Commentary by Joshua Lee MD, Ellie Grossman MD and Marc Gourevitch MD, NYU Division of General Internal Medicine
Please also see Part 1 of this series, posted last week
Alcohol treatment in primary care: evidence for effectiveness and neharmacotherapies
Brief interventions by primary care physicians to address unhealthy alcohol use have been shown in multiple studies and settings to promote reduced drinking and engagement in other treatment, although long-term impact on alcohol-related morbidity and mortality is not clear.(Saitz 2005) Standard brief intervention techniques are based on the 4 A’s: Ask (about drinking using validated screens); Advise (regarding a diagnosis of hazardous drinking, alcohol abuse, or alcohol dependence); Assist (with the patient’s motivation for change), and Arrange (follow-up with the physician or refer to a treatment program). Brief intervention is indeed intended to be brief – only 5-10 minutes of discussion with a patient per session has been shown to be an effective intervention (http:/niaaa.gov/cliniciansguide2008/).
Pharmacotherapies for Alcohol. With the 2006 FDA approval of extended-release naltrexone (XR-NTX, Vivitrol), the physician has four FDA-labeled agents available for the treatment of alcohol dependence: disulfiram (Antabuse), oral naltrexone (ReVia, 1994), acamprosate (Campral, 2004), and extended-release naltrexone. The recent COMBINE study employed a complex 3×3 randomized factorial design to study oral naltrexone and acamprosate on their own and combined, with or without other treatment modalities.(Anton 2006) These researchers found that alcohol treatment delivered by a physician (medical management) on its own was as effective as cognitive behavioral therapy or motivation enhancement delivered as additional individual therapy. In addition, oral naltrexone pharmacotherapy in addition to medical management was more effective at reducing alcohol use than acamprosate or placebo. Separate efficacy trials have shown disulfiram, XR-NTX, and acamprosate are beneficial when compared to placebo (Kiefer F et al. 2003.; Garbutt 2005).
XR-NTX is the newest addition to the alcohol-dependence pharmacotherapy armamentarium.(Garbutt 2005) Its development was grounded in the experience that oral naltrexone is effective at reducing alcohol use, but only for patients who actually took the drug – a significant barrier for a disease rooted in daily behavior like alcohol dependence. XR-NTX is a depot formulation that is injected monthly into the gluteal region – thereby overcoming issues of daily medication adherence. However, use of this medication remains lower than anticipated due to its high cost (and incomplete coverage by public insurers) and its injection format. Unlike primary care practices, most office-based addiction psychiatrists may not be equipped to perform injections or comfortable with such an invasive procedure. XR-NTX prescribing has to date mostly occurred in specialty addiction centers and internal medicine and family practice office-based settings. To date in an on-going single-arm study of primary care-based pharmacotherapy of alcohol dependence at Bellevue Hospital, we have shown that offering XR-NTX to low-income and uninsured patients is feasible: interest and acceptance of XR-NTX therapy is high among eligible patients, and retention through a 3 month treatment phase is roughly 75% per month (25% per month discontinue treatment). This compares favorably to other outpatient medical or psychosocial alcohol treatment, the literature for which reports generally lower rates of short-term treatment retention. Self-reported alcohol use in those remaining in XR-NTX treatment has been substantially lower than at baseline, as expected.
Limitations and referrals
The primary care or office-based specialty physician ready and willing to offer frontline addiction treatment can look forward to many rewarding cases, as patients are often younger and in otherwise good health excepting problematic substance use. However, psychiatric comorbidities, polysubstance dependencies, and chaotic social circumstances including homelessness, unemployment, and insurance difficulties often appear as complications to straight-forward treatment and recovery. Even in the simplest cases, chronic difficulties with cravings and relapse are the rule. The office—based practitioner always needs to keep these realities and limitations in mind, with other referral sources and backup resources available when more help is required. Linkages to general psychiatric care and specialty addiction treatment resources are practical next steps when a case requires that primary psychiatric diagnoses be addressed, or more comprehensive addiction care, including inpatient detoxification, residential rehabilitation, or intensive outpatient care involving individual counseling and frequent structured group therapy, be considered.
References
Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A Treatment Improvement Protocol (TIP) Series 40. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004
Lee JD, Grossman E, DiRocco D, Gourevitch M. At-Home Buprenorphine/Naloxone Induction in Urban Primary Care. Association for Medical Education and Research in Substance Abuse (AMERSA) National Meeting (podium) Washington DC, Nov. 10, 2007; Society of General Internal Medicine Annual Meeting (poster) Pittsburgh PA, April 10, 2008; American Society of Addiction Medicine Annual Scientific and Medical Meeting (poster) Toronto, ON, April 11, 2008.
Anton RF et al, Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA, 295(17), 2006:2003-17.
Garbutt JC et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA, 293(13), 2005:1617-25.
Lee JD, Grossman E, DiRocco D, Truncali A, Rotrosen J, Hanley K, Stevens D, Gourevitch MN. Extended-release Naltrexone Injectable Suspension for Treatment of Alcohol Dependence in Urban Primary Care – A Feasibility Study: Preliminary Analysis. Society of General Internal Medicine Annual Meeting (poster) Pittsburgh PA, April 10, 2008; American Society of Addiction Medicine Annual Scientific and Medical Meeting (poster) Toronto, ON, April 11, 2008; College of Problems on Drug Dependence (poster) San Juan PR, June 18, 2008; Research Studies on Alcoholism (poster) Washington DC, July 2, 2008.
Kiefer F. et al. Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind ,placebo-controlled study. Arch Gen Psychiatry 2003 Jan;60(1):92-9.Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596-607.