By: Valerie J.
Slaymaker, Kirk J. Brower and Mike Crawford
Combining pharmacotherapy and psychotherapy for alcohol use disorders has the potential for achieving greater efficacy than either one alone. Psychotherapy here includes all forms of therapy: dynamic, milieu and cognitive-behavioural. Theoretically, the two types of treatment could operate synergistically through different mechanisms.
Combining pharmacotherapy and psychotherapy for alcohol use disorders has the potential for achieving greater efficacy than either one alone. Psychotherapy here includes all forms of therapy: dynamic, milieu and cognitive-behavioural. Theoretically, the two types of treatment could operate synergistically through different mechanisms.
For
example, naltrexone might reduce both urges to drink and the reinforcing effects of drinking, while
cognitive-behavioral therapy (CBT) might increase a
patient’s skills and confidence at managing high-risk
situations that had previously triggered drinking.
Similarly, patients that take disulfiram abstain from
drinking to avoid aversive medical complications, while behavioral therapies
can be used to enhance compliance with disulfiram
and reinforce other recovery activities. These two
examples also illustrate that different medications might be optimized by different types of psychotherapy
(i.e. CBT and behavioral therapy for naltrexone and
disulfiram, respectively).
Current
consensus recommends against the use of medication to treat alcohol dependence without also using addiction-focused psychotherapy. Nevertheless, knowledge about which particular psychotherapy (e.g. CBT ‘cognitive-behavioral therapy’, MET ‘Motivational enhancement therapy’ or TSF ‘Twelve-Step Facilitation’) should be
combined with a given medication
is limited. Conversely, psychotherapy for alcohol
dependence is commonly provided in the absence of
addiction-specific medication. Therefore, knowledge about the added value of a particular medication when combined with a specific psychotherapy will be a fruitful area for future research to guide treatment
options.
The
use of alcohol-specific medications to prevent relapse is uncommon in the USA despite
the growing evidence in support of these medications). The latest
National Survey of Substance Abuse Treatment
Services from 2003, for example, found that only
20% of treatment centers were using pharmacotherapies (17% using disulfiram;
12% using naltrexone; 5% using buprenorphine;
Substance Abuse and Mental Health Service
Administration, 2004). Moreover, relapse prevention
medications are viewed as adjunctive to psychosocial treatment in the USA, and simple
medication monitoring by itself is not
considered sufficient treatment.
This
guideline is reflected in the FDA labeling for disulfiram and acamprosate, and
in the US Department of Health and Human Services practice guideline for
naltrexone (O’Malley, 1998). The
guideline implies that combination therapy will usually be administered in
specialized addiction
treatment settings because this is where addiction-focused psychosocial therapy
is predominantly available. Further studies are needed to determine the
efficacy of simple medical management approaches
(Johnson et al., 2003; Pettinati et al., 2004; Volpicelli et al., 2001).
It
is emphasized, however, that even ‘simple’ medical management approaches require highly
trained healthcare professionals who help patients set goals and solve problems in addition to simply writing prescriptions (Pettinati et al., 2004).
Nevertheless, if medical management approaches prove effective, then pharmacotherapy could favorably be administered in
primary care settings, and the use of relapse
prevention medications could potentially increase.
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
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