to the editor: Drs. Miller and Gold¹ present a thorough discussion of the pharmacotherapy for withdrawal syndromes, the medications for the prevention of relapse and the psychosocial treatment of alcohol dependence. It is the absence of a prime treatment factor, Al-Anon, that I wish to discuss.

Al-Anon is a 12-step program designed to help the family and friends of the alcoholic patient. Al-Anon teaches the family and friends how to recover from their reactions to this disease. This family recovery allows the alcoholic patient to return from treatment to a safe, supportive environment. The outcome is not only positive for the alcoholic, but is also positive for the family.

I would encourage colleagues to attend an Al-Anon meeting. It only takes one hour. Health Partners Family Medicine Residency Program in St. Paul, Minn., has encouraged all of its residents to attend at least one Al-Anon meeting. During 15 years, not a single resident failed to be deeply impressed.

in reply: I feel, as does the American Society of Addiction Medicine, that disulfiram should not be the first step in the treatment of alcoholism.¹ Rather, I would use naltrexone or acamprosate as pharmacologic treatments that reduce the risk of relapse when used as part of an abstinence-based treatment regimen for alcoholism.

Naltrexone, an opioid antagonist, was the first medication in 50 years to be approved by the Food and Drug Administration for the treatment of alcoholism. Taking 50 mg of naltrexone per day for three months reduces alcohol intake and decreases relapse to heavy drinking. Patients treated with naltrexone report decreased cravings for alcohol before, during and after a relapse. Naltrexone may be especially effective in patients with a family history of alcoholism. Before the introduction of naltrexone, pharmacologic treatments for alcohol dependence showed disappointing results.² Naltrexone has improved treatment outcome, but compliance and relapse after discontinuation of treatment remain problematic.

The most recent treatment for alcoholism is acamprosate. It reduces acute alcohol withdrawal and may reduce protracted withdrawal, thus explaining its novel efficacy in reducing relapse rates. Acamprosate appears to interact with the glutamate receptor and may also have effects elsewhere.³ These newer treatments have numerous safety and efficacy advantages over disulfiram. Disadvantages of naltrexone and acamprosate include cost, availability on formulary and side effects.

The success of any pharmacologic treatment still depends on patient compliance. Among patients using disulfiram who have experienced long-term abstinence, disulfiram is frequently the reason for an office visit or the patients' treatment of choice. In such instances, treatment compliance may be outstanding. Naltrexone, acamprosate and disulfiram have been tested as adjuncts to 12-step programs and other psychosocial treatments and not the other way around. Alcoholics are more likely to go to Alcoholics Anonymous than to receive any other type of treatment program or to consult with their physician.⁴

I agree with Dr. Malerich that the list of medications used to treat alcoholism is short, including only disulfiram, naltrexone and acamprosate. Antidepressants may reduce depressive symptoms in alcoholics, but these agents are not treatments for alcoholism. I am unfamiliar with direct treatment comparison of patients with alcohol dependence randomly assigned to treatment with naltrexone or acamprosate versus disulfiram. This type of research is necessary before we can decide which treatments are ideal for which patients, and when.

At this point, no single treatment for alcohol dependence has proven to be more effective than any other, and prospective matching of patient to treatment has, thus far, been disappointing. Previous treatment success or patient confidence in the success of treatment with disulfiram, as well as the cost and unavailability of alternatives, has kept disulfiram in the pharmacopoeia. Detoxification is not treatment. Treatment happens after detoxification to prevent a relapse and rebuild a healthy, productive life. Twelve-step programs, such as Alcoholics Anonymous, Al-Anon, Narcotics Anonymous and Cocaine Anonymous, are the most cost-effective and widely available form of long-term support for patients in recovery.⁵

As with other chronic diseases, such as diabetes, the need for continuity of care, monitoring of progress and referral when necessary make addiction a primary care disease. Relapse prevention in alcoholism is similar to that in diabetes or hypertension. The physician must work within the therapeutic relationship, maintain a nonjudgmental attitude, communicate empathy and reinforce meeting participation and behavioral changes while working with the patient and the family.⁶