Back From the Drink

Volpicelli thinks that naltrexone may prove far more valuable than disulfiram, a 40-year-old drug well known as Antabuse. Disulfiram interferes with alcohol metabolism, so that takers suffer nausea, cramps, headaches, and vomiting when they drink. In practice, though, the drinker stops taking it, because the physiological effects often build to such a crescendo -- including violent heartbeats and hot flushes -- that impending death is feared.

Buspirone (BuSpar), an antianxiety agent, may help alcoholics by minimizing the effects of withdrawal. Many doctors traditionally give benzodiazepine drugs, such as Valium, to dampen withdrawal symptoms -- but those drugs can be addictive and may further blunt the memory of heavy drinkers. Buspirone may be a safer alternative. Other drugs that have shown promise include cipramine, which helps alcoholics who are also suffering from major depression, and deispramine, another antidepressant that seems to reduce drinking.

The new view of alcoholism is of a complex condition arising from the intricate and unpredictable interplay of social, biological, and psychological factors. "Alcoholism is not a disorder caused uniquely by genes," explains Mark Schuckit, M.D., of the Veteran's Administration Medical Center in La Jolla, California. "Some persons become alcoholic solely through environmental exposure; others have biological and psychological predispositions. There are many different paths to alcoholism. Once a person drinks regularly, however, the body's reaction to and tolerance of alcohol changes, so that the person needs more alcohol. Patients need to be educated about the many factors that contribute to the disorder, so they can understand that the situation is not hopeless."

Studies show that the type of therapy an alcoholic receives isn't as important as the fact that he or she gets some treatment.

"There are very few harmful or useless treatment programs for substance use disorders," says Schuckit. "If you are highly motivated, then you are likely to do well in almost any program you choose."

The programs most alcoholics choose are based on the Minnesota Model, which views alcoholism as an incurable disease. It involves group counseling to confront a "denying" drunk, education about alcohol's consequences, and confessional self-help organizations like the AA.

There are already cracks in the Minnesota Model's clinical monopoly. Although the personal experiences of thousands of alcoholics attest to the model's value, its failure rate -- about 50 percent -- reveals the futility of assembly-line treatment. Indeed, aversion therapy, stress-management, and family therapy are proving effective for many alcoholics.

Take the fact that an alcoholic's memory may be impaired -- leading to treatment problems that have little to do with the so-called ubiquitous "denial" syndrome. "Ten years ago, if an alcoholic didn't seem to be catching on to treatment, it was assumed that he or she was 'in denial'," says Tim Sheehan, R.N., Ph.D., of Minnesota's Hazelden Foundation, arguably the archerypal inpatient treatment center. "Now we're recognizing that there may be lingering cognitive deficits." During treatment, these patients are exposed to fewer concepts, which are reinforced often.

Three new approaches -- all of them "heretical" by the traditional abstinence model -- eschew ideology and spiritual baggage in favor of simple pragmatism. Some alcoholics do quite well with them. They are:

o Harm reduction, which recognizes that moderate drinking is preferable to lost weekends. Any decrease in alcohol intake is grounds for a (alcohol-free) toast.

o Brief intervention. In as little as half an hour, an intervention attempts to show the subject how drinking may be impairing everything from his liver to his livelihood; helps him rate himself on a series of questions about his life and drinking; and then places him on a continuum with his drinking peers so that he has a sense of the nature of his problem. In addition, brief sessions help the person focus on motivations for reducing drinking. Brief intervention, lasting four sessions at most, can be as effective as more intensive treatments for many individuals, says Donovan.

o Cue exposure, or systematically exposing and desensitizing the alcoholic to cues that might trigger drinking. According to Liljegren, "traditional treatment says it's heresy to expose the drinker, it will just increase his craving. In fact, the opposite seems true; the data suggest cue exposure is the very thing we should be doing."