An introduction fromAddiction Professional's Editor
This is the fifth in a series of six articles designed to provide you with the latest information on the use of medications in alcohol dependence treatment. Medications (pharmacotherapy) used as adjuncts to counseling techniques and biopsychosocial, educational, and spiritual therapies are an increasingly important part of a comprehensive treatment approach for alcohol dependence.
Expanding knowledge of how medications may interact with and complement counseling will help the addiction counseling community optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice not only provides the latest efficacy and safety data on these medications, it also explores how we can build better relationships among addiction professionals and medication prescribers. The series also examines current barriers to medication use in treatment while offering potential solutions.
Previous articles in this series, which began in the January/February 2007 issue, addressed the topics of facilitating the process of change through medication use; examining recent research on the approved medications for alcohol dependence; overcoming biases against greater use of medications in treating alcohol dependence; and integrating medication into nonprescribing clinicians' treatment planning. In this fifth article, Thomas J. Brady, MD, MBA, outlines how prescribers and nonprescribing clinicians can improve collaboration for the benefit of the alcohol-dependent patient. The final article, in the November 2007 issue, will present case studies that illustrate how medications have helped individuals break their dependence on alcohol.
Treatment of alcohol dependence and other addictions has increasingly become “medicalized” because of a greater understanding of brain neurophysiology and the accompanying rise in the number of effective medications for these disorders. There is also an increasing demand for treatment accountability and evidence-based treatment driven in part by patients, who have more information available to them through the Internet and other sources, as well as by managed care, which attempts to make healthcare delivery decisions based on proven treatments. These trends are spurring treatment providers to examine the demand for and use of medications—those with efficacy that has been demonstrated in clinical trials—and require increased collaboration between medication prescribers (usually physicians) and nonprescribing addiction specialists (counselors, psychologists, etc.).
Professional societies, such as the American Medical Association and the American Psychiatric Association, require that their members cooperate and respect colleagues as well as maintain and increase their competency (the two associations' principles of medical ethics may be accessed at http://www.ama-assn.org/ama/pub/category/2512.html and http://www.psych.org/psych_pract/ethics/ppaethics.cfm, respectively). However, team-oriented care of alcohol dependence employing different treatment providers traditionally has been difficult because of differences in treatment philosophies, knowledge of issues, and willingness to cooperate or “share” patients. In addition, more than half of addiction treatment programs do not have a full-time physician or nurse who could prescribe medications; thus, there is often a missing connection between prescribers and nonprescribers, which is needed for proper medication management.1
Barriers to cooperation
Counselors might not see physicians as their allies in the treatment of alcohol dependence because of the perceived or real deficiencies of physicians in this field. Many physicians do not adequately screen for alcohol dependence2 or shy away from dealing with patients who have drinking problems.2,3, Indeed, many physicians have received minimal training in treating addictions, and many might feel unprepared and uncomfortable treating patients with alcohol use disorders.3 In addition, physicians may not make appropriate referrals, and some counselors might think physicians even compound patients' problems. For example, physicians might prescribe benzodiazepines to help treat symptoms following withdrawal from alcohol. But if these potentially addictive medications are prescribed inappropriately, or if there is inadequate monitoring and follow-up, patients might develop new addictions or problems with these medications.
Another barrier to proper treatment and collaboration between counselors and physicians stems from the views among some physicians that alcoholism is a moral defect rather than an illness.4 Physicians with these beliefs may think counselors cannot help alcohol-dependent patients or could even enable them. For physicians who lack knowledge or appreciation of alcohol dependence, counselors can serve as an educational resource.