maintenance of alcoholism¹⁰.

While the complexity of factors influencing the development and maintenance of alcoholism may partially account for the differences in treatment response², numerous studies have found that health care and other social costs are significantly reduced among alcoholics and other substance abusers who have received treatment for their addictive disorder^{e.g., 11-13}. Thus, there is compelling data indicating that accessible alcoholism treatment benefits the individual and society as a whole.

Featured Course

Alcoholism Treatment From An
Evidence-Based Perspective

(5 CEs) Mark Rose, MA

Building on the foundation of Alcoholics Anonymous (AA), formed in 1935, and the introduction of disulfiram in the 1950's, the last two decades have brought about a breakthrough in the treatment of alcoholism. Modern, effective theory- and evidence-based therapeutic interventions include more refined medications, such as Naltrexone and acamprosate, which diminish the reinforcing effects of alcohol and craving for alcohol^14,15 and psychosocial interventions, such as cognitive-behavioral approaches, which facilitate change in the attitudes and beliefs surrounding drinking^{e.g., 16-20}.

Relative and absolute demonstrations of alcoholism treatment efficacy are difficult to draw inferences from since treatment may be effective through alternate mechanisms than those purported²¹. Two effective components that do emerge across therapeutic modalities include addressing maladaptive beliefs and attitudes toward drinking cognitive-behavioral therapies and 12-step therapy;^{e.g., 22, 23} and restructuring the social support network of the alcoholic community reinforcement behavioral therapy, behavioral couples therapy, and AA involvement;^{e.g., 24, 19}.

However, since alcoholism is a disease of heterogeneous genetic and environmental origin, and because alcoholics display wide response variability to any one treatment, no single treatment modality will work for all patients meeting this diagnosis, and elements of several different treatment approaches may be needed for some alcoholic patients²⁵. For example, alcohol dependence is best conceptualized as a chronic disorder with a variable course of relapse and remission—similar to type 2 diabetes, hypertension and chronic depression. Chronic illnesses are best managed by lower-intensity long-term support, with acute, high-intensity interventions administered periodically²⁶. Thus, self-help organizations such as AA complement rather than compete with acute care interventions, and provide a vital resource for the person seeking recovery from alcoholism²⁷. Additional therapeutic approaches such as anticraving medications may also be beneficial and should be embraced by practitioners²⁸.

This online continuing education course will provide a comprehensive definition of alcoholism and allow for an understanding of its demography and epidemiology. A brief review of the neurobiology of alcoholism is presented, along with an overview of the medical and psychiatric conditions commonly associated with alcoholism. The effectiveness of psychosocial therapies, self-help organizations, anti-craving medications, and alternative/complementary therapies that are currently used with alcohol dependence is discussed using a theory- and evidence-based approach. Lastly, the synergistic impact of these therapies is addressed.

About the Author Mark Rose, MA – Licensed psychologist and researcher. He has published on addictive disorders, as well as other medical disorders, and was recently involved in the development and testing of a novel pharmacotherapy for alcoholism. Member of the Board of Directors of the Minneapolis-based International Institute of Anti-Aging Medicine.

References

1. Center for Disease Control (2004). National Center for Chronic Disease Prevention and Health Promotion. Alcohol-Attributable Deaths Report, United States 2001. Retrieved April 24, 2006, from the Center for Disease Control web site.
2. West, S.L., Garbutt, J.C., Carey, T.S., Lux, L.J., Jackman, A.M., Tolleson-Rinehart, S., Lohr, K.N., & Crews, F.T. (1999). Pharmacotherapy for alcohol dependence. Evidence report number 3. AHCPR publication no. 99-E004. Retrieved April 20, 2006, from Agency for Health Care Policy and Research Web site.
3. Mokdad, A.H., Marks, J.S., Stroup, D.F. & Gerberding, J.L. (2004).  Actual causes of death in the United States.  JAMA, 291, 1238-1245.
4. Rehm, J., Gmel, G., Sempos, C.T., & Trevisan, M. (2004). Alcohol–Related Morbidity and Mortality.
5. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC.
6. Volpicelli, J.R. (2001). Alcohol abuse and alcoholism: an overview. Journal of Clinical Psychiatry, 62 (Suppl 20), 4-10.
7. Schuckit, M.A. (1994).  A clinical model of genetic influences in alcohol dependence. Journal of Studies on Alcohol, 55, 5-17.
8. Bohman, M., Sigvardsson, S., Cloninger, R., & von Knorring, A.L. (1987). Alcoholism: lessons from population, family and adoption studies. Alcohol and Alcoholism Supplement, 1, 55-60.
9. Herbert, W. (1997). Politics of biology: How the nature vs. nurture debate shapes public policy — and our view of ourselves. US News and World Report, April 21, 1997.
10. National Institute on Alcohol Abuse and Alcoholism (2000). Why do some people drink too much?  The role of genetic and psychosocial influences. Alcoholism Research and Health, 24, 17-26.
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15. Croissant, B., Diehl, A., Klein, O., Zambrano, S., Nakovics, H., Heinz, A. & Mann, K. (2006). A pilot study of oxcarbazepine versus acamprosate in alcohol-dependent patients. Alcoholism: Clinical and Experimental Research, 30, 630-5.
16. Longabaugh, R. & Morgenstern, J. (1999). Cognitive-behavioral coping-skills therapy for alcohol dependence. Current status and future directions. Alcoholism Research and Health, 23, 78-85.
17. Marinelli-Casey, P., Domier, C.P. & Rawson, R.A. (2002). The Gap Between Research and Practice In Substance Abuse Treatment.  Psychiatric Services, 53, 984–987.
18. Monti, P.M. & Rohsenow, D.J. (1999). Coping-skills training and cue-exposure therapy in the treatment of alcoholism. Alcoholism Research and Health, 23, 107-115.
19. McCaul, M.E. & Petry, N.M. (2003).  The role of psychosocial treatments in pharmacotherapy for alcoholism. American Journal of Addiction, 12 Suppl 1, S41-52.
20. Kadden, R.M. (2001). Behavioral and cognitive-behavioral treatments for alcoholism: research opportunities. Addictive Behavior, 26, 489-507.
21. Morgenstern, J. & Longabaugh, R. (2000). Cognitive-behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action. Addiction, 95, 1475-1490.
22. Humphreys, K. (1999).  Professional interventions that facilitate 12-step self-help group involvement. Alcoholism Research and Health, 23, 93-98.
23. AHCPR. Treatment Improvement Protocol Series 34 (1999). Brief interventions and brief therapies for substance abuse. Retrieved April 1, 2006, from the Agency for Health Care Policy and Research Consensus Panel web site. 
24. Miller, W.R., Meyers, R.J. & Hiller-Sturmhofel, S. (1999). The community-reinforcement approach. Alcoholism Research and Health, 23, 116-21.
25. Grant, B.F., Chou, S.P., Pickering, R.P., & Hasin, D.S. (1992). Empirical subtypes of DSM-III-R alcohol dependence: United States, 1988. Drug and Alcohol Dependence, 30, 75-84.
26. Anton, R.F., O'Malley, S.S., Ciraulo, D.A., Cisler, R.A., Couper, D., Donovan, D.M., Gastfriend, D.R., Hosking, J.D., Johnson, B.A., LoCastro, J.S., Longabaugh, R., Mason, B.J., Mattson, M.E., Miller, W.R., Pettinati, H.M., Randall, C.L., Swift, R., Weiss, R.D., Williams, L.D. & Zweben, A.; COMBINE Study Research Group. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. Journal of the American Medical Association, 295, 2003-17.
27. Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., Horvath, A.T., Kaskutas, L.A., Kirk, T., Kivlahan, D., Laudet, A., McCrady, B.S., McLellan, A.T., Morgenstern, J., Townsend, M. & Weiss, R. (2004). Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy. Journal of Substance Abuse Treatment, 26, 151-158.
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