Conference Report Highlights of the 17th Annual Meeting of the American Academy of Addiction Psychiatry
Performance Monitoring for Addiction Psychiatrists
The American Academy of Addiction Psychiatry (AAAP), an organization founded in 1985 to promote research, education, and improved clinical practice in addiction psychiatry, convened its 17th Annual Meeting in St. Petersburg, Florida, on December 7-10, 2006. Among a number of topics of interest to addiction professionals was the issue of optimizing pharmacotherapy for alcohol dependence, which was explored in several presentations.
On Friday, December 8, Mark Willenbring, MD,[1] of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Bethesda, Maryland, presented a draft of a self-audit instrument developed by the AAAP Evidence-based Practice Committee that is designed to help members assess their own medical practices. The first audit tool to be developed by the Committee, this instrument was designed to monitor performance in providing pharmacotherapy for alcohol dependence, as such treatment was considered to be a core area of addiction psychiatry supported by a substantial evidence base for the use of US Food and Drug Administration-approved medications. As yet unnamed, the instrument is expected to take approximately 10 minutes to use, and is recommended for a sample of 10-20 charts per physician per year. It will be available both in paper form and on the AAAP Web site, as will a site for each physician to input his or her own anonymous results for the formation of a database providing normative data from all physicians who use the audit. Though initially planned for AAAP members, the audit instrument may be made available to the American Society for Addiction Medicine and the APA Council on Addiction Psychiatry in the future.
Initial experiences with the self-audit instrument in both the academic medical center and private practice settings were presented. Daniel Hall-Flavin, MD,[2] of the Mayo Clinic Department of Psychiatry, Rochester, Minnesota, discussed the results of a retrospective chart review of acamprosate treatment using the instrument in both residential and intensive outpatient programs. A surprising initial finding of this review was the low rate of prescribing of the medication (15%), even among patients considered appropriate candidates. Over the 18-month course of developing the database using the audit instrument, however, Dr. Hall-Flavin noted that the rate of prescribing more than doubled, to 37%. This experience was echoed by Syed Pirzada Sattar, MD,[3] who reported the results of his application of the audit instrument to monitor his private practice. With increased practice in using the instrument, he found that the time to complete the audit fell to approximately 4 minutes per chart, and that documentation of treatment rationale and potential risks and side effects improved considerably. Perhaps of greatest importance, the rate of certain medication prescriptions for alcohol dependence increased.
According to the panel discussants, pharmacotherapy for alcohol dependence continues to be grossly underutilized for a variety of reasons, including therapeutic nihilism, patient resistance, or lack of access to physicians experienced in providing the treatment. As described by Drs. Hall-Flavin and Sattar, however, even addiction psychiatrists may underuse these treatments or use them inconsistently. Interventions that improve a clinician's awareness of his or her own prescription patterns thus have the potential to enhance patient care significantly. The self-audit instrument developed by the AAAP Evidence-based Practice Committee appears to be feasible in diverse settings and is likely to optimize pharmacotherapy for alcoholism, both in terms of standardization of treatments and improved prescription rates. According to Dr. Willenbring, the Evidence-based Practice Committee plans to identify additional areas for performance monitoring annually.
Empirical Research on 12-Step Programs
Several well-known researchers participated in Symposium III, "Twelve Step Programs: Empirical Research and Potential Clinical Applications," organized collaboratively with support from the NIAAA and the National Institute on Drug Abuse (NIDA) and chaired by Dr. Marc Galanter of New York University School of Medicine.
Dr. Willenbring[4] of the NIAAA began the symposium with an introduction that emphasized the demonstrated success of 12-step programs and the importance of understanding how these programs are successful. He noted that more people recover from alcoholism outside of medical treatment than in treatment. In a study based on the 1992 National Longitudinal Alcohol Epidemiologic Survey, 87.3% of respondents with an alcohol use disorder never perceived an unmet need for treatment.[5] Yet participation in Alcoholics Anonymous (AA) is widespread, and multiple studies have reported a strong correlation between participation in AA and abstinence from alcohol.[6-8] Although AA and other 12-step programs have existed for decades, they have received little systematic study until relatively recently. As an attempt to understand the social context of addiction recovery, the NIAAA has introduced the Mechanisms of Behavioral Change initiative, designed to study systems from "the genome to the sociome," according to Dr. Willenbring. [See http://grants.nih.gov/grants/guide/rfa-files/RFA-AA-07-005.html for the relevant Funding Opportunity Announcement from the National Institutes of Health.]
Scott Tonigan, PhD,[9] of the University of New Mexico, Albuquerque, described the recent expansion of empirical research on processes of 12-step programs following the completion of Project MATCH,[10] the multicenter trial of different psychotherapies in alcoholics with distinct patient characteristics, almost 10 years ago. According to Dr. Tonigan, this work demonstrated that 12-step facilitation therapy, a manual-guided psychotherapy designed to familiarize patients with AA philosophy and encourage AA participation, was more effective than either cognitive behavioral therapy or motivational enhancement therapy in promoting abstinence from alcohol regardless of the clinical subtype of the patient. As presented by Dr. Tonigan, 24% of outpatients who received 12-step facilitation therapy were abstinent from alcohol, compared with 15% of those who received cognitive behavioral therapy and 14% of those who received motivational enhancement therapy at 1 year following treatment.[9] Elucidating the mechanisms that contributed to the increased abstinence in the 12-step facilitation group has been the subject of much subsequent work since the completion of Project MATCH.
Dr. Tonigan and colleagues have studied at least 3 hypothesized mechanisms by which 12-step facilitation may have increased abstinence rates in Project MATCH: (1) increased attendance and involvement in AA, (2) insistence on complete abstinence, and (3) emphasis on spirituality in 12-step program philosophy.[9,11-13] According to Dr. Tonigan, research to date has found that only one of these mechanisms, namely increased involvement in AA, was predictive of higher rates of abstinence from alcohol at 1 year after treatment.[9] Though AA attendance increased in all 3 treatment arms of Project MATCH, attendance in AA was highest in the 12-step facilitation group. Involvement and engagement in AA ( sponsoring, helping other AA members) was highest . in this group[9] and was associated with lower likelihood of relapse, independent of the number of AA meetings attended.[13] Consonant with this finding, follow-up analyses of Project MATCH participants have demonstrated that 10-year abstinence rates are predicted by current, but not prior, AA attendance, according to Dr. Tonigan.[9]
Other hypothesized mechanisms of behavioral change in 12-step programs have not received empirical support. Initial adherence to complete abstinence, a key feature of 12-step facilitation therapy, has predicted delayed relapse to both the first drink and to heavy drinking, but not abstinence, at 1 year posttreatment, according to Dr. Tonigan.[9] Emphasis on spirituality in 12-step programs, although suggested by some cross-sectional studies to be associated with improved drinking outcomes, does not predict long-term abstinence in prospective longitudinal analyses of Project MATCH participants.[12] This result is in agreement with data presented later in the symposium by Jon Morgenstern, PhD,[14] of Columbia University, New York City, who summarized research including but not limited to Project MATCH. While affiliation with AA was correlated with positive drinking outcomes in multiple studies, adherence to the emphasis on spirituality in 12-step programs was not predictive of long-term abstinence rates in the literature as a whole. The panel discussants noted, however, that because spirituality may serve as a shared ideology that can maintain affiliation with AA, it is important to recognize the spiritual orientation of any individual patient when encouraging AA participation.
Relevance of Craving Concepts to the Treatment of Alcoholism
In the last session of the meeting devoted to treatments for alcohol dependence, Larissa Loukianova, MD, PhD, and Dr. Hall-Flavin, both of the Mayo Clinic, presented Workshop C-5, "Understanding Craving: Toward Identification of Treatment Targets in Alcoholism."
Dr. Loukianova[15] began the workshop with a comprehensive review of the neurobiology of craving, from the level of cellular events within a single neuron to complex cortical-subcortical circuits in the normal and alcohol-dependent mammalian brain. She noted that although alcoholism is a complex heterogeneous phenotype that is unlikely to respond to a single treatment, a pathologically high motivation to use alcohol is common among all alcoholics. Recent advances in the neuroscience of reward and motivation present multiple potential therapeutic strategies.
Though difficult to operationalize, craving may be defined as the conscious experience of the desire to use alcohol or other drugs of abuse. The frequent experience of craving as a conflict between conscious resistance to using a substance and the loss of conscious control over drug-seeking behavior has suggested the involvement of neural circuits that include both cortical and subcortical brain regions. Data from addiction studies in animals have implicated dopamine, gamma-aminobutyric acid, and glutamate neurotransmission of the mesocorticolimbic and corticostriatal pathways in assigning incentive motivational salience to previously neutral cues, a process thought to be common to self-administration of virtually all abused substances.[16] This literature contrasts with earlier, more simplistic concepts of dopamine as the "pleasure chemical" released in the nucleus accumbens (ventral striatum) by all drugs of abuse. Instead, more recent investigations have demonstrated a role for specific frontal-subcortical circuits known to be important in motivation, executive function, and impulse control. Our understanding of these circuits in humans is informed by studies of naturally occurring and traumatic lesions and, more recently, by the results of neuroimaging research.[17]
Dr. Loukianova reviewed neuroimaging evidence for involvement of 3 cortical regions and their connections to limbic structures in cue-induced cravings for alcohol and other drugs of abuse. These regions include the anterior cingulate cortex, the orbitofrontal cortex, and the dorsolateral prefrontal cortex. The anterior cingulate may be subdivided into ventral and dorsal regions, associated with affective and cognitive components of motivational salience, respectively. Similarly, lateral and medial subdivisions of the orbitofrontal cortex appear to mediate social and object recognition aspects of motivation. Both of these cortical regions are active in response to incentive-salient events and are influenced by the predictability of a reward such as alcohol or other addictive drugs.[16,17] Consistent evidence from human neuroimaging studies suggests that both the anterior cingulate and orbitofrontal cortex show reduced activity in the drug-free state in human addicts, but are hyperactive in response to alcohol- or other drug-related cues in a manner that correlates with the intensity of subjective craving in addicted human volunteers.[16-18] The dorsolateral prefrontal cortex, which is associated with executive function, also appears to be dysregulated in human addicts, which may contribute to alcohol- or drug-dependent individuals' inability to resist compulsive drug-seeking in the face of serious adverse consequences. Though still on the horizon, each of these pathways may offer targets for addiction pharmacotherapy as our understanding of their complex neurocircuitry and their roles in drug and alcohol craving unfold.
Finally, Dr. Hall-Flavin discussed current concepts of subtypes of craving and their relevance to existing anticraving therapeutic strategies.[19] In the case of alcoholism, the speaker distinguished reinforcement craving from withdrawal craving despite the absence of good instruments for differentiating these in the clinical population. Reinforcement craving was defined as the subjective experience of increased alcohol-seeking immediately following exposure to alcohol, and may be reduced by currently approved medications such as oral or depot naltrexone.[19-21] Opioid antagonists may thus prevent progression or relapse by reducing the acute reinforcing properties of alcohol after an initial re-exposure. By contrast, withdrawal craving is the subjective experience of increased alcohol-seeking after some period of abstinence from the drug, ostensibly related to the desire to relieve the aversive properties of withdrawal. This phenomenon may be reduced by acamprosate.[20,22-24]
A key question that remains is: Can we predict whether certain patients will respond preferentially to one of these treatment strategies? Dr. Hall-Flavin hypothesized that patients early in the course of alcoholism may be best treated with medications aimed at reinforcement craving, whereas those in later stages of the illness may respond better to medications that reduce withdrawal craving. However, there is currently little empirical evidence to support this hypothesis, he said. Additional considerations that remain unresolved at this time are whether alcoholic subtype, genetic constitution, or psychiatric comorbidities may influence responsiveness to different classes of anticraving medications.
