Tag Archives: Alcohol dependence

If it wasn’t rational, cont’d

PET brain scans show chemical differences in t...

PET brain scans show chemical differences in the brain between addicts and non-addicts. The normal images in the bottom row come from non-addicts; the abnormal images in the top row come from patients with addiction disorders. These PET brain scans show that that addicts have fewer than average dopamine receptors in their brains, so that weaker dopamine signals are sent between cells. (Photo credit: Wikipedia)

Sam Wilkinson responds to the the coverage of Hart’s research (That crack and meth addicts in a lab will decline drugs for money.) and agrees that addiction is rational.

Hart has found the same thing. It isn’t the addicts are powerless; it’s that nothing on the other side of the scale weighs as much as does the benefit of the whatever-is-being-sought. Back on that Sunday in September 2006, nothing on that scale weighed as much as getting blind drunk. My perceived options in that moment were narrow. By artificially increasing the number of options, Hart shows that even the farthest gone can still make what we might be more willing to describe as the rational decision. Where we stumble is in misunderstanding that the desire the use is rational too.

He goes on to give a really wonderful description of addiction.

Addiction is so harrowing a foe because it literally becomes the solution for everything. The mind’s calculator shows the same answer no matter what the problem is. How do I solve an emotionally devastating day? Beer. How do I celebrate a beautiful day? Beer. How do I unwind after a long day? Beer. How do I endure an uncomfortable situation? Beer. How do I…? Beer. The answer is beer. It does not matter what comes after the ellipses. I wrote this several months ago after giving alcohol as a gift. I am more than six years sober and if I don’t pause long enough to think about the answer my brain is giving me, drinking suddenly starts to make an incredible amount of sense. But if I did stop short of that longer consideration, my conclusion wouldn’t be irrational, especially if I’d only thought to consider all of the good things there are about drinking. And there are good things.

I have a few thoughts.

First, I’m not sure Wilkinson and I are so far apart. During educational talks, I sometimes say, “If drugs did for you what they did for me, you’d be an addict too!” So, if he’s saying that a fundamental characteristic of addiction is that there’s something different about the way addicts/alcoholics experience drugs and that this dramatically changes the decisional balance about using, then I’d agree. I’m not sure I’d strenuously argue that this is rational. Sure, there’s an internal logic to it, but that’s only because the equation is rigged by brain dysfunction.

Second, I’m also not sure that I’d argue this means addicts have control. Hart’s experiments demonstrate that addicts have influence over their use, not that they have control–that they can delay their use, not that they can stop because of incentives. Does anyone really question what the addict is going to do with that $20 after the study is over? I mean, if I’m really hungry and you offer me $20 to skip a meal, I might take you up on that. But, eventually, no amount of money is going to be enough to get me to skip a meal. Sure, some people are super-human and have the force of will to starve themselves in the name of a cause, but that seems like a case where the exception proves the rule.

Third, Wilkinson uses his own experience to understand the matter. He’s 31, which means he was in his mid-twenties when he quit. We know that large numbers of people in their late teens and early 20s meet diagnostic criteria for alcohol dependence and that something like 60% of them will “mature out” and moderate or quit without any professional help or involvement in a mutual aid group. I believe strongly that those who mature out and those who have chronic problems have categorically different problems and we need to be very careful using the experience of one group to understand the other. I don’t know the writer and I don’t know which category he falls into, but he certainly fits the maturing out pattern.

Fourth, the degree to which we insist on free will and rationality is striking. Think for a moment about the argument that it’s rational for people to destroy their lives using drugs. We’re willing to twist ourselves in meaningless mental knots, ignore the obvious (like the fact that Hart’s subjects are very likely to use the money they get in these studies on drugs), and ignore the common sense ethical problems (experiments that put addicts up for a week, provide them with drugs and release them with a pocket full of money). All to make it fit into our monoculture.

2 Comments

Filed under Controversies, Policy, Research

“No” to rehab?

Alcoholism 01

Alcoholism 01 (Photo credit: Wikipedia)

I was asked by a friend to comment on this article.

Here’s the response I sent him:

Well, he’s got a point. But he’s also gotten a lot wrong, including the name of the NIAAA. It’s National Institute on Alcohol Abuse and Alcohol-ism.
What he’s right about is that not everyone who has an alcohol problem needs or should receive treatment. And, surveys of looking at the prevalence and course of alcoholism and addiction find that large numbers of people experience “natural recovery”, “maturing out” or “spontaneous remission”. Some abstain and others moderate.

He interprets these findings as meaning that anyone who chooses to quit, can.

My interpretation of the findings are that “alcohol dependence” does not equal alcoholism and that conflating the two produces a lot of false positives for alcoholism. The NIAAA article says:

In most persons affected, alcohol dependence (commonly known as alcoholism) looks less like Nicolas Cage in Leaving Las Vegas than it does your party-hardy college roommate or that hard-driving colleague in the next cubicle.

Large numbers of college students meet criteria for dependence but will moderate or quit once they graduate, start careers and form families.

We have the same problem in studies of “recovery”: http://wp.me/p1n5A8-2Em

It’s a lot like the stories of Vietnam veteran spontaneous recoveries from heroin addiction: http://wp.me/p1n5A8-1SO

We also know that lots of alcoholics recover without treatment. (Jim and I did.) Whether your an alcoholic or a heavy drinker, you’re more likely to successfully resolve your problem if you have a lot of recovery capital. His 7 things address a lot of recovery capital domains.

I’m a fan of motivational interviewing, we train staff in it (Though I see it as a tool rather than a solution.) and I agree that a confrontive style is both ineffective and unethical. However, studies don’t find it to be more effective than other approaches. Just this week, a study was published that found few differences between MET (based on motivational interviewing) and counseling-as-usual: http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/a0017045

2 Comments

Filed under Controversies, Mutual Aid, Research, Treatment

2012’s most popular posts #10 – Almost Alcoholic

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Related articles

2 Comments

Filed under Controversies, Policy, Research, Treatment

Acomprosate – A Randomized, Double-Blind, Placebo-Controlled Study

For What It's Worth (Placebo song)

For What It’s Worth (Placebo song) (Photo credit: Wikipedia)

Recently published and found no “evidence of efficacy for acamprosate compared to placebo”.

However, “A goal of abstinence was significantly associated with improved drinking outcomes”.

Efficacy of Acamprosate for Alcohol Dependence in a Family Medicine Setting in the United States: A Randomized, Double-Blind, Placebo-Controlled Study

Background

Acamprosate has been found to enhance rates of complete abstinence and to increase percent days abstinent (PDA) from alcohol relative to placebo treatment. As most U.S. clinical trials of acamprosate have been conducted in alcohol and other drug specialty clinics, there is a need to examine the efficacy of acamprosate in generalist settings. This study tested the efficacy of acamprosate versus placebo on the primary study outcome of PDA in the treatment of alcohol-dependent patients in a family medicine setting. Secondary study outcomes included percent heavy drinking days (%HDD) and gamma glutamyltransferase level (normal or high).

Methods

A randomized, double-blind, placebo-controlled, parallel group design of acamprosate was conducted in 2 family medicine settings (North Carolina and Wisconsin). One hundred volunteers were recruited primarily by advertisement, and participants were assigned to 666 mg (2 pills) oral acamprosate 3 times daily (1,998 mg/d) or matching placebo over a 12-week period. All participants concomitantly received 5 sessions of a brief behavioral intervention from a family/primary care physician.

Results

No significant treatment effect of acamprosate was found on PDA or the secondary outcomes. Significant treatment goal by time interaction effects was found on PDA and %HDD. Participants who had an initial goal of abstinence versus a reduction in alcohol use improved on average over time in PDA and had less %HDD from baseline to the end of treatment.

Conclusions

This clinical trial did not find evidence of efficacy for acamprosate compared to placebo among alcohol-dependent individuals recruited primarily by advertisement as studied in a primary care setting. Drinking outcomes significantly improved regardless of medication condition. A goal of abstinence was significantly associated with improved drinking outcomes, suggesting that alcohol-dependent patients with such a goal may do particularly well with counseling in a family medicine setting.

Comments Off on Acomprosate – A Randomized, Double-Blind, Placebo-Controlled Study

Filed under Research, Treatment

Group treatment has long term benefits

A photo of a group conducting psychotherapy.

A photo of a group conducting psychotherapy. (Photo credit: Wikipedia)

From the journal, Alcoholism: Clinical and Experimental Research:

Background:  Group psychotherapy (PT) is one of the most common interventions used to treat alcohol dependence (AD), and it is assumed to be effective. Despite its common clinical use, long-term trials that have been conducted to examine the efficacy of group PT in the treatment of outpatients with AD are limited and often lack appropriate comparisons. On that basis, a long-term comparative trial was performed with the main objective of evaluating the effectiveness of continuing group PT for outpatients with AD.

Methods:  Quasi-experimental trial was conducted from January 2004 to May 2010 in 177 AD subjects who had completed an inpatient 10-week alcohol treatment program. Abstinence rates of the combined group (experimental group: outpatient individual PT plus group PT,N = 94) and the standard outpatient individual PT-only group (comparison group, N = 83) were statistically compared using Kaplan–Meier survival analysis. Predictive factors of abstinence rate for alcohol were assessed using Cox regression analysis.

Results:  Abstinence rates of the combined PT group were significantly high relative to those of the outpatient individual PT-only group. Significant predictive factors for the alcohol abstinence rate were outpatient group PT and age. Even after controlling for confounding factors, outpatient group PT was a significant predictive factor for the alcohol abstinence rate.

Conclusions:  Our findings indicate that for AD patients who had completed an inpatient 10-week alcohol treatment, outpatient group PT appears to be an effective form of continuing care or aftercare within the context of an outpatient service delivery system.

Comments Off on Group treatment has long term benefits

Filed under Research, Treatment

Almost alcoholic?

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

4 Comments

Filed under Controversies, Policy, Treatment