SAMHSA Issues Guide on Medication-Assisted Therapy for Alcohol Use Disorders

According to a recent analysis from the Substance Abuse and Mental Health Services Administration (SAMHSA), around 18 million Americans are estimated to have an alcohol use disorder, yet less than 10 percent of them have received any formal assistance, such as counseling or enlisting in a treatment program (mutual-help groups like Alcoholics Anonymous are not considered formal). And only a fraction of those in treatment were given medication to supplement their therapy.

The reasons for the underuse of medications to treat alcohol disorders are likely varied, involving historical biases and biological shortcomings as well as a lack of public awareness about recent progress in the development of drugs to treat alcohol use.

To help clarify the situation, SAMHSA and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recently convened a panel of experts in alcohol research, clinical care, medical education, and public policy to review current evidence on the available medications for the treatment of alcohol use disorders and develop guidance for their clinical use. The collected recommendations can now be viewed in “Medication for the Treatment of Alcohol Use Disorder: A Brief Guide.”

The guide provides information in six key areas. The first section offers a breakdown of the biological properties, indicated clinical uses, and potential adverse effects of three medications currently approved by the Food and Drug Administration—acamprosate, naltrexone (oral and injectable versions), and disulfiram—for the treatment of alcohol use disorders. Other sections include recommendations for screening patients, assessing patient need for medication assistance, developing a treatment plan, treating co-occurring disorders, and monitoring patient progress.

SAMHSA and NIAAA developed this guide in part as the high prevalence of alcohol use disorders uncovered in recent analyses, coupled with the implementation of the Patient Protection and Affordable Care Act (which includes language for substance abuse therapies), provides considerable potential for expanding the use of medication-assisted treatment.

“Historically, there was an ideological conflict in the addiction treatment field,” John Krystal, M.D., chair of the Department of Psychiatry at Yale School of Medicine and chief of psychiatry at Yale-New Haven Hospital, told Psychiatric News. “Some people felt that effective alcohol treatment required patients to rid their bodies of as many foreign substances as possible, including therapeutic medications. However, with research and education, the prejudice against pharmacotherapy has greatly subsided. For example, there are now even ‘12-step’ groups that support adherence to alcoholism pharmacotherapies.”

Krystal did caution that as the information is disseminated—SAMHSA will promote the new guide through its website, blog, emails, social media applications, and work with relevant professional societies and other stakeholder organizations—care should be taken not to promise results that most patients won’t realize.

“The marketing strategies for some of these medications led doctors to expect that most of their patients would clearly benefit, but this hasn’t been the case,” Krystal said. This has led to some disenchantment in the medical community, but that shouldn’t mask that some patients can benefit, he said.

If use of medications to treat alcohol use disorders does increase, it may prompt federal or private agencies to provide more resources to research this area. That could include pharmacogenetic studies to help identify which patients would benefit most from medication, like a recent Mayo Clinic study that found a gene that may be tied to longer abstinence with acamprosate therapy (Psychiatric News, December 15, 2014). It may even spur the search for the next breakthrough abstinence drug.

SAMHSA did stress that its educational efforts on alcohol use medications does not imply any preference over behavioral or mutual-help therapies, specifically noting that it uses the term “medication-assisted.”

“Pharmacotherapy is only one aspect of a comprehensive approach to treat substance use disorders; it is not a replacement or alternative to behavioral therapies,” said Melinda Campopiano, M.D., a medical officer at SAMHSA’s Center for Substance Abuse Treatment. “More people receiving medication-assisted treatment should, in fact, produce an increase in the use of mutual aid or behavioral therapies.” ■

“Medication for the Treatment of Alcohol Use Disorder: A Brief Guide” can be accessed here.