A Sea Change in the Treatment of Alcoholism

“Factors Associated with Remission From Alcohol Dependence in an American Indian Community Group,” by Gilder et al. (1) is a well designed and carefully implemented study that provides valuable new information for American Indian communities but also for society at large. Perhaps the most salient finding is the relatively high rate of 6-month remission: 59% in an ethnic group whose remission rates 25 years ago ranged from 0% to 21% (2 – 4) . Another study recently revealed a 41% 1-year full remission in 199 American Indian people with substance use disorder, confirming the salutary finding of Gilder and coworkers (1) .

What has occurred over the last few decades in Native American communities to permit such a dramatic change? One factor lies in leadership: many tribal leaders have identified substance abuse as a major social and health problem (5) . The fact that Gilder and coworkers could carry out such a study in Indian communities today bespeaks this critical political change. Second, many American Indian professionals and researchers have devoted their efforts to eliminating substance abuse from American Indian lives and communities (6 , 7) .

Findings in this report by Gilder et al. (1) reflect deep changes in all sectors of American society that foster remission. For example, in their study, only 36% of people with alcohol dependence received specific treatment for alcohol problems. Today, many people in the United States achieve remission following brief interventions and ongoing support for sobriety from many sectors outside of specialty alcoholism care. These other sectors include primary health care, family members and friends, visiting nurses, staff of social agencies and jails, schools, churches, corporations, courts, and law enforcement officers.

As a result of this virtual revolution in society at large, the characteristics of those who achieve remission has changed irrevocably. Formerly, women and those with depression had poorer prognoses than others with alcohol dependence. In this study by Gilder et al. (1) , these characteristics predicted remission, as they do in other populations (8) . These momentous changes have been due to treatment system modifications. For example, many alcoholism treatment programs now meet the special needs of women, providing child care, integration of substance abuse services with physical and mental health care, special programming for women and staff workshops in the care of women with substance disorders (9) .

The authors note remission with increased age in their sample, described as the “aging out” of alcoholism previously observed in Navajo and other American Indian drinkers (10) . This may reflect the respected role of elders in tribal societies. It could also be the result of high mortality among American Indian drinkers, many of whom binge drink within a group rather than alone. Many American Indian drinkers have elected for sobriety after drinking companions have died. Although “aging out” and loss of drinking companions appear characteristic of American Indian sobriety, these pathways to remission might be fostered in other ethnic groups.

These data might also cause one to question the utility of alcoholism treatment, since remission rates were comparable with and without treatment. Although the authors have not compared those who sought treatment with those who did not, perhaps they will do so in a subsequent analysis; their data would allow a critical comparison. Compared to those who have not sought treatment, treatment seekers generally comprise a more morbid group, with fewer factors favoring remission. If this were the case in this group, the fact that the posttreatment remission rate equaled that in the nontreatment group would credit alcoholism treatment.

Challenges remain. Gilder and coworkers (1) found a lifetime prevalence of 43.8% alcohol dependence among these 580 study participants. Similar lifetime prevalence rates have been observed in other American Indian communities (4 , 7 , 11) . Alcoholism and drug abuse continue to claim many lives prematurely, undermine the mental health of children, and give rise to numerous associated mental health problems, including traumatic brain injury and posttraumatic stress disorder as they do in the society at large with its 13% adult lifetime prevalence rate of alcohol dependence. American Indian communities are experimenting with preventive approaches, including on-reservation prohibition, abstinence-oriented religion and spirituality, peer pressure against public drunkenness, and nondrinking pow-wows. Results of these efforts may inform and guide society at large in its prevention endeavors.

Weaknesses in our treatment alternatives test our resolve and ingenuity. Gilder and coworkers (1) documented the high rate of treatment resistance even among those who have received treatment for alcohol problems: half of treated cases failed to achieve remission, a fairly typical finding nationally in community programs. People in rural areas (where over half of American Indian people live) have not benefited from a modernized system to the same extent as urban dwellers (12) . Many substance abuse treatment programs still do not occur in a context of integrated health care, a demoralizing symptom of our American “nonsystem” of health care. To reverse this national scourge, we need to improve on our treatment success, ensure that rural care is equivalent to urban care, and embed treatment for alcoholism in a system of integrated health care.

Also in this issue of the Journal , an important study by Wrase and coworkers (13) links increased craving with small amygdala volumes in a cross-sectional study comparing 51 alcohol-dependent patients and 52 comparison subjects. It is unclear whether small amygdala size is a premorbid “trait” characteristic versus a postmorbid “state” characteristic. Were small amygdala size to be postmorbid, we would expect the remission would decrease with increasing duration of alcohol abuse in the study by Gilder et al. (1) . On the contrary, remission was associated with younger age at onset of alcohol dependence and with advancing age, both of which were associated with increased duration of alcohol dependence. Thus, the findings of Gilder et al. (1) would favor the trait rather the state explanation for small amygdala size. Epidemiological findings and clinical findings at times fail to confirm each other, however, so that the critical follow-up studies recommended by Wrase et al. (13) are yet needed to understand the pathophysiology of those coming to treatment.