Science and the Big Book

Over my 50-year career in Addiction Psychiatry and Neuroscience, I have had the chance to work closely with many pioneers in the field. Drs Douglas Talbot, Conway Hunter, Herb Kleber, Robert Millman, Chuck O’Brien, Garrett O’Connor, Harry Haroutunian, David Smith, Tom McLellan, and Bob Dupont. They taught me a great deal about the disease we call addiction. At Conway Hunter’s annual conference at Jekyll Island, I had the chance to try out various concepts, merging the new research and evidence in addiction science and the tried-and-true practices and methods in the Big Book. Doug Talbott called my part of the program “Science and the Big Book,” and it stuck. At ASAM and other Addiction Conferences, as well as APA and psychiatric Conferences, I tried to show how it was not either science or AA. How outcomes were the ideal measure of a treatment approach and managing detoxification, reducing early dropouts in the first 90-180 days, and staying in treatment could be facilitated with a comprehensive approach embracing science and medication-assisted treatments and full engagement in the 12-step recovery community.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) defines AUD as a problematic drinking pattern causing significant impairment or distress, as indicated by meeting at least 2 of 11 criteria within a 12-month span. These criteria include consuming alcohol in larger amounts or for longer durations than intended, unsuccessful attempts to cut down or control alcohol intake, dedicating substantial time to obtain, use, or recover from alcohol, experiencing strong cravings for alcohol, failing to fulfill major obligations due to alcohol use, persistent social or interpersonal problems resulting from alcohol use, giving up important activities due to alcohol, engaging in alcohol use in physically hazardous situations, continuing alcohol use despite knowledge of related physical or psychological problems, developing tolerance requiring increased alcohol consumption for desired effects, and experiencing withdrawal symptoms when alcohol use is discontinued.

NIAAA estimates that less than 10% of individuals with AUD are prescribed medications like Naltrexone, Acamprosate, Disulfiram, or Vivitrol (Srivastava AB, Gold MS. Naltrexone: A History and Future Directions. Cerebrum. 2018 Sep 1;2018:cer-13-18. PMID: 30746025; PMCID: PMC6353110.). Stigma, shame, denial, and lack of insurance coverage for these medications have been identified as the main reasons for the lack of utilization. While medication-assisted treatments (MATs) have been the major therapeutic approach for opioid use disorders, alcohol use disorders have gone mostly untreated. Yet alcohol misuse is believed to be responsible for more than 140,000 deaths annually in the United States. In addition, nearly 1 in 6 Americans reportedly binge drink, and binge drinkers may be male or female.

Doctors David Smith in Addiction Medicine, Stephen Batki MD in Addiction Psychiatry, and Pi Driscoll in internal and addiction medicine have been role models and mentors pioneering the outcome-driven treatment for alcohol use and other substance use disorders. Alta Mira is very lucky to have such an accomplished team leading the day-to-day program on-site in Sausalito, California, Sausalito in Marin County, California, across the Golden Gate Strait, and overlooking the City of San Francisco. This October 2024 in-depth overview of alcohol use, misuse, and disorders will also highlight the complexities surrounding Alcohol Use Disorder (AUD) and its treatment.

Key Points:

Prevalence and Impact: AUD affects millions of people worldwide, contributing to significant morbidity and mortality. It is a leading preventable cause of death and is associated with over 200 diseases and health conditions.

Diagnostic Criteria: AUD is diagnosed based on the DSM-5 criteria, which categorizes the disorder’s severity based on the number of symptoms an individual presents.

Female AUD may be a distinct disease: In a new Yale study, researchers provided extensive data that gender differences in AUD and treatments may explain the lack of treatment response with naltrexone in some patients. For example, brain activity related to alcohol craving and future heavy drinking differs between the sexes, which could have implications for treatment. The brain circuits underlying alcohol craving and heavy drinking share some similarities between men and women, but there are many important differences, as the study reveals. Previous research has shown individuals with AUD who experience strong alcohol cravings triggered by stressful life events relapse into heavy drinking. Researchers and new data are now questioning whether these patterns are the same in men and women. In the last two decades, there has been a very steep increase in binge drinking among women in the United States, much more so than in men. The Yale University Department of Psychiatry May 2024 fMRI study to examine how men and women with AUD respond differently to stress and alcohol-related cues found that while alcohol cues triggered stronger cravings in men, stress cues had a similar impact on women, suggesting the need for sex-specific treatment strategies. Brain circuits—particularly those connected to emotion, reward, regulation of stress and emotion, and impulse control—responded differently in men and women. Alcohol cues led to stronger cravings in men than stress cues did; in women, stress and alcohol cues led to the same cravings in women. In women, those circuits were clearly blunted, but in men they were hyperactive. Dual Diagnosis is important too in women the Yale researchers found. Anxiety, depression, trauma and PTSD should be diagnosed and treated, or they may undermine addiction treatments. “In women, disruptions in brain regions associated with anxiety were related to future heavy drinking.” These sex differences in craving and its underlying brain systems suggest that men and women are different and would benefit from personalized and targeted therapeutic approaches.

Health Risks: Alcohol consumption is linked to an increased risk of various cancers, cardiovascular diseases, mental health issues, liver diseases, accidents, and injuries.

Public Health Initiatives: State Medical Societies and professional health and wellness initiatives have both supported physicians and health providers in finding treatment but also supervised and reported treatment outcomes for them as a Group. The work has helped establish a “gold standard” of response to treatment reported in the literature by Tom McLellan, Bob Dupont, Lisa Merlo, William White and I as greater than 80% recovery at 5 years with return to work, pre-morbid social functioning, and remission of the disease actively maintained by continuing care and treatment

Pre-Addiction: In JAMA Psychiatry, Nora Volkow, NIDA Director Tom McLellan of the Treatment Research Institute, National Institute on Alcohol Abuse and Alcoholism Director George Koob, present a plan for better detection and support of those in the early stages of substance use disorder called pre-addiction. Pre-addiction, if untreated, leads to a severe health condition—alcohol use disorder. Addiction, rather than a person who uses alcohol, is a person who acts like they do not have free will and are compelled to use alcohol. Historically, we thought that someone must hit “rock bottom” before treatment can work. But it is much more logical and preferable to raise their bottom, prevent harm, and intervene sooner. Screening and early intervention can identify drug or alcohol misuse that may eventually meet the threshold of addiction, sometimes defined as severe substance use disorder. The best time to get help is as soon as possible. Identification of “pre-addiction” as an early condition of addiction could motivate greater attention to the risks associated with early-stage substance use disorder like pre-diabetes has done for type 2 diabetes, enabling early intervention and treatment.

12-Steps: Addiction is the inability to control drug use despite adverse health consequences and even despite a desire to change. Alcoholics Anonymous reports an estimated 2.1 million members worldwide as it is free, non-judgmental, available day or night multiple times a day in many cities and has been used successfully by millions to reduce alcohol intake and loss of control over alcohol. Successful AA members usually become a sponsor once they are senior member of AA or NA who has been in recovery for at least a year. Sponsors help new members navigate meeting variety, availability, answer questions, work on the 12-Steps, and offer accountability. According to studies, sponsorship leads to better treatment outcomes, and those in 12-Step programs with a sponsor have better attendance and more involvement in the group. Many celebrities have discussed their addictions publicly and their treatment in residential and other settings. Rob Lowe, Carrie Fisher, Bradley Cooper, Naomi Campell, Tom Holland, Drew Barrymore, Robert Downey Jr., Jamie Lee Curtis, Tim McGraw, Eminem, and Jessica Simpson are some of stars who’ve spoken about their long-term sobriety. A sponsor is also a confidant who has the essential lived experiences, has been there, a confidant and someone you can call 24-7 to stay on your recovery journey. Just 10% of people who could benefit from treatment get it. Before reaching this point, however, it is easier for people to go to an addiction expert, ask their provider for help cutting down, or go to an AA meeting to support their efforts to exert control, including by setting limits and being more mindful of their alcohol use.

Medication-Assisted Treatment for AUDs: The most commonly used and recognized MATs for Alcohol Use Disorders include:

• • Naltrexone: Oral (Revia, Depade): Taken daily, it helps total drinks consumed per day, reduce cravings and the pleasurable effects of alcohol.
  • Extended-Release Injection (Vivitrol): Given once a month, it provides a long-lasting effect. Acamprosate (Campral): This medication helps reduce withdrawal symptoms and cravings by stabilizing the chemical balance in the brain. It is usually taken three times a day.
  • Naltrexone and Acamprosate are commonly used in the United States and have robust evidence supporting their effectiveness in reducing heavy drinking and promoting abstinence.
  • Disulfiram (Antabuse): This medication causes unpleasant reactions (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent. It is taken daily. Disulfiram is less commonly used due to its potential for severe reactions but can be effective in highly motivated patients.
  • Nalmefene (Selincro): Used primarily in Europe, this medication is like naltrexone. It is often used for reducing consumption rather than promoting complete abstinence and binge drinking and is taken as needed, typically one to two hours before a potential drinking problem.People with alcohol problems have medical and nutritional problems that need identification and treatment and psychiatric problems that need the same. According to the Journal of the American Medical Association, 37% of alcohol abusers also have at least one serious mental illness. Among people who die by suicide, AUD is the second most common mental disorder and involved in roughly 1 in 4 deaths by suicide.

Genes: Alcohol use disorder (AUD) has been studied for years, starting with twin studies comparing identical or fraternal twins and their risk for AUD and adoption studies comparing adopted children to their birth parents. These studies demonstrated that the heritability of alcohol dependence is up to 60%. Some genes increase a person’s risk for AUD, while others decrease that risk. 22% of adults in the United States have at least one biological parent with alcohol use disorder (AUD). The odds of lifetime AUD are 2.5 times higher for the offspring of one AUD parent and 4.4 times higher for the offspring of two AUD parents, as compared to children of non-AUD parents. Genes are not destiny, and environmental experiences also play a role. For example, a study of more than 3 million people suggests that marriage may protect against AUD, particularly for those with genetic loading for AUD. However, researchers also noted that while marriage to a spouse without alcohol problems may protect against alcohol use disorders, being married to a spouse with alcohol use problems has the opposite effect, increasing one’s risk. It is also known that pain, either psychological or physical, as well as PTSD and trauma, can make AUD more likely, as the additive relief of distress seems to increase brain-related rewards derived from alcohol.

Gene Predictors of MATs for AUD: Genetics may also help doctors provide individualized advice and patients to make personalized medicine choices. As a result of MUSC’s Dr Ray Anton’s research, it’s clear that personalized treatment and choosing the right medication for the right patient is becoming possible in AUD. For example, performing a few relatively simple genetic tests identifying variations in three brain genes will enable physicians to predict which patients would benefit most from taking naltrexone, an FDA-approved medication for AUD. If tests show patients will not benefit, other medications could be tried. Alternatively, new medications might be developed based on genetic testing results. Rather than taking a drug that could never work well because of one’s genetic makeup, wouldn’t it be best to know this upfront and potentially choose an alternative? Also, knowing a drug is likely to work might encourage more people to consider medication-assisted treatment. Other research may help elucidate roles for anhedonia, dopamine, and other systems in addictions and addiction liability.

Treatment Gaps: Despite the availability of AA, ASAM experts in Addiction Medicine, FDA-approved medications for AUD and the effectiveness of treatments like injectable Naltrexone (Vivitrol) as an adjunct to the comprehensive and individualized evaluation and treatment of the whole person, there is a significant treatment gap, with many individuals not receiving adequate care. Rather than either, patients with major depression, PTSD, or trauma should get treatment for their AUD and psychiatric illness. Patients with pain, nutritional deficiencies, and medical or neurological illness should get treatment promptly after diagnosis, but not at the expense of their addiction treatment. Patients who are detoxified from alcohol as part of their AUD treatment plan should be great candidates for 90 meetings in 90 days and also 90 days or 3 Vivitrol shots.

Changing Perceptions: Movements like Dry January and the Sober Curious movement are gaining traction, reflecting a growing societal shift towards rethinking alcohol consumption. Nutritional guidelines are likely to shift more toward the European and Canadian approach which redefines any drinking as a risk.

Challenges in Treatment: Stigma, denial, shame, failures to identify comorbidities and treat them, lack of insurance coverage, and reluctance to take medications are major barriers to 1 and 5-year outcomes defined as effective treatment. There is also a need for more comprehensive approaches that combine medication with behavioral therapies and support groups like AA.