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Advances in Clinical Care for Patients with Alcohol Dependence
Satellite Television Broadcast, Webcast, Telephone Simulcast
Premiere Date:
Wednesday, February 13, 2008
Live Broadcast:
12:00-1:00 p.m. ET
"After the Show" live Q&A webcast: 1:02 p.m. ET
Taped Re-Air:
3:00-4:00 p.m. ET
MODERATOR
Robert R. Conley, MD |
FACULTY
Michael W. Carlton, MD |
Christopher W. Shea, MA, CRAT, CAC-AD |
Register Now! 
Atypicals in Practice: Case Studies on Dosing
Satellite Television Broadcast, Webcast, Telephone Simulcast
Premiere Date:
Wednesday, March 5, 2008
MODERATOR
Charles B. Nemeroff, MD, PhD |
FACULTY
Stephen R. Marder, MD |
Sheldon H. Preskorn, MD |
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neuroscienceCME Journal Club - Featured Article: Shift work and inter-individual differences in sleep and sleepiness
Audioconference + Webcast
Premiere Date:
Monday, March 10, 2008
GUEST
HOST
Thomas Roth, PhD |
FEATURED
AUTHOR
Hans P. A. Van Dongen, PhD |
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SELF-STUDY CME/CE |
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Combating the Consequences of Excessive Sleepiness
Archived Videoconference
Released December 5, 2007
FACULTY
Charles B. Nemeroff, MD, PhD
David F. Dinges, PhD
Thomas Roth, PhD
Participate Order Online
Waking Up to the Problem of OSA: Consequences and Improved Recognition
Archived Audioconference
Released October 16, 2007
FACULTY
Sonia Ancoli-Israel, PhD
Barbara A. Phillips, MD, MSPH, FCCP
Participate Order Online
Practical Management Options for Alcohol Dependence, Part 3 of 3 - Initiating Pharmacotherapy in Patients with Alcohol Dependence
Monograph
Released December 19, 2007
FACULTY
Kyle M. Kampman, MD
Participate Order Online
Expert Discussions on Sleep-Wake Medicine, Part 1 - Recognition, Neurobiology, and Cognitive Impact of Excessive Sleepiness
Podcast
Released December 10, 2007
FACULTY
Charles B. Nemeroff, MD, PhD
Thomas Roth, PhD
Boadie W. Dunlop, MD
David F. Dinges, PhD
Participate
Expert Discussions on Sleep-Wake Medicine, Part 2 - Identifying the Consequences and Improving Outcomes in Patients Exhibiting the Symptom of Excessive Sleepiness
Podcast
Released December 10, 2007
FACULTY
Charles B. Nemeroff, MD, PhD
Leslie P. Lundt, MD
Terri E. Weaver, PhD, FAAN, RN
Mary B. O'Malley, MD, PhD
Participate
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SPECIAL SUPPLEMENT FOR ADDICTION COUNSELORS
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CME Outfitters, LLC, developed a series of meetings held around the country to discuss the challenges facing healthcare practitioners in the management of alcohol dependence. The meetings provided addiction treatment professionals with the latest evidence in research and treatment options and how to incorporate these findings into individualized treatment plans for patients with alcohol dependence. Physicians, nurses, pharmacists, addiction counselors, case managers, and CEOs of treatment centers had an opportunity to meet and collaborate on bringing the best research, process, and treatment into everyday practice. You can log in to www.neuroscienceCME.com/cmea.asp?ID=290 and see an online archive of the meeting in Philadelphia with Kyle Kampman, MD, Associate Professor of Psychiatry, University of Pennsylvania Treatment Research Center, and Gail Kaempf, MSN, CRNP, Nursing Services Supervisor, University of Pennsylvania Treatment Research Center.
At the end of the presentation, participants had an opportunity to ask the faculty questions about management strategies for patients with alcohol dependence. The emphasis on the neurobiological foundation of alcohol dependence was helpful for most attendees, and stimulated a good deal of discussion. As mentioned in Part 3 of the Clinical Navigator series, Initiating Pharmacotherapy in Patients with Alcohol Dependence, there is reciprocal feedback between the cortical and limbic structures. Overall, the cortex is active in decision-making and responsive to counseling; whereas the limbic region is active in the reward pathway and responsive to pharmacotherapy.(1,2) A two-pronged approach to alcohol-dependence treatment is essential. Understanding the neurobiology of alcohol dependence points to the need for management strategies that combine pharmacotherapy and evidence-based psychosocial interventions.
Christopher Shea, MA, CRAT, CAC-AD, Clinical Director at Fr. Martin's Ashley in Havre de Grace, MD, was careful to point out that using medication as therapy for alcohol dependence does not diminish the crucial role of counselors in the recovery process. Counselors are the mainstay of the treatment program and can reach out to prescribing physicians as needed. Pharmacotherapy can help diminish the effects of alcohol or the craving for alcohol, that in turn allows the patient to focus on changing behavior through counseling. Combining these two effective treatments can often improve outcomes.
In the meeting presentation, the COMBINE study by Anton and colleagues was used as one example of combination treatment. In a study of 1,383 patients, 74% achieved a good clinical outcome by combining naltrexone and medical management versus 58% for those in the placebo and medical management group.(3)
There were many questions about the results of clinical trials and how they may translate to the practice setting. Patients who voluntarily enter a trial may be more motivated to reach and maintain abstinence or a reduction in drinking than patients in outpatient clinics. In this context, a distinction was drawn between patients who realize they are alcohol dependent and present themselves for treatment, those who were farther along in the process of change(4) and are actively seeking recovery, and those who may have been remanded by the court.
Relapse and how to handle or prevent it was also discussed. Rob Conley, MD, Distinguished Scholar, Eli Lilly and Company, and Adjunct Professor or Psychiatry and Pharmacy Science, University of Maryland, Baltimore, MD, pointed out that relapse or "slipping" is not failure. The case study of the woman who drinks heavily on the weekends (Case 1 in the online archive) is an example of a patient that has a high probability for slips. It is important to have a goal that is truly attainable and to understand what "better" really means. In this case, after many "failed attempts" at treatment, the patient responded to a combination of medical management and pharmacotherapy.
Participants also had specific questions about the medications. One of the most-asked questions was, "Is this lifetime therapy"? Dr. Conley suggests that the length of pharmacotherapy can be based on the Alcoholics Anonymous (AA) model where members receive a coin for a year of abstinence. He sets goals to abstinence saying, "If we get this far, we can discuss discontinuing," and takes one step at a time with each patient.
Other questions asked about pharmacotherapy:
What about homeless and uninsured patients? Is treatment with medication out of their reach? While some of these patients seem to have ready access to psychotropics, medications for alcohol dependence could be cost-prohibitive. One of our presenters, Bernard Gottschalk, MD, Medical Director of the Wilmington Treatment Center in Wilmington, NC, acknowledged the difficulty, but also recommended contacting the pharmaceutical companies to see if assistance programs are available. The Partnership for Prescription Assistance (PPA)(5) program may also be able to help with access.
Can you use these medications in combinations?
Overall, these medications have only mild, transient adverse effects and many patients are on a number of combinations. For example, many patients are treated with the combination of naltrexone and acamprosate.(6)
How do you approach someone with polydrug use?
In general, the most serious problem should be treated first, i.e., if the patient is a heroin user who is liable to overdose, treat that addiction before you treat chronic alcohol abuse.
We encourage you to log in to neuroscienceCME.com and participate in the archived online meeting, Improving the Continuum of Care in Alcohol Dependence: Latest Evidence for Counselors and Clinicians. And we invite you to sign up for our live broadcast on February 13, 2008 at noon (rebroadcast at 3:00 PM ET) for Advances in Clinical Care for Patients with Alcohol Dependence with Michael Carlton, MD, Chief Executive Officer of Phoenix Recovery and Medical Director Community Bridges, Phoenix St. Luke's Chemical Dependence Unit, Phoenix, AZ, and Christopher Shea, MA, CRAT, CAC-AD, Clinical Director at Fr. Martin's Ashley in Havre de Grace, MD, moderated by Rob Conley, MD, Distinguished Scholar, Eli Lilly and Company, and Adjunct Professor or Psychiatry and Pharmacy Science, University of Maryland, Baltimore, MD. See you then!
References
- Dom G, Sabbe B, Hulstijn W, van den Brink W. Substance use disorders and the orbitofrontal cortex: systematic review of behavioural decision-making and neuroimaging studies. Br J Psychiatry 2005;187:209-220.
- Kalivas P, Volkow N. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry 2005;162:1403-1413.
- Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence. The COMBINE Study: a randomized controlled trial. JAMA 2006;295:2003-2017.
- DiClemente CC. Addiction and Change: How Addictions Develop and Addicted People Recover. New York City: The Guilford Press; 2003.
- Partnership for Prescription Access. Available at: https://www.pparx.org/Intro.php. Accessed on January 8, 2008.
- Mason BJ. Rationale for combining acamprosate and naltrexone for treating alcohol dependence. J Stud Alcohol 2005;Jul(suppl):148-156.
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