One form of treatment that has not been widely applied to alcohol use disorder is intervention with medicine. A recent study by Amanda J. Abraham and Paul M. Roman examined the early adoption of naltrexone as an injectable drug for alcohol use disorder. The study looked at the private-treatment sector to see how injectable naltrexone was being administered.

The study began with the understanding that the substance abuse treatment facilities in the United States have not been enthusiastic about using medications for alcohol use disorders.

The objectives of the study were focused on understanding how the characteristics of injectable naltrexone shape decisions whether the use the medication at the organizational level and on identifying predictors of adoption and barriers that discourage adoption.

The study looked at 345 privately-funded U.S. substance abuse treatment programs. The data was obtained from a nationally representative sample of programs, and the researchers used the data to examine use of injectable naltrexone.

The results of the study show that 16 percent of the programs examined were early adopters of injectable naltrexone as a treatment for alcohol use disorder. The researchers used multivariate logistic regression models to determine that there are certain factors that predict adoption of injectable naltrexone: the percentage of patients paying with private insurance and organizational size.

The strongest predictor of adoption, however, is innovation compatibility. Innovation compatibility is measured by how the program utilizes other types of pharmacotherapies for alcohol use disorder.

There are also several predictors of treatment facilities not using the medicine as a treatment for alcohol use disorder. Factors such as cost, lack of access to prescribing physicians and lack of knowledge about injectable naltrexone can all be circumstances that affect the use of the medication.

70 percent of the patients that receive the medication continue its use for at least two months, which is evidence that injectable naltrexone addresses the patient compliance barrier.

The use of injectable naltrexone gives treatment facilities another tool to assist individuals who are struggling with alcohol use disorder. Its adoption into more treatment facilities may provide those for whom other treatment strategies have not worked another option in healing.
 

Unresolved anger is often considered a trigger for unhealthy decisions related to alcohol, and often dealing with the root of the anger can help AA participants lead healthier lives. But if anger is not addressed, it may lead to a continuing struggle for alcoholics.

Anger is often understood as a trigger for relapse in alcoholics. AA literature indicates that addressing anger issues is critical for recovery, but it has not been fully investigated scientifically. A recent study led by John F. Kelly examined whether AA’s success is due in part to reducing anger.

The researchers used lagged, controlled hierarchical linear modeling analyses to determine whether AA participation mobilized changes in anger. The impact of such changes on AA-related benefit was also examined.

The study involved 1,706 alcohol-dependent adults who were receiving treatment in a clinical trial setting. The participants were assessed at baseline and at 3, 6, 9, 12, and 15 months.

The results of the study show that there were significantly higher levels of anger among those in the AA program when compared with the general population (98th percentile). The anger levels of the participants decreased over the 15-month study period but remained high when compared with general levels (89th percentile).

Participation in AA was positively associated with better alcohol choices, and higher levels of anger were associated with heavier drinking. However, attendance at AA meetings was not related to anger reduction.

The results of the study suggest that anger is not a mediator for alcohol abuse, but there was a strong connection between AA’s focus on anger and the findings of the study. Anger does appear to be a strong predictor for relapse and heavy alcohol consumption.

Though there may have been factors relating to methodology that contributed to the findings showing no association between AA and anger, the findings do indicate that AA participation alone does not specifically alleviate the suffering and alcohol-related risks associated with anger.

Understanding anger issues and how they contribute to alcohol abuse is important for organizations like AA to help alcoholics reduce their struggle with relapse. While this study indicates that anger is not significantly reduced due to AA participation, program organizers may be able to utilize the new research to make anger management in AA more effective for alcoholics.
 

"Oral naltrexone was approved by the Food and Drug Administration in 1994," explained Henry R. Kranzler, a professor in the department of psychiatry at the University of Connecticut Health Center and corresponding author for the study. "It was the first medication approved to treat alcohol dependence since disulfiram was approved in 1949, and its approval was based on a demonstration of efficacy using a randomized, controlled trial design. The FDA has since approved acamprosate and long-acting naltrexone."

Kranzler believes that oral naltrexone is covered by most health plans as a generic drug.
For this study, Kranzler and his colleagues used data from the MarketScan Commercial Claims and Encounters Database for 2000 to 2004 to create three groups: a naltrexone group (n=1,138) with an alcohol-related diagnosis and at least one pharmacy claim for oral naltrexone; an alcohol control group (n=3,411) with an alcohol-related diagnosis but no prescription for alcoholism-treatment medication; and a non-alcohol control group (n=3,410) with no alcohol-related diagnosis and no prescription for alcoholism-treatment medication. The two groups with an alcohol-related diagnosis were matched to each other on a variety of demographic and clinical dimensions. Healthcare expenditures were calculated for the six-month periods before and after naltrexone drug claims, and dates were matched for the two control groups.

"We found that, prior to the start of the study period, individuals treated with naltrexone had higher healthcare costs than the group with an alcohol-related diagnosis but no naltrexone treatment," said Kranzler. "However, during the period after receiving the medication, the naltrexone group showed a significantly smaller increase in healthcare expenditures (both alcohol-related and non-alcohol-related) than the group with an alcohol-related diagnosis but no naltrexone treatment." In other words, oral naltrexone seemed to reduce healthcare costs for patients with an alcohol-related diagnosis.

Kranzler said these findings have implications for two groups. "I think that the greatest applications of these results are for healthcare policy makers, treatment-program managers, insurance companies, and health-benefits managers," he said. "They also show researchers that developments in treatment can pay dividends in cost savings."
Furthermore, he added, this study shows there is a common ground between effective treatment measures and cost-savings.

"As a physician, I am interested in all treatments that can alleviate suffering and improve people’s lives, however, I am also cognizant of the need to contain healthcare costs. This study suggests that an alcoholism treatment medication can help to contain healthcare costs and that wider consideration of the economic value of such approaches is warranted."

"This paper assesses the validity of the severity ranking of the 11 criteria and the overall severity score with respect to known AUD correlates, including alcohol consumption, psychological functioning, family history, antisociality, and early initiation of drinking, in a representative population sample of U.S. past-year drinkers (n=26,946). The unadjusted mean values for all validating measures increased steadily with the severity threshold score, except that legal problems, the criterion with the highest score, was associated with lower values than expected.

“After adjusting for the total number of criteria endorsed, this direct relationship was no longer evident. The overall severity score was no more highly correlated with the validating measures than a simple count of criteria endorsed, nor did the two measures yield different risk curves. This reflects both within-criterion variation in severity and the fact that the number of criteria endorsed and their severity are so highly correlated that severity is essentially redundant," wrote D.A. Dawson and colleagues of the National Institute on Alcohol Abuse and Alcoholism.

The researchers concluded: "Attempts to formulate a scalar measure of AUD will do as well by relying on simple counts of criteria or symptom items as by using scales weighted by IRT measures of severity."

The primary source for healthcare coverage in the United States is employer-sponsored insurance for those under the age of 65. However, many low-wage jobs do not include healthcare coverage, or because of escalating premiums and deductibles, employees are opting out of employer-sponsored healthcare coverage.

To establish which persons are uninsured, employed, and in need of substance abuse treatment, the NSDUH asks a battery of questions relate

d to those three areas. To determine employment, the NSDUH considers respondents who have worked 35 hours per week on a regular basis as full-time employees.

The NSDUH classified respondents needing substance abuse treatment as those who met the criteria for dependence or abuse, or if they received substance abuse treatment at a specialty facility within the last year.

The survey reported that more than 18.4 million full-time employees between the ages of 18 and 64 had no health insurance coverage, representing over half (54.5 percent) of uninsured adults under the age of 65. Lack of health insurance was more common among males, among younger adults and among Hispanics than other racial/ethnic categories.

There were also associations found with income and education. Full-time workers with the least education and income were the most likely to be without health insurance.

An estimated 16.3 percent of full-time uninsured workers were in need of treatment for alcohol or illicit drug use in the past year. 13.3 percent needed alcohol treatment, 5.6 percent needed illicit drug use treatment, and 2.7 percent were in need of combined alcohol and illicit drug use treatment.

Of the 3 million uninsured full-time workers who needed substance abuse treatment, about 12.6 percent actually received treatment at a specialty facility. 87.4 percent needed but did not receive treatment. 6.6 percent recognized a need for treatment, while 80.8 percent did not recognize a need for treatment.

Uninsured full-time working males were more likely than their female counterparts to have received treatment at a specialty facility.

The perception of the American public is that most of the uninsured are under-employed workers or unemployed, but this study reveals that over half of the uninsured are full-time employees. The information provided by the NSDUH highlights the need for substance abuse treatment among full-time uninsured workers.

During 2006, nearly a quarter of all admissions to substance abuse treatment were aged 18 to 25. If medical professionals and policymakers were to understand the characteristics of repeat admissions in this age group, they may be better equipped to develop treatment strategies that can promote a successful outcome in initial treatment and prevent relapse later on.

Those substance abusers in the age range of 18 to 25 who used heroin and other opiates as their primary substance of abuse were repeat substance abuse treatment admissions 27 percent of the time, versus 12 percent for first time admissions. When multiple substances were used, repeat admissions occurred 67 percent of the time, versus 56 percent for first time admissions.

This division changed when the primary substance reported was alcohol or marijuana. When the primary substance was alcohol, repeat admissions were only 26 percent versus 35 percent for first time admissions. For marijuana, 22 percent were repeat admissions, as 28 percent were the primary substance of abuse.

Repeat admissions within this age range tended to be kept in the Northeast at 61 percent and the Midwest at 52 percent. At the same time, less than one third of substance abuse treatment admissions of the same age in the South were only 31 percent and in the West were 40 percent.

Within the studied age range, men and women accounted for the same proportions of first-time and repeat admissions. Repeat admissions were more likely than first-time admissions to be White, 74 percent versus 67 percent, and less likely to be Black at 10 percent versus 14 percent. At 10 percent versus 14 percent, repeat admissions were also less likely to be Hispanic.

For repeat admission patients, the average age of first use was younger than for first-time admissions of the same age. This difference ranged from five to 14 months, depending on the substance of abuse.

The criminal justice system seemed to be the principal source of referrals to substance abuse treatment for both repeat admissions at 46 percent and first-time admissions at 52 percent. At the same time, self or individual referrals and abuse care providers accounted for a higher proportion of repeat than first-time admissions.

Among those repeat admissions, patients were more likely than first-time admissions to have Medicaid for their health insurance. In fact, repeat admissions were consistently six to nine percentage points more likely than first-time admissions to have Medicaid for each single year of age. Among the group studied, both first-time and repeat admissions were nearly equally likely to have private types of health insurance.
 

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When flies and mice were treated with these drugs, they became more sensitive to alcohol. Rats given the drug spontaneously consumed less alcohol when it was freely available to them, but they continued to drink sugar water, another rewarding beverage. "This is a very powerful example of how simple model organisms—and the little fruit fly in particular—can be used to move quickly from an unknown gene to a potential therapy for drug addiction," said Ulrike Heberlein of the University of California, San Francisco.

Earlier studies have shown that fruit flies are a useful tool for discovering the basis for the effects of alcohol. Several genes that were previously identified as playing a role in the flies’ alcohol response play similar roles in mammals. In this new study, researchers screened mutant flies for those less sensitive to the cancer-fighting drugs. This led them to the happyhour gene, which has an important and previously unknown role in controlling the insects’ response to alcohol.

Heberlein’s team explained that because genetics seem to play a large role in alcoholism, genes and pathways involved in the acute response to alcohol can yield insight into the genetic factors that contribute to the more complex process of addition. Although they still don’t know exactly how alcohol influences the EGF pathway or how that leads to alcoholic intoxication, Heberlein said, “…the fact that we’ve come, in an unbiased way, to molecules in the same pathway is telling us that this is really, really important.”
 

Chronic alcoholics often lament that if there were a medical cure to help them stop drinking, they’d take it.

A Boston-area biotechnology company claims it has just such a drug and, in fact, has been marketing it for nearly three years. But detractors say traditional means of abstinence — including counseling and therapy — remain the most effective and reliable means of providing relief from alcoholism.

Alkermes Inc. makes Vivitrol, a prescription drug that is injected once a month in the muscle of the buttocks. Vivitrol is the brand name for naltrexone, which is also known as naltrexone.

Testimonials abound for the effectiveness of Vivitrol, but the firm recently told the Boston Globe that it expects to generate no more than $24 million in sales for this fiscal year.

Among its drawbacks is the cost: About $800 a month, or $9,600 a year. But there are other issues challenging the success of Vivitrol. Many alcohol treatment programs are resistant to the use of drugs, and some doctors say Vivitrol won’t work for most of their patients.

Vivitrol acts on the brain’s receptors for pleasure, blocking the receptor’s ability to gain any reaction from chemicals such as alcohol. This is intended to reduce an alcoholic’s craving for alcohol by slowly releasing the drug over the course of a month.

As a rule, most alcohol treatment centers have relied on counseling and therapy rather than medication. Many addiction treatment centers prefer their clients be free of drugs, suggesting 12-step programs such as Alcoholics Anonymous provide a much more effective solution than prescription drugs.

Jim Frates, Alkermes’ chief financial officer, said his company recommends Vivitrol as a supplement to counseling, not as a replacement. And his company has its supporters.

Dr. Punyamurtula Kishore, medical director of Preventive Medicine Associates Inc. in Massachusetts, told the Boston Globe that Vivitrol has been used very successfully in his three-dozen clinics. He said he has prescribed it for hundreds of patients.

Other doctors said they have misgivings about Vivitrol studies. Dr. David Sack, chief executive of the Promises Treatment Centers in Malibu, Calif., said the drug works only for a small percentage of alcoholics. He prescribes it for patients who have intense cravings for alcohol even after weeks of therapy.

And Dr. Kim Dennis, medical director at the Timberline Knolls treatment center near Chicago, said the same mechanism that helps diminish the need for alcohol also dulls the natural highs of exercise, sex, or other activities.

It is natural to feel uncomfortable taking your first steps toward recovery.  When we abuse alcohol or drugs, we spend a lot of energy trying to disguise and hide our addiction.  We keep a lot of secrets.  Breaking that tradition of secrecy can make us anxious and panicky. 

"I remember the day I called the employee assistance program. I knew I was in trouble.  I wanted to talk to somebody.  I did not want to admit it was about alcohol, but something in me – I like to think of it as a survivor instinct – pushed me to say it immediately in the phone call: I think I have a problem with alcohol.  The cat was out of the bag!  I felt relief, which was quickly followed by regret.  I now knew they would ask me about it in my first session. Oh boy. What if I still wanted to drink?  I knew alcoholics couldn’t drink.  But the relief part was great – now I couldn’t hide it. I had taken the first and most important step. I was on the road to recovery."  – DA, recovering alcoholic

Asking for help isn’t easy, but it’s critical to getting on the path to recovery.  There is a saying in AA – you are only as sick as your secrets.

If you have extreme anxiety about "letting the cat out of the bag" remember this: it’s probably not as big a secret as you think.  If you abuse alcohol, people will figure it out. Your behavior and your health will certainly give you away at some point.

Some initial ways to ask for help are:

Call Alcoholics Anonymous and talk to someone in recovery

Attend an Alcoholics Anonymous meeeting (it’s ANONYMOUS and you don’t have to introduce yourself if you don’t want to)

Call your employee assistance program and make an appointment

Find a therapist who specializes in addiction and recovery

If you know someone in recovery, ask them if you can talk to them privately

Call a treatment center that specializes in alcohol rehabilitation and talk to a counselor