Recent findings from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) are challenging traditional views of alcoholism and point to the need for a paradigm shift in prevention and treatment strategies, a leading expert says.
Among other findings, recent data from NESARC, a prospective, population-based study that surveyed 43,000 US adults in 2001–2002 and again in 2004–2005, show that more than half of alcohol-dependent individuals are healthy, functional, young adults — a far cry from the stereotypical middle-aged, white-male, skid-row alcoholic, said Mark L. Willenbring, MD, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
“Much of what we thought we knew about alcoholism was based on middle-aged people, primarily white men in treatment programs and Alcoholics Anonymous, but the NESARC data are turning what we thought we knew about alcoholism completely on its head,” Dr. Willenbring told reporters attending a press conference here at the American Psychiatric Association 162nd Annual Meeting.
NESARC data also show that young adult alcohol-dependent individuals tend not to seek treatment and have the lowest rates of recovery and full remission.
Tip of the Iceberg
Furthermore, he said, the NESARC results show 72% of individuals who have alcohol dependence in their lifetime have 1 episode that lasts an average of 3 to 4 years and then remits and does not come back.
“This isn’t how I have traditionally viewed alcoholism, because I have worked in treatment programs where we see the most severely affected patients — those with chronic and severe dependence who frequently have psychiatric, medical, and social comorbidities,” Dr. Willenbring told Medscape Psychiatry in a follow-up interview.
“The fact is that most people who develop heavy drinking or alcohol dependence do not fit that stereotype. There are many who are not falling apart — their marriage is intact, they parent, they go to work, and in many cases nobody even knows they are coming home and drinking a pint or more of whisky, and these people are not getting any attention at all,” he said.
The NIAAA guidelines recommend that women should drink no more than 3 drinks in any day and 7 drinks in any week. Men should drink no more than 4 drinks in any day and 14 drinks in any week. One standard drink equals 14 g of ethanol, the amount in 12 oz of beer, 5 oz of table wine, or 1.5 oz of 80-proof spirits.
Dr. Willenbring added that only 1 in 8 individuals who develop alcohol dependence ever receives any treatment for the disorder and only 1 in 4 gets any kind of support such as going to an Alcoholics Anonymous meeting or talking to a counselor.
“We are really missing the boat here, and we need to shift our focus and start paying attention to this large group of people who are heavy drinkers and focus on risk reduction, early identification, and treatment.”
To help clinicians screen and treat their at-risk patients, NIAAA has developed 2 resources. The first, Helping Patients Who Drink Too Much: A Clinician’s Guide, is available in booklet form and on the Internet (www.niaaa.nih.gov/guide). It provides training to help clinicians identify and counsel at-risk drinkers as well as treat individuals with mild to moderate alcohol dependence.
The second resource, Rethinking Drinking, is a patient guide that is also available online or in booklet form that is geared toward individuals who are heavy drinkers or who are concerned about their drinking (www.rethinkingdrinking.niaaa.nih.gov).
Waiting for the Prozac Moment
One particularly promising area is the recent development of medications to treat alcoholism. While behavioral therapy can be effective, 1 of the major challenges with this mode of treatment is that it is not widely available, said Dr. Willenbring.
However, he said, the development of medications to help treat alcohol-dependence provides an opportunity to reach a greater number of individuals with drinking problems.
“I think treatment for alcohol dependence is going to mirror what happened with depression treatment — that is, 35 or 40 years ago very few people got treatment for depression and only psychiatrists treated it. Then along came Prozac and all of the other medications that revolutionized the treatment of depression.”
Primary-care physicians treat most patients with depression today, while psychiatrists treat the most severe and chronic cases.
“I think that’s where we’re heading with treatment for alcohol dependence. The bulk of people with mild to moderate dependence, who are the majority, can be effectively treated with medication and brief behavioral support in primary care and general psychiatry,” said Dr. Willenbring