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Pr Henri-Jean Aubin: A new paradigm in alcohol dependence

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Treatment of alcohol dependence




Hello! You’re on MD-FM INSIGHT, the first medical web radio. Today we’ll be devoting our "Question & Answer" program to the treatment of alcohol dependence.




Controlled consumption for the management of alcohol dependence is rapidly gaining ground among addiction specialists. In this new approach, patients are no longer required to remain abstinent. At the International Congress on Addiction, Hepatitis and AIDS, which took place in Biarritz, France, last October, Professor Henri-Jean Aubin, from Hospital Paul Brousse, in Villejuif, France, gave a presentation on “this shift in paradigm”, as he calls it. Listen to our interview with Pr. Aubin:




First of all, tell us: as of today, what would you say is the main concern in the management of alcohol dependence?


Aubin: “One big concern is the treatment gap with so many people who are affected with an alcohol use disorder and who are not treated. I know that in Great Britain, only 10 per cent are in treatment. That leaves 90 per cent of alcohol dependent patients out, with no treatment. We know that some of those can get better with no intervention, that’s true, there are self change processes that have been shown, but it is our responsibility to get these patients in treatment and one important thing for us is to match patients’ expectations on treatment and what we can offer, and I think the match is not so good today, we have to work on that.”



Ok and so: if I understand correctly, controlled consumption is offered as an alternative to abstinence in the hope of getting more patients under treatment. When did this concept first appear?


Aubin: “Until recently, it was a prevailing idea in the medical field: that any alcoholic or any alcohol dependent individual should abstain; it’s the only way. Now, very progressively, in the 60s, in the US, and then more in the 70s, there have been very few researchers, psychology researchers, who showed that this dogma is not really evidence-based. They had series of patients who were severe alcoholics and who managed to reduce their drinking on the long term. And they published that, and it was the beginning of a strong controversy.



And today?


Aubin: “Their ideas are well recognized today and, at least in France it’s very recent. There’s a shift from one paradigm, which was “abstinence is the only way out of alcohol dependence” and another one where abstinence is maybe the safest way out but it’s not the only way out and one should be more tolerant about the idea of reducing, even in severe patients.”



Ok and how do you go about it?


Aubin: “One of the main therapy style that has gained a lot of audience since the 1990s is called “motivational interviewing.” And now it’s really a reference in our field, the addiction field. One main principal of motivational interviewing is that it’s a patient-centered therapy. So, really, the idea is that the therapist can offer a menu of options that, at the end of the day, he should really listen to patients’ way of thinking, of understanding the situation and the options that he will choose. If the patient has the feeling that he chose the options, he has the feeling that he’s in charge and he will get much more involved in the process.”



Ok so you offer both approaches –abstinence and controlled consumption. But I guess some patients are better suited for one approach rather than the other? How do you know what suits who?


Aubin: “Yes we know that the more severe the illness the less likely they can reduce and more likely abstinence will be the right way out. We also know that the quality of the social support, is very important. Someone with a nice social support and a nice non-alcoholic environment is likely to succeed in controlled drinking, as someone who is very isolated or who has a very pro-alcohol environment will have a hard time to reduce.”



And in terms of treatments –is it based on the same process? 


Aubin: “The treatment process is a little different. When you work on an abstinence-oriented treatment there is this detoxification phase which can be a challenge or not, depending on the patient, and if you are in the reduction-oriented treatment, usually you don’t go through a detox. And then, on the counseling level, it’s pretty different to help patients to avoid all drinking and give them behavioral cognitive tools to achieve that. It’s a little different if the goal is to accept some drinks in some situations but to limit themselves. It’s not exactly the same type of counseling work.”



I know there are medications prescribed for abstinence, is there anything to help patients for controlled consumption?


Aubin: “For alcohol reduction there is nalmefene, which has just been launched in many European countries and it’s the only labeled drug in that indication to date.”



So all in all, what would be your take home message today?


Aubin: “My recommendation is to try to meet as much as possible patients’ expectations, to get them to accept an intervention that is thought as meeting these expectations from this patient, and once he is in the treatment process, the patient will change his goals, he might change for abstinence but the first thing is to accept, to get him in.”




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