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Doctor's office may be next rehab site

December 24, 2007|Melissa Healy | Times Staff Writer

British songstress Amy Winehouse, who croons "no, no, no" to rehab, has a lot of American company this time of year -- both in her heavy-drinking ways and her unwillingness to spend weeks in a specialized facility to get sober.

But experts say there may be new hope for rehab refuseniks like Winehouse and an estimated 5.7 million alcoholics in the United States who are not in treatment -- hope that could be as close as the family doctor.

New research and a growing arsenal of medications have set the stage for a major shift in the treatment of alcoholism, from specialized clinic to the "primary care office setting," the Journal of the American Medical Assn. reported in its Dec. 5 issue.

But if the promise of "office-based" treatment of alcoholism is to become a reality, the nation's 337,000 general-practice physicians -- and the systems within which they work -- will have to undergo some transformation themselves, addiction experts say.

Doctors must overcome their reluctance to broach the subject of drinking and learn how best to intervene when they suspect alcoholism. Medical practices may need to add staff to help counsel recovering patients. And insurance companies and federal insurance programs will need to be persuaded to reimburse patients for medication that can be costly and to pay physicians for taking on a new role in patients' care.

Several new drugs are making office-based treatment a realistic prospect. In April 2006, a monthly injectable form of the drug naltrexone won approval from the Food and Drug Administration. Marketed as Vivitrol, the new formulation of a long-available drug can be started after only four days of abstinence and appears to cause less nausea than pills taken daily -- features that make it easier for patients to start and stay on the treatment. It joined two other medications approved to curb alcohol cravings.

Evidence is growing for the effectiveness of these and other addiction medications, such as the anti-convulsive drug topiramate, which, although not FDA-approved for this purpose, is also widely prescribed off-label to help alcoholics stay away from drink. And more FDA approvals for drugs that treat alcohol dependence are on the horizon.

At the same time, studies published this year underscored the effect that a few frank words from the doctor can have on patients whose drinking appears to have become excessive.

These developments could be the "tipping point" into a new era of alcohol treatment, says Mark Willenbring, director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism. With new confidence in their powers of persuasion and new pharmaceutical tools in their black bags, primary care physicians -- who have been notoriously shy of confronting patients about their drinking habits -- may grow more willing to flag an alcohol problem, offer medication and dispense advice during routine office visits, Willenbring says.

In turn, as patients grow more confident that they can curb their drinking without the time, expense and stigma of a stay in a clinic, more will likely step forward for help.

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Parallel with depression

"In many ways, we are with alcoholism where we were with depression 30 years ago," Willenbring says. As a new generation of antidepressants came to market in the early 1980s, physicians on the front lines of patient care grew more attentive to the signs of depression and more willing to treat it. Patients with protracted bouts of blue mood turned to their family doctors for help in increasing numbers.

In the process, depression was transformed from a highly stigmatized mental illness that was rarely treated before a suicide attempt or outside a psychiatric hospital to a condition for which 80% of patients turn first to a general medical practitioner.

A similar shift in the treatment of alcohol-related disorders won't happen overnight, Willenbring says. But with 19.5 million Americans thought to have alcohol-related disorders in 2006, and only 1.6 million getting specialized treatment, he says, "we have to start thinking creatively about how to provide more accessible, appealing and creative options" to encourage patients with drinking problems to get the help they need before they hit the skids.

Experts warn, however, that as general-care physicians armed with medications shoulder a greater role in treating alcohol dependence, patients and public officials must ensure that the sickest patients do not suffer in a rush to treat alcoholism more economically.

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