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Alcohol dependence treatment: Facilitating the process of change with medications

January 1, 2007
by Carlo C. Diclemente, PhD, ABPP
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An introduction from Addiction Professional's


Welcome to the first 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. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) demonstrated this trend in its 2005 guidelines, which recommend that all FDA-approved medications be considered when treating individuals who have active alcohol dependence or who have stopped drinking recently but are experiencing cravings or slips.

The addiction counseling community needs to understand how these medications are used in order to optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice will not only provide the latest efficacy and safety data on these medications, it will also explore how we can build better relationships among addiction professionals and medication prescribers. Additionally, clinical case studies and how these relate to the treatment planning process will be discussed. The series will also examine the current barriers to medication use in treatment while offering potential solutions. Finally, the series will discuss specific instances of how medication can be used in typical alcohol-dependent individuals.

The series begins with an article by Carlo DiClemente, PhD, who discusses recovery from alcohol dependence as a process of behavioral change requiring work between the addicted individual and treatment providers using established psychosocial therapies. DiClemente examines how medications may complement counseling and facilitate that process of change, and he cautions against the potential drawbacks of medication use, especially if used improperly.

Anyone who has treated addictions understands the challenges facing the addicted individual and the treatment provider, due to the sheer number of factors affecting why and how individuals become addicted and manage recovery. Numerous models of addiction have been proposed, including the more integrative bio-psycho-social-spiritual model, whose lengthy name reflects the variety and scope of factors that clinicians must take into consideration during treatment. Genetics, personality, family and social influences, and spirituality can all play a role in the process of recovery. How can we clinicians put these influences into a perspective that allows us to understand how individuals cope with and overcome addiction? The answer is to understand better how patients change their addictive behavior.

Several years ago, Dr. James O. Prochaska and I developed the Transtheoretical Model of Change,1 which characterizes intentional behavioral change as a process consisting of a series of stages through which patients can progress, regress, or recycle and which represent critical tasks that need to be accomplished to achieve sustained change. These stages are precontemplation, contemplation, preparation, action, maintenance, and relapse.

Precontemplation describes an individual's state in which there is little or no thought or interest in changing a behavior. For example, many alcohol-dependent individuals begin here, having no desire to stop drinking. In contemplation, the risks and benefits of change are assessed by the individual as part of decision making. At the preparation stage, an individual gets ready to change and tests the waters, gathering enough commitment to implement the action plan until the act of practicing the new behavior is taken. Maintenance is the stage where individuals stay committed to the behavioral change and integrate it into a new lifestyle. For many, however, action and maintenance are difficult, and relapse, which describes a return to the old behavior, may occur.

These stages of change can help clinicians better understand where a patient is and what they need to do in the process of recovery from addiction.2 Each stage presents unique challenges to treatment, and some of our treatment techniques are better suited for helping patients in one stage than in another. But if we consider all the various bio-psycho-social-spiritual elements that are part of the addiction in the context of these different stages, we have a better chance of helping patients to move from motivation to executing a behavior change—and sustaining that change.

Tools for change

Since the conceptualization of the stages, a number of new tools have been developed to assist clinicians in promoting movement through the stages of change for alcohol-dependent patients. New psychosocial therapies, such as motivational interviewing, have been developed. And, in addition to disulfiram, we now have three other medications approved by the FDA to treat alcohol dependence: oral naltrexone, acamprosate, and extended-release naltrexone (an intramuscular injectable formulation given once a month). However, these approaches and medications are not yet part of some clinicians’ practice, perhaps because of their comparative newness or possibly because medication use for alcohol dependence treatment is not consistent with some clinicians’ treatment philosophies.