Integrated psychosocial and opioid-antagonist treatment for alcohol dependence: A systematic review of controlled evaluations

Methodological characteristics and outcomes of 14 controlled clinical investigations of integrated psychosocial and opioid-antagonist alcohol dependence treatment were evaluated. The 14 studies were identified through computerized bibliographic and manual literature searches. Clients receiving integrated psychosocial and opioid-antagonist treatment had outcomes superior to those of clients receiving monotherapy (generally placebo and standard psychosocial treatment). Rates of relapse, levels of self-reported alcohol craving, and extent of posttreatment alcohol consumption were significantly reduced in clients receiving integrated therapy relative to controls. However, the long-term efficacy of integrated psychosocial and opioid-antagonist alcohol dependence treatment was not established, and client factors associated with the differential effectiveness of integrated interventions were not identified. Key words: alcohol dependence; evidence-based practice; integrated treatments; naltrexone; systematic review ********** Effective treatments for alcohol abuse and dependence are critically needed given the substantial prevalence of these disorders nationally and the manifold deleterious consequences attending habitual alcohol use (Sammons & Schmidt, 2001). Epidemiological findings indicate that approximately 9.3% to 13.4% of men and 3.0% to 4.4% of women meet Diagnostic and Statistical Manual of Mental Disorders criteria for alcohol use disorders in any given year (DSM-IV-TR) (American Psychiatric Association [APA], 2000; Caetano & Tam, 1995; Grant, Harford, Dawson, et al., 1994; Grant, Harford, Hasin, Chou, & Pickering, 1992). Annual costs of alcohol-related health and social problems in the United States exceed $185 billion (National Institute on Alcohol Abuse and Alcoholism, 2000). Alcohol use disorders are especially debilitating to the vulnerable client populations social workers serve (Hester & Miller, 2002). Thus, it is important that practitioners be aware of the most effective approaches to alcohol dependence treatment (Nathan, Gorman, & Salkind, 1999). In a seminal study attempting to identify treatments that work for this population, Miller and colleagues (1995) found little or no empirical support for nearly three-quarters of the 43 alcohol dependence treatment modalities they evaluated. Among the most effective interventions they identified were a variety of psychosocial and cognitive-behavioral approaches, including brief interventions, skills training, behavior contracting, motivational enhancement therapy, and the community reinforcement approach. Opioid-antagonist medications had not emerged as potential treatments for alcohol dependence at the time Miller and colleagues conducted their comprehensive review. Early studies indicating that the opioid-antagonist naltrexone was nontoxic and appeared to reduce craving for alcohol and posttreatment alcohol consumption led to more widespread application of naltrexone pharmacotherapy with alcoholics. Increasingly, psychosocial and opioid-antagonist treatments are considered complementary (Volpicelli, Pettinati, McLellan, & O'Brien, 2001), and growing support for integrated treatments has emerged for a range of mental health disorders (Sammons & Schmidt, 2001). Psychosocial interventions used in association with opioid-antagonist medications include individualized manual-based cognitive-behavioral therapies focusing on coping skills, relapse prevention training, and abstinence reinforcement. Psychosocial and behavioral interventions have also been used to help alcohol-dependent clients initiate behavior change, be compliant with pharmacotherapeutic regimens, manage negative emotions, and increase environmental supports. The best known and most widely researched opioid-antagonist medications are naltrexone and nalmefene (Volpicelli et al., 1997). These agents are nonaddictive, produce few side effects, and appear to reduce craving for alcohol and the pleasurable effects associated with alcohol's stimulation of the endogenous opioid system and related reward systems should drinking occur (Greenstein, Fudala, & O'Brien, 1997). …