Published: May 3, 2006
Careful medical attention, combined with psychotherapy or an addiction drug, is the most effective way to help heavy, chronic drinkers reduce their alcohol consumption, researchers are reporting today from the largest-ever trial to compare treatments for alcohol dependence.
In the study, the drinkers who received the best medical attention available reduced the amount they drank by 80 percent, and many controlled their habits for more than a year.
The widely anticipated government study is being published in The Journal of the American Medical Association.
All told, about three-quarters of the nearly 1,400 people in the study were abstinent or drinking moderately after four months of treatment, and more than half of those were still doing well a year later.
Experts said the results were impressive but should be interpreted with caution. The men and women in the study spent far more time with doctors, nurses and other staff members than most people who seek treatment do; such lavish attention itself acts as therapy, they said. And the researchers did not report how many of the participants were entirely abstinent by the end of the trial, an important measure of lasting success for many drinkers.
Fewer than 10 percent of the estimated eight million Americans who are dependent on alcohol ever receive specialized treatments, and fewer than one in 100 are ever offered medication, surveys find.
"This is a beautiful study, in terms of the way it was designed and executed, in that it gives us a good look at how well a variety of treatments work," said Dr. Edward Nunes, a professor of clinical psychiatry at Columbia, who was not involved in the research.
Dr. Nunes added: "What the study shows is that it doesn't seem to matter much what kind of treatment you get, as long as you get an approach with a good rationale. Most people in the study reduced their drinking significantly."
Dr. Raymond Anton of the Medical University of South Carolina led a research team that randomly assigned 1,383 problem drinkers to one of nine treatment groups. Some received the drug naltrexone, with or without regular therapy sessions; others took acamprosate, another popular addiction drug, by itself or with therapy; still others received dummy pills, combined with different therapies. All had regular visits with doctors, nurses and staff members working on the study.
The talk therapy included up to 20 hourlong sessions, in which people learned to recognize the cues that spurred their cravings, like the sight of a familiar bar, and how to diffuse or ignore them. Therapists engaged family members and friends to help, when possible, and used 12-step techniques, when appropriate.
After four months, about three-quarters of those receiving naltrexone, talk therapy or both were abstinent or drinking no more than one or two drinks a day on average, the study found. And these approaches proved more effective than medical management by itself or acamprosate treatment.
In previous studies, acamprosate has roughly doubled people's chances of becoming abstinent, and most addiction doctors consider it a useful therapy. The study's authors said they would conduct further analyses to see whether the drug benefited a subgroup of drinkers in the new study.
Many researchers expected that naltrexone, which blunts the rush of heavy drinking, and acamprosate, which soothes the drumming irritation of withdrawal, would work better together than alone, as previous research had suggested. Yet combining the drugs did not make any difference in the new study.
Taking pills — any pills, whether placebo or prescription — greatly increased people's odds of curbing their habits, the study found. Drinkers who attended talk therapy classes and took placebo pills did significantly better than those who received the same therapy without placebos or drugs.
"The act of taking the pills itself reinforces commitment to abstinence," said Dr. Barbara Mason, of the Scripps Research Institute, a co-author of the study. Dr. Mason said that both drugs were given in high doses with very few adverse effects and that "one of the main findings of the study was that the drugs are safe."
The differences between the groups disappeared in the year after treatment was completed, the researchers found: about 47 percent of the drinkers still had their drinking under control, regardless of which treatment they had received.
"What happens is that, after treatment is over, a certain number of people relapse," Dr. Anton said. "And like many chronic conditions, the farther out you go, the more people relapse."
Extending the length of treatment, in some form, might be the best way to preserve drinkers' early gains, the researchers concluded.