Diagnosing the degree of a patient’s alcohol use disorder (AUD), as well as identifying the best treatment options, is difficult with today’s generalized diagnostic and treatment tools. A new model for examining an individual’s symptoms and behaviors throughout the addiction cycle might provide the field with additional data that could lead to more targeted treatments.
In a paper published in Biological Psychiatry on the Addictions Neuroclinical Assessment (ANA), National Institute on Alcohol Abuse and Alcoholism (NIAAA) Clinical Director David Goldman, MD, clinical research psychologist Laura Kwako, PhD, and other researchers outline which assessments could be used to gain a deeper understanding of how an individual progresses through the addiction cycle, why that person's progression varies from someone else’s, and at what points treatment might be most viable.
AUD manifests differently in different individuals, with drinking patterns, motivations, symptoms and other factors contributing to the variation. An example presented in the report is an individual who might have trouble controlling drinking because of stress, while another might drink because he/she doesn’t gain pleasure from things that are rewarding for others.
The ANA uses knowledge about addiction more precisely, examining individuals beyond the “yes” and “no” questions currently used in addiction diagnosis.
The standard for diagnosing alcohol abuse disorders in adults is the DSM-5, through which a diagnosis is formulated based on observable signs and symptoms. The current method does account for some variations in severity, but Kwako says AUD diagnosis remains heterogeneous.
“While still a ways off, if the ANA can help us tease apart the heterogeneity inherent in addictive disorders, that understanding would be very useful for clinicians in better targeting their treatment efforts,” Kwako tells Addiction Professional. “Many, if not most, clinicians individualize their treatment to a given patient as part of clinical practice, but the ANA could potentially help ground this personalization in empirical data.”
Stages of addiction
The ANA model is organized around the three stages of alcohol addiction: the binge/intoxication stage where there is a loss of control over intake, the withdrawal/negative effect stage where the individual experiences a negative emotional state in the absence of alcohol, and the preoccupation/anticipation stage as the compulsion to seek out and consume more alcohol takes over.
The model assesses the neurobiological features of each stage using a variety of tests including genetic testing, imaging, and behavioral assessments, according to the NIAAA's report. The results could be used to help identify more clinically relevant treatment and prevention measures that are tailored to the individual patient.
Similar strategies are used in treating other diseases. Precision medicine—the practice of preventing and treating disease based on individual variability—also identifies which patient might be most likely to respond to various treatments. According to the report, researchers are looking into whether patterns in brain activity can be used to predict which types of people are most likely to relapse when exposed to certain stimuli, and which treatments are most effective in individuals with certain gene variants.
Neurobiological and genetic variations may play a role in why behavioral and medication-based treatments for AUD don’t work the same for all patients who seek treatment. Kwako and Goldman believe a deeper understanding of how addiction affects individuals differently may help develop more targeted treatments.
Kwako cautions that the ANA is less of a clinical tool at this point and more of a research framework.
“We are using a set of measures, including self-report and behavioral tasks, along with neuroimaging and genetics, to explore function in domains related to addiction,” she says. “We will be able to collect a lot of data about individuals who might be considered to be addicted to alcohol, and those not addicted, to examine how those groups differ.”
Although formal research on the ANA as a clinical tool has not started yet, Kwako hopes work will start soon.
“In addition, providing continuing clinical education around the ANA domains and the neuroscience of addiction may provide clinicians with additional strategies for working with patients and may help psychiatrists target pharmacotherapy more precisely,” she says.