FROM THE CLINICAL KNOWLEDGE CENTER
Consideration of Reduction in Heavy Drinking as a Treatment Outcome and a Public Health Strategy

by Anne Lambert, MS

This month, Clinical Compass™ turns its attention to current issues surrounding the management of chronic alcohol dependence. Healthcare practitioners can play a major role in the care of patients who have or are at risk for alcohol dependence by actively screening and identifying these patients and by implementing an appropriate treatment plan.

A major treatment goal for alcohol dependence is to increase rates of abstinence. When used in combination with psychosocial support, pharmacologic agents can help committed patients reach this goal. However, healthcare practitioners continue to struggle with challenges in the management of alcohol dependence. Not every patient referred to treatment, or interested in recovery, is able to actually stop drinking. If individuals are able to stop drinking, they are still subject to cravings and urges to drink and may be able to only reduce their amount of alcohol consumption.

Each patient needs individualized treatment as they begin the process of recovery. For example, in the National Institute on Alcohol Abuse and Alcoholism's updated 2005 guidelines, abstinence is recommended as the safest course, with the additional recommendation to individualize goals for patients who may be ready to substantially reduce their alcohol consumption, but who are not ready to commit to abstinence.(1) Similarly, the Federal government's Substance Abuse and Mental Health Services Administration (SAMHSA) has created treatment principles that are specific to patients with co-occurring disorders.(2) They focus on the need for individualized treatment for each patient and recognize the challenges presented by co-occurring disorders.

While reduction in heavy drinking fosters recovery and improvement in overall health, abstinence is still seen as the hallmark of successful treatment. In a recent article, Gastfriend and colleagues(3) presented the case for consideration of the quantity and frequency of alcohol consumption as alternative measures of treatment effectiveness in patients with alcohol dependence in a clinical setting.

The authors cited Grant and colleagues,(4) who demonstrated that patients with alcohol dependence comprise approximately 4% of the US adult population in a 12-month period. And chronic heavy drinking has been associated with increased morbidity and mortality, suicidality, and domestic violence. In a multisite study by Kranzler, et al, to evaluate quality of life (QoL) measures and outcome in 624 alcohol-dependent outpatients following treatment with injectable extended-release naltrexone and psychosocial therapy, the investigators reported that a high rate of heaving drinking was associated with problems in function and QoL scores on the Medical Outcomes Study 36-item Short Form Mental Component Summary. Deficits in mental health-related QoL were significantly correlated with heavy drinking.(5)

There is no chronic disease, except alcohol dependence, that uses complete remission of all symptoms as the criterion for success. In 2001, Miller and colleagues combined data from seven large multisite studies and found that 75% of the participants had ongoing episodes of drinking, yet alcohol consumption was reduced overall by 87% among those who continued to drink with a corresponding 60% decrease in alcohol-related problems. Reduction in heavy drinking, not total abstinence, was shown to be a realistic and clinically meaningful outcome for a majority of the participants.(6)

In the COMBINE study, Anton and colleagues chose "time to first heavy drinking day" as one of the primary efficacy measures. In this study, oral naltrexone combined with medical management was found to reduce the risk of a heavy drinking day over time compared with placebo.(7)

However, Gastfriend and colleagues pointed out that simply measuring the time to first drink does not capture the actual drinking behavior on any given day. For example, a patient may be abstinent for 10 weeks and then drink heavily every day for the remainder of a 12-week trial compared with a patient who may drink every Saturday but is abstinent during the week. Recent evidence suggests that the pattern of drinking may be more important to recovery than the abstinence itself. Clinicians need to re-evaluate goals for each patient as treatment progresses over time so that the treatment plan realistically matches the patient's readiness for the next step. This model has been used in other medical diseases, such as hypertension, with notable success.

In an editorial accompanying the above article, Thomas McLellan(8) explores reduction in heavy drinking as a possible public health strategy and treatment goal. He uses the treatment model for hypertension as a basis for the new strategy. For example, in both alcohol and hypertension research initiatives, when drinking or blood pressure exceed an empirically derived threshold, clinicians infer an abnormal process or disease progression requiring intervention.

The public is well aware of the blood pressure threshold of 130/80 mmHg as the safety limit. Individuals routinely engage in self-care including diet, exercise, and medications to keep their blood pressure levels below this threshold. The NIAAA could create a similar public health effect by disseminating threshold levels for heavy drinking (more than 5 drinks/day for men and more than 4 drinks/day for women). Several studies have already demonstrated the impact of heavy drinking on common chronic diseases and the positive impact of brief interventions.

The hypertension model, where blood pressure returns to normal levels, might lead the alcohol treatment field to adopt "return to normal drinking" as an interim treatment goal. If clinicians hold to total abstinence as the only goal, many individuals may continue to turn away from the process of recovery.

Again, looking at the hypertension model, if patients and physicians wait until blood pressure is dangerously high, there may be long-term effects that could have been prevented. However, primary care physicians have done an excellent job of educating, supporting, and successfully treating blood pressure.

This model has worked because the treatments are readily available and that accessibility has increased the willingness of primary care physicians to engage in screening their patients. This has, in turn, increased the number of patients being treated. And finally, if specialty care is needed, the primary care physician can refer the patient in a timely fashion.

The application of this model to patients with alcohol dependence and the healthcare practitioners who treat them has clear and beneficial implications for public health. The availability of screening tools, patient education materials, and medications could provide the impetus for the healthcare practitioners to expand their screening and treatment of alcohol-dependent patients. If patients with alcohol dependence are not ready to commit to abstinence, the model presented here may help them reduce heavy drinking as an interim goal on the way to recovery.

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