The Transformation of Alcohol Treatment (Transcript)

Good morning and welcome to the Kolmac Clinic. For the next few minutes I would like to tell you about the quiet transformation that has occurred in the treatment of alcohol problems over the past 40 years and the role that medications have played in this change. In contrast to changes that add to the crisis of escalating health care costs – this change has resulted in dramatic reductions in the cost of alcohol treatment. There are 3 elements of this transformation, all developing at roughly the same time. They are: first, the shift from an inpatient to an intensive outpatient setting; secondly, the evolution of a new psychological framework, and lastly the progress in our understanding of the neurobiology of addiction and the development of new medications. I will comment on each of these areas briefly.

The heart of the transformation is the shift in the primary location in treatment from inpatient to intensive outpatient. After many years of frustration, successful professional treatment of alcoholism was finally developed in the 1950’s. This took the form of residential rehabilitation centers which limited their patient population to alcoholics and in which the principles of Alcoholics Anonymous were applied, using a group therapy modality. The “Minnesota Model” is the term often applied to these facilities. At the same time, milieu therapy was being developed in psychiatric hospitals to reduce some the inherently anti-therapeutic features of alcohol treatment in a residential environment. These studies of therapeutic environments led to the discovery that effective rehabilitation could be done without the residential component by creating these structured environments in an outpatient setting. These centers are called “psychiatric day hospitals” or “psychiatric partial hospitalization.”

In the 1960’s, Dr. Vernelle Fox, was the first to establish such a daylong program for alcoholics in a public setting at the Georgian Clinic in Atlanta. In 1973, here at the Kolmac Clinic, we established the first Intensive Outpatient Program. This is a 3-hour a day program which allows patients not only to live at home, but also to stay on at their jobs while they receive treatment. Although insurance and managed care companies have been severely criticized in the addiction field for denying treatment, they have in fact been supportive of this outpatient approach. Moreover they have been able to stretch healthcare dollars to cover treatment for a larger percentage of alcoholic patients than under the earlier unsustainably free spending system.

The second element of the transformation was the evolution of a modern psychological framework in which to understand and work with alcoholics. Psychoanalytic approaches were notoriously ineffective. The precepts of Alcoholics Anonymous, while providing a language for personal recovery, were explicitly non-professional. Moreover, clinicians were moving in the direction of increasingly adversarial and argumentative interactions with patients. Given this situation, the development of motivational enhancement and cognitive behavioral therapy were welcome events. Using these approaches, the patient’s ambivalence about giving up alcohol became a central focus. The patient’s thoughts and behaviors rather than their unconscious processes were the arena in which the therapy occurred. Perhaps most importantly, these treatment strategies facilitated more empathic and respectful interactions with patients.

The third and last element is in the biological area, where the neurobiology of alcoholism is slowly being clarified and medications have been developed. The most significant advance occurred in the 1960’s with the discovery that the benzodiazepine minor tranquilizers – Librium and Valium – could transform the process of alcohol detoxification from one of misery and potential death to one of comfort and safety. Importantly, they allowed ambulatory detoxification so that the process could be safely and effectively carried out in an outpatient setting without the need for hospitalization. This also allowed the design of programs in which entry into the rehabilitation phase of treatment could be done at the same time as detoxification, thus interrupting the so-called “revolving door” of repeated hospitalizations for detoxification.

Less consensus exists regarding Antabuse and its ability to prevent relapses by providing a chemical barrier between the patient and alcohol. Compliance with taking the medication has been the main limitation in its effectiveness. At Kolmac we have addressed this by having patients take it during each session and have found that when used in this way, it appears to facilitate the recovery process. More recently, naltrexone (also known as Revia) and acamprosate (also known as Campral) have been found to help reduce relapses and have been welcome additions to alcohol treatment. A long acting injectable form of naltrexone, known as Vivitrol, is also becoming available this month.

Advances in neurobiology and medications have converged to help us decide which medications might be more effective with which patients. For example, naltrexone seems to be particularly effective with those patients who develop alcoholism at an early age and have a strong family history of alcoholism. When these patients drink alcohol, internal opioids are released creating a particularly reinforcing experience. Naltrexone as an opioid antagonist blocks this effect.

I would like to close with two observations about future progress in the alcohol treatment field. First is the importance of maintaining a balanced view about new medications. The understandable desire for break through improvements can lead to an overvaluation of new medications as “wonder drugs” only to be inevitably followed by disillusionment and undervaluation. Although the medications that I have mentioned are effective, they are only moderately so, with the exception of the benzodiazepines for detoxification. Furthermore, pressures of time and money can lead to medication being taken without rehabilitation, which leads to a significant reduction in effectiveness.

Secondly, while it is understandable that one of the first questions asked of alcohol treatment programs is “What is your success rate?” – such a question has the potential of evoking defensiveness on the part of the clinician. I think that it is critical to focus openly and directly on our so called “treatment failures” – those patients who do not successfully complete our programs. I believe that it is by continuing to work together with this group of patients to understand what else is needed that we will move our field ahead. I would like to think that the pioneering founders of AA, Bill W. and Dr. Bob, would have agreed.

Thank you.

(Speech by Dr. George Kolodner)

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