Treating Alcohol Use Disorders

“For a long time, when it’s working, the drink feels like a path to a kind of self-enlightenment, something that turns us into the person we wish to be, or the person we think we are. In some ways the dynamic is simple: alcohol makes everything better, until it makes everything worse.”  ― Caroline Knapp, Drinking: A Love Story

It’s important to start this paper with a refresher as to how exactly a substances and substance use disorders are defined. A substance is any natural or synthetic product that has psychoactive effects–perceptions, thoughts, emotions, and behaviors are changed. Substance use disorders are lifelong difficulties when it comes to resisting the urge to drink alcohol or take other drugs. Conditions important in defining the use of substances are as follows: intoxication, withdrawal, abuse, and dependence. Intoxication is a change that occurs, both behaviorally and psychologically, that results in a substance having physiological effects on the central nervous system.  Withdrawal is a series of symptoms that one goes through when trying to stop or greatly reduce their alcohol intake after after having imbibed heavily for prolonged periods of time.  It should be noted that there is a difference between substance abuse and substance dependence.  Substance abuse is when a person’s reoccurring use of a substance, more often than not, results in significant harmful consequences consisting of: 1) failing to fulfill important obligations—such as work or school—continuing to use the substance, even in situations in which it is hazardous to do so. 2) Repeatedly having legal problems as a result of substance use, and still continuing to use the substance even after continuous social or legal problems brought on by the substance. While on the other hand, substance dependence—or what most people refer to as “drug addiction”—refers to people who are dependent on, or addicted to a substance. They will most often times show signs of tolerance— that is, experiencing diminished effects from the same dose of a substance and needing more and more of it to achieve the same result as when the first time they took it—when they are using the substance and signs of withdrawal when they are not using the substance.  The three stages of alcohol withdrawal are of the following: The first includes tremulousness, weakness, and profuse perspiration—such as sweating. Experiencing anxiety, headache, nausea, and abdominal cramps are common in this stage.  The second includes convulsions, such as seizures, which may begin as soon as 12 hours after drinking stops.  Finally, the third is characterized by hallucinations—auditory, visual, and tactile.  Now that we know the terminology behind what a substance is and disorders associated with it, let us explore what would lead one to begin to drink in the first place.

Why people begin to drink has a lot to do with one’s own drinking motives. Drinking motives are a desire or need to regulate positive versus negative affect.  This can be taken to mean that people drink not only to decrease negative emotions but also to increase positive emotions. These affects result in a unique pattern associated with easily distinguishable alcohol use and etiologic processes.  Though sad to hear, drinking motives are persistent over time, predict later problem drinking, and are partly heritable. Those who drink to cope with negative affect are at greater risk of alcohol problems than others. Drinking to enhance positive can be defined as a desire to satisfy motivational process that time and time again predicts heavy drinking and drinking to intoxication.  In other words, drinking motives have an enduring and robust influence on alcohol-related behaviors, even years later. Drinking possesses an ever-present hold, which influences one’s drinking behavior. Since traumatic events will continue to occur, though, understanding how drinking motives lead to increased drinking after trauma can help one plan for said possibility.  This may even lead to a general improvement in understanding the etiology of heavy drinking and alcohol use disorders.

A popular motive for drinking is what is known as self-medicating. This is people using alcohol for the sole purpose of trying to soothe themselves of their past or current afflictions. Some individuals reach for banned substances to subdue symptoms of physical or mental illness. “This phenomenon underlies the main tense of the self-medication hypothesis” (Lo, C. C., et al.).  However, heavy alcohol use can lead to numerous other mental health conditions. So the process of self-medication is a bit of a contradiction.  That is because it can worsen a person’s already fragile physical and mental health.

People self-medicate to help cope with feelings of anxiety, anger, and/or sadness after faced with a traumatic experience.  The DSM-5 constrains traumas to events in which individuals are exposed to actual or threatened death, serious injury, or sexual violation.  Early childhood traumatic experiences in particular are regarded as a major risk factor for developing an alcohol use disorder in adolescence and maintaining it into adulthood.  Studies have shown that respondents who had experienced physical and sexual abuse sometime during their life were more likely to use alcohol.  Because of the childhood trauma group reporting an earlier age of having their first drink when compared to the adult trauma group, it can be inferred that trauma experienced in childhood may contribute to an earlier trajectory of alcohol use compared to trauma experienced in adulthood.  These results lead us to believe that people with a history of childhood abuse or neglect are vulnerable to using alcohol in order to cope with stressful situations.  Because trauma can lead to not only overwhelming but also numbing symptoms.  It is because of this that children exposed to trauma may be especially vulnerable to substance use disorders.  That is because trauma can contribute both to an intensification of intrusive negative emotions and to a dulling of positive affect. It is for this reason that trauma survivors may be more so motivated to use alcohol problematically.  Also, individuals may use alcohol to regulate emotions of positive and negative valence. Those who do so explained that the alcohol helps to decrease negative affect when overaroused and/or enhance positive emotions when hypoaroused.  In other terms, trauma may lead to increased risk for substance misuse in adolescence.  This is because of them possibly trying to suppress negative emotions and enhance positive ones.  Heavy substance users with a trauma history may be at higher risk for more severe substance problems.

Childhood adversity is not only associated with alcohol use disorders, but also with an increased risk of post-traumatic stress disorder (PTSD).  PTSD is the outcome after experiencing extreme stressors, often referred to as traumas.  This makes sense then that PTSD would result after a trauma, given that it has the word “trauma” in its name.  There is a high co-occurrence of PTSD and alcohol disorders.  It should be noted, however, that the development of PTSD precedes the development of the substance use disorder.  While PTSD has been shown to increase the risk of alcohol abuse or dependence among the general population, it has been suggested through findings that early traumatization may lead to an enhanced vulnerability to heavy drinking at a faster rate than in persons with adulthood trauma.  These high rates of childhood abuse in individuals with PTSD and alcohol and other substance-related problems suggests that there is a link between childhood adversity and the development of these disorders (Brady, K. T., & Back, S. E.).  It makes sense then to intervene as soon as possible.

When intervening and thinking of treatment, cognitive-behavioral therapies (CBTs) seem like the most successful route to take.  That is because cognitive-behavioral interventions are directive, structured, goal-directed, and time-limited treatment, and most types involve the client in a one-on-one setting with the counselor or therapist.  The use of homework assignments and skills practice is common, along with a focus on problem-solving ability.  CBTs are the most widely studied and empirically valid treatments for both PTSD and alcohol use disorders.  Integrative psychosocial interventions addresses both trauma/PTSD and substance use orders simultaneously, so theoretically it would be a more practical treatment to use.  That is because patients who engage in integrative CBT interventions typically experience significant improvements in both conditions. Also, the rates of relapse are not increased by the introduction of therapy for trauma.  Supporters of integrative treatments assume that unprocessed trauma-related memories and PTSD symptoms may, at least in part, drive alcohol use.  That would be why attending to and treating the trauma-related symptoms early in the process of therapy may improve the chances of long-term recovery from alcohol (Brady, K. T., & Back, S. E.).  When pharmacological products are used, treatment should be more closely monitored.  That is because of the risk of simultaneously abusing both the medication and alcohol. It is for this reason that the pharmacological product with the least abuse liability potential should be chosen for a person trying to get over addiction. Most studies to date, however, show promise and suggest that patients with co-occurring alcohol dependence and trauma/PTSD respond well to standard PTSD pharmacotherapies.

Sertraline and other pharmaceuticals also show great promise as a form of treatment.  A sertraline treatment group showed greater improvement in the experience of sudden flashbacks of the traumatic event and hyperarousal symptoms.  Follow-up analyses suggested that individuals with primary PTSD, compared with primary alcohol dependence, derived more benefit from sertraline treatment as evidenced by significantly less severe alcohol (Brady, K. T., & Back, S. E.).  When it comes to the medications Naltrexone and Disulfiram, either one or a combination of the both significantly improved alcohol-related outcomes in patients treated with either medication alone or with combination therapy.  This strongly suggests that alcohol-dependent patients with co-occurring PTSD should receive medications targeting alcohol use.  Unfortunately, no matter the treatment route you decide to take, there is always the potential for relapse.  Studies have shown that patients with a history of sexual abuse are more likely than nonabused patients to relapse to alcohol use.  They are also more likely to relapse quicker than nonabused patients.  This most usually happens in the first year following inpatient treatment for alcohol dependence.

References:

Beseler, C. L., Aharonovich, E., & Hasin, D. S. (2011). The Enduring Influence of Drinking Motives on Alcohol Consumption After Fateful Trauma. Alcoholism: Clinical and Experimental Research, 35(5), 1004-1010.

Brady, K. T., & Back, S. E. (2012). Childhood trauma, posttraumatic stress disorder, and alcohol dependence. Alcohol Research: Current Reviews, 34(4), 408-413.

Jester, J. M., Steinberg, D. B., Heitzeg, M. M., & Zucker, R. A. (2015). Coping expectancies, not enhancement expectancies, mediate trauma experience effects on problem alcohol use: A prospective study from early childhood to adolescence. Journal of Studies on Alcohol and Drugs, 76(5), 781-789.

Lo, C. C., Monge, A. N., Howell, R. J., & Cheng, T. C. (2013). The Role of Mental Illness in Alcohol Abuse and Prescription Drug Misuse: Gender-Specific Analysis of College Students. Journal of Psychoactive Drugs, 45(1), 39-47.

Nolen-Hoeksema, S. (2014). Abnormal Psychology (6th ed.). New York, NY: McGraw-Hill Education.

Waldrop, A. E., Ana, E. J., Saladin, M. E., Mcrae, A. L., & Brady, K. T. (2007). Differences in Early Onset Alcohol Use and Heavy Drinking among Persons with Childhood and Adulthood Trauma. Am J Addict American Journal on Addictions, 16(6), 439-442.