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CABHR views alcohol and substance problems as medical and behavioral as well
 or countless Americans, it’s a simple pleasure. An ice cold beer at the ball park. A warming brandy after a long winter’s day.
For others, it’s much more. Alcohol dependence has transformed the simple act of taking a drink into a weakness. Evidence of a character flaw. A dangerous choice. Or, thanks to research being conducted by Allen Zweben, Ron Cisler, and their colleagues at the Center for Addiction and Behavioral Health Research, it may finally be recognized as what many believe it truly is: a medical problem treatable by a mix of prescription drugs and other therapies. “Why is one illness defined as a medical problem and treated with drugs while another isn’t?” asks Zweben, UWM professor of social work and director of the Center. “In America there’s been a social bias against thinking of alcohol dependence as an illness and treating it that way.” CABHR, a non-profit partnership between UWM, Marquette University, Covenant Healthcare Systems, Inc., Rogers Memorial Hospital, Innovative Resource Group, and Aurora Healthcare, is one of 11 treatment research centers in the United States participating in the first large-scale examination of both pharmacological and behavioral treatments for alcoholism. The “Combining Medications and Behavioral Interventions Study,” known as COMBINE, is being funded and coordinated by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). As part of COMBINE, CABHR has received a six-year, $1.4 million NIAAA grant. It is an FDA classified Phase III study, in which the study drug or treatment is given to large groups of people (1,000-3,000) to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug or treatment to be used safely. What kinds of people might benefit from the treatment of alcoholism as a medical problem? Zweben gives some examples: • A man is in the middle of a custody battle with his ex-wife. His participation in AA or an alcohol or other drug abuse (AODA) counseling program might count against him when the judge makes a custody decision. The father might instead opt to avoid treatment, making him more susceptible to relapse. In this scenario, a medication-based treatment program could be viewed more neutrally by the court. • A white-collar professional wants to stem functional alcoholism, but she worries about who she might meet at a neighborhood or church Alcoholics Anonymous meeting. AA tenets mandate strict confidentiality toward all who attend meetings and their stories. If she sees a colleague or superior at such a meeting, however, she might fear potential repercussions in the workplace. Medical treatment and counseling provided within the confines of a health care center might be the most effective approach for the professional.
At the heart of COMBINE are two medicines that have shown promise in helping alcoholics remain abstinent. Naltrexone is an opiate antagonist, approved in 1994 by the U.S. Food and Drug Administration for use in treating alcoholism. It blocks the effects of opiates in the brain and interferes with some pleasurable effects such as the high of alcohol. Unlike Antabuse—a drug commonly used to treat alcoholism because it produces hangover-like symptoms when mixed with alcohol—Naltrexone merely reduces or eliminates a physical incentive for relapse in a user motivated toward abstinence. Acamprosate, on the other hand, does not work through the brain’s opiate receptors, but is commonly thought to work by modifying its chemical neurotransmitters. It has been approved only as an investigational drug in the U.S., although it has been used to treat alcoholism in Europe since 1989. These neurotransmitters can become unbalanced after repeated alcohol use. When the alcoholic stops drinking, the chemical neurotransmitters can become overexcited, leaving the person in a hyper-excited state. As a result, he or she may sleep poorly, become irritable and keyed up, and return to drinking as an attempt to self-medicate. Acamprosate has shown some ability to short-circuit this process. The drug study comes at a time when the use of, and controversy over, drugs to treat what were once considered purely “mental” illnesses is at an all-time high. Depression, post-traumatic stress disorder, social anxiety, and others can all now be treated by a combination of drugs and counseling, and Zweben thinks it’s time to add alcohol dependency to that list. “A lot of people look at this situation and say that people are using drugs or alcohol, so as treatment we have to take drugs away from them,” he explains. “They also end up taking away medication. “There’s been this bias against medicine, and so you have a situation where patients want medication to treat a medical problem but they don’t get it. I say why not? Why not give them the medication?”
A prejudice against treating alcoholism as a medical problem is a “bio-psycho-social” phenomenon, Zweben says, based in part on an American tendency to see alcohol dependence as a moral weakness. “Look at the terms they use—terms like ‘substance abuse.’ So now you’re doing something bad. Contrast that with the term ‘addiction,’ which is a diagnosis. Instead of describing the problem as alcohol addiction, a lot of Americans would rather describe it as alcohol abuse.” “When a person comes to a doctor with heart disease, most people won’t say he abused his heart,” Zweben says. “When they come in with diabetes, we don’t say they abused sugar. You know there’s a physical illness there. A lot of it comes from genetic factors, from a predisposition. But people there have made choices too that affect their illness.” “The medicalization of alcoholism allows us to bring patients in for treatment who wouldn’t come in otherwise because of negative attributions and perceptions toward alcohol dependence.” For either Naltrexone or Acamprosate to work, however, the user must not only be motivated to stop drinking, but remain committed to taking the medicine. The keys to maintaining that motivation are under investigation in the second part of COMBINE. Participants will take either Naltrexone, Acamprosate, both, or a placebo while also receiving one of two behavioral treatments.
The moderate-intensity “combined behavioral intervention” offers lengthier and more intensive treatment sessions. The three psychosocial interventions were shown to be effective by previous CABHR research in Project MATCH (See accompanying article). Locating patients who meet study criteria, screening and randomly assigning the 20 or so current participants to groups, and managing and scheduling treatments has been CABHR’s primary COMBINE focus so far. “It’s a bit complicated,” Zweben explains. “Participants need to be abstinent for a four-day period before they are eligible to receive the medication. They should be stabilized, but at the same time have had a drink within the last 21 days. “They can’t be drug dependent, and should not be taking psychotropic drugs (such as Prozac or Zoloft, often used to treat depression),” he says. “The focus of the study isn’t looking at the effects of these medications when used in conjunction with others.” Unfortunately, the NIAAA considers Milwaukee a preferred site for clinical trials with alcoholics because the area has a large population of heavy drinkers. But the concentration of a significant population of potential study participants is not the only factor that has led to such significant trials being conducted in Milwaukee. Of the 11 COMBINE treatment sites nationwide, CABHR is the only one not located at a university medical center or hospital. The reason for UWM’s participation in the study, Zweben says, is its strength as a true community-based partnership. “We have no medical center, no hospital at UWM,” he explains. “The other sites are at medical care facilities. We owe our participation in medical studies to our very strong partnership with Aurora Healthcare and other community agencies. “We are unique in that we recruit our study subjects from the community population, and we ourselves are a community of scientists with common interests who have recognized that putting together partnerships is the key for all of us in doing high-level medical studies.” CABHR was established in 1991 when two major federal grants dealing with substance abuse issues were awarded to UWM and Marquette University. The Center was seen as a way to attract investigators interested in addictions and mental health research. Since then it has become an important vehicle for training and educating students and professionals in the area of substance abuse as well as other areas of health care. The Center currently involves the efforts of over 50 people throughout the Milwaukee area, working in fields including allied health, business, communications, advertising, economics, education, emergency and family medicine, nursing, psychiatry, psychology, and social welfare. 
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