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Commentaries

Naltrexone Reduces Heavy Drinking in Problem Drinkers Across the Spectrum of Dependence

See Article by O’Malley et al.

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Naltrexone Reduces Heavy Drinking in Problem Drinkers Across the Spectrum of Dependence

Drinking lies on a continuum like hypertension. One’s drinking habits and consequences can range from risky to hazardous to physically dependent at the extreme end of the spectrum. Heavy drinking is defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as 5 or more standard drinks for men or 4 or more drinks for women within 2 hours on 1 occasion.1 So how prevalent is heavy drinking? Currently, 43% of men and 29% of adult women have drunk heavily at least once in the last 12 months.2

Similarly, health-related problems associated with drinking can range from mild to severe, with corresponding health care costs. Taken as a whole, heavy drinking causes significant negative consequences both to patients and to society in the form of health care costs.

One often overlooked aspect of this picture is that there are 4 times as many heavy drinkers who are not dependent as there are dependent drinkers.3 And the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that while the prevalence of dependent drinkers decreased over a 10-year period, the prevalence of heavy drinkers who were not dependent increased during that same period (Figure 1).4

Figure 1

Click figure to enlarge

Nondependent drinkers do not come to the attention of health care providers unless there are screening and interventions for them in place in primary care settings. And these drinkers usually do not go to abstinence-oriented treatment programs unless they are compelled to by the judicial system. Consequently, they are an underserved patient population associated with significant and growing health care costs.

Interventions for Less-Dependent Heavy Drinkers

While empirically supported interventions (eg, brief motivational interventions) and moderate drinking programs (eg, www.moderatedrinking.com) are effective interventions for less-dependent drinkers, barriers to their widespread utilization persist. For example, traditional alcohol treatment programs in the United States typically treat drinkers at the most severe end of the dependence spectrum. And for these more-dependent patients, abstinence is usually prescribed and the most appropriate goal of change. Less-dependent heavy drinkers, on the other hand, will usually choose a goal of moderation when they decide to change. And moderation is an achievable goal for less-dependent drinkers.2 This mismatch in goals results in less-dependent drinkers not receiving the help they could use to reduce their heavy drinking.

It is in this context that O’ Malley and colleagues’ article5 is most welcome. Their article is the first randomized clinical trial to demonstrate what many of us who work with less-dependent heavy drinkers have suspected for years now: naltrexone can help nondependent heavy drinkers moderate their consumption.

From the very beginning of naltrexone trials, the primary outcome with dependent drinkers has been a reduction in heavy drinking. And this has been a consistent finding in the randomized clinical trials of naltrexone. And now O’ Malley and colleagues5 have demonstrated naltrexone’s effectiveness in reducing heavy drinking in young adults, many of whom did not meet alcohol dependence criteria. And while the differences are modest, I suspect that is, in large part, because the study control group received 3 interventions known to reduce heavy drinking in young adults: a brief motivational intervention, medication management that included harm reduction-oriented discussions during follow-up sessions every other week, and extensive assessment at baseline, daily during the trial, and at 4- and 8-week follow-ups. That combined intervention for the control group makes the significant differences between the naltrexone group and the placebo group even that much more clinically meaningful.

Clinical Implications

Clearly the outcomes of this study support the use of naltrexone for heavy drinking in young adults. But they go beyond that. These data provide support for physicians who could offer it to their patients who engage in heavy drinking, regardless of where their drinking lies on the spectrum of dependence. The more options we have to address heavy drinking in nondependent populations, the more likely we are to have a positive impact on not only these patients but also public health.

Author affiliations: Behavior Therapy Associates, LLC, Albuquerque, New Mexico.

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. National Institute on Alcohol Abuse and Alcoholism. Rethinking drinking: alcohol and your health. http://www.rethinkingdrinking.niaaa.nih.gov/isyourdrinkingpatternrisky/
whatsatriskorheavydrinking.asp
. Accessed December 15, 2014.

2. Hester RK, Delaney HD, Campbell W. Moderatedrinking.com and Moderation Management: 12-month outcomes of a randomized clinical trial. J Consult Clin Psychol. 2011;79(2):215-224. PubMed doi:10.1037/a0022487

3. Esser MB, Hedden SL, Kanny D, et al. Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009-2011. Prev Chronic Dis. 2014;11:140329.

4. National Institute on Alcohol Abuse and Alcoholism. Alcohol abuse increases, dependence declines across decade, 2004. http://www.niaaa.nih.gov/news-events/news-releases/alcohol-abuse-increases-dependence-declines-across-decade-young-adult. Accessed September 11, 2013.

5. O’ Malley SS, Corbin WR, Leeman RF, et al. Reduction of alcohol drinking in young adults by naltrexone: a double-blind, placebo-controlled, randomized clinical trial of efficacy and safety. J Clin Psychiatry. 2015;76(2):e207-e213.

Submitted: July 9, 2014; accepted July 9, 2014.

Corresponding author: Reid K. Hester, PhD, Behavior Therapy Associates, LLC, 9426 Indian School Rd NE Ste 1, Albuquerque, NM 87112 (reidkhester@gmail.com).

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