When illnesses are defined by symptoms, the chances are high that several very different diseases will be packaged into a single group. To an extent, that depends on how disease is defined in the first place. Headache, for example, is a symptom that might result from underlying hypertension or from a physical blow to the head, among other potential causes. Both headaches might have the same subjective feel, and yet the treatment approaches necessary would be quite different once the cause has been established.

Addictive diseases can be viewed as a group based upon the addictive symptoms observed. Some obvious differences set a few of the major subcategories apart from one another. Opioid dependence, for example, responds well to a harm reduction approach, and patients with this illness often have drug craving even after significant time has passed since their last use. Sedative dependence responds to an abstinence-based approach, and craving is present only rarely. In both instances, the presence of the disease is independent of the quantity or frequency of substance use. The diseases can be identified by the way the patient uses, by the degree to which they use control — people without the disease don’t control their use while people with the disease do — and by some clear factors, in the initial history.

The literature has been filled recently with articles that are based upon clear misunderstandings of sedative dependence and its differences from addictive disease in general. These articles often discuss new medications, and indeed, several medications have recently gained indication for use in alcohol dependence. These new medications might be helpful in the treatment of alcoholism, but they have yet to be shown to have such value.

Let’s go back to headache for a moment: imagine we are treating a group of people with headache caused by underlying hypertension. I successfully demonstrate that these people feel substantially better after being given aspirin. I then conclude that aspirin is an excellent treatment for headache. Several logical errors have been made. First, I concluded something about treatment for headache even though I was studying only a subset of that group: those with headache caused by hypertension. Second, I concluded that aspirin works well for headache because there was subjective improvement in the symptom; long-term morbidity and mortality is unchanged, however, since my treatment does nothing for the real illness. The only improvement is that these patients will temporarily be symptom-free while awaiting the arrival of real problems.

Understanding the disease
If I want to say something about alcohol dependence, I must first demonstrate an understanding of the disease. A conclusion that revolves around the frequency of alcohol intake or quantity of alcohol imbibed indicates a failure to look in the right place, since neither parameter is germane to the existence of the disease or to the degree of disease severity. A drug that successfully results in a decrease in alcohol use for a short period of time might have several long term results:

a) The patient uses less alcohol briefly, then returns to his original quantity of use.
b) The patient uses less alcohol for a time, then eventually discontinues use.
c) The patient uses less alcohol for an extended period of time.

The percent of patients in group (b) may be lower with use of the drug than would be ultimately in that group without the drug — possibly, as a result of being told that they are likely to improve as a result of a medication, something quite dangerous to tell this patient population without a drug that really works. And of course, what is important here — given the lifelong nature of this illness — is the long range outcome.

If I want to say something about alcohol dependence, I must also demonstrate applicability of my treatment to those with alcoholism, not to those with some subset of the disease. It cannot be just those wanting treatment, or just those drinking a certain quantity, or just those who have had several past failed efforts at discontinuing substance use.

And finally, if I want to say something about any disease treatment, I must use the best available contemporary treatment as a comparison group. Diabetics have better results as measured by their hemoglobin A1C’s when treated by specialists than when treated by primary care clinicians. The current studies have not used as a comparison group patients treated by addiction specialist physicians. Such care has been demonstrated as having an excellent long-term outcome, but unless it is incorporated into a contemporary study as part of the research, it is not possible to tell whether the treatment under study is truly of value.

I’ve left my usual area of focus this month because of the great likelihood that you’ll be hearing more about naltrexone, acamprosate, and other medications in coming months either from professional colleagues or from the media. These medications eventually may be demonstrated as useful. For now, the studies have failed entirely to demonstrate significant value for the treatment of alcohol dependence; they have also failed to investigate the potential harm that could be shown only with several years of following the study population. The best move at this point is to wait, watch, and to ensure that you read the applicable literature closely. Don’t trust the general media, the review articles, or the meta-analyses. Look only at the original article — if you determine that it has not suffered from one of the errors I’ve described here, then maybe we will have a finding that we can use in our day-to-day practices.

What have your experiences been with use of new medications in the treatment of sedative dependence? Have you anecdotally found them useful, and if so, in what way? Let me know and we’ll revisit this topic in a few months.

Dr. Gitlow is on the Board of the American Society of Addiction Medicine and serves as Chair of the American Medical Association’s Task Force on Alcohol. His textbook, Substance Use Disorders: A Practical Guide, will have its second edition released any day now from Lippincott Williams & Wilkins.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2006, v.7, n.4, pp.44-45.

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