Pharmacotherapy Scant for Alcohol Use Disorders

A discussion of pharmacotherapy treatments for alcohol use disorders drew a standing-room-only crowd to Symposium 2 Friday.

A discussion of pharmacotherapy treatments for alcohol use disorders drew a standing-room-only crowd to Symposium 2 Friday.

Not nearly enough patients needing medication treatment for alcohol use disorders are receiving it. This recurring message emerged in the first presentations of Friday’s Symposium 2, “Update on Medications for Alcohol Dependence and Their Implementation into Practice,” cosponsored by the National Institute on Alcohol Abuse and Alcoholism, and ASAM.

The Veterans Health Administration (VHA) “should be a national model for implementation of medication treatment for alcohol dependence, but we are not. Only a tiny fraction of veterans with alcohol use disorders is being treated—3.4 percent,” says Alexander Harris, Ph.D., Director and Research Coordinator, VA Substance Use Disorder Quality Enhancement Research Initiative, and Associate Director, Program Evaluation and Resource Center, Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, Calif.

The reason the VHA should be the beacon is its policies encouraging medication treatment for alcohol dependence. In fact, the current VHA Handbook states that prescribing staff must be dedicated to providing pharmacotherapy for all patients with alcohol or opioid use disorders in the VA’s 220 specialty addiction treatment programs in the United States.

To discover why VHA addiction treatment programs were not fully using effective pharmacotherapy, Dr. Harris initiated a study on the barriers and facilitators among clinicians, managers, and pharmacists in VA addiction treatment programs. In facilities with low pharmacotherapy adoption, he found either no prescribers available or limited access to prescribers. He also discovered limited staff or time to treat patients, lack of skills or knowledge about medications, pharmacy formulary restrictions, and provider reluctance to prescribe. The reverse was true in high pharmacotherapy adoption treatment programs.

Intervention strategies to promote pharmacotherapy in these facilities included 11/2 days training for addiction, mental health, and behavioral health staff, Dr. Harris says.

“Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the system, practice, and individual patients,” he says. “Multifaceted efforts directed through all three of these levels may be needed to speed pharmacotherapy.”

Substance abuse disorder treatment providers across the board in the United States “have been slow to adopt medications for treatment of alcohol use disorders (AUD), resulting in a research-to-practice gap,” says Amanda J. Abraham, Assistant Research Scientist and Assistant Director, National Treatment Center Study, University of Georgia, Athens, Ga. She reported on a study to examine the availability of medications for alcohol use disorders—disulfiram, tablet naltrexone, acamprosate, and injectable naltrexone.

Of the 293 study participants, few centers adopted AUD medications—only 12.3 percent adopted disulfiram, 18 percent adopted acamprosate, 13.7 percent adopted tablet naltrexone, and 7.2 percent adopted injectable naltrexone.

“Only 25 percent of programs prescribe any single AUD medication, and only 28 percent of programs have physicians on staff to accommodate prescribing these medications,” she says. “Of 175 programs with a physician on staff or on contract, 65 percent did not prescribe any AUD medications.”

In addressing the efficacy of pharmacotherapy to treat AUD, Bankole A. Johnson, D.Sc., M.D., Alumni Professor and Chairman, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, says, “It really is not enough just to provide psychotherapy. Relapse rates are lower when psychotherapy is combined with pharmacotherapy. The goal is to find the right medicine for the right patient at the right time and for the right length of time.”

He recommends improving the efficacy of medications by improving existing methodology of alcohol clinical trials, developing promising medication targets and approaches, validating screening models with animal and human lab paradigms, and advancing personalized medicine.

“There are many genetic variants that allow us to personalize medicine,” Dr. Johnson says. “Alcoholism is a 60 percent heritable disorder. The genetic pathway is so very important. This is going to be developed in a way to look at genome-wide studies by which we can define responders and non-responders. We are going to use mapping models to understand who we can identify and target for future treatment.”