Alcohol consumption represents a significant factor for mortality in the world: 6.3% in men and 1.1% in women. Alcohol use disorder is also very common: 5.4% in men, 1.5% in women. Despite its high frequency and the seriousness of this disorder, only 8% of all alcohol-dependants are ever treated. Recent meta-analyses have shown that if we can increase current figures by 40%, we could decrease alcohol-related morality rates by 13% in men and 9% in women. Thus, it is important to motivate both physicians and patients to participate in treatment in alcohol use disorder. Recent epidemiological data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) are currently challenging the notion of alcohol use disorder as a fixed entity. Among a cohort of 4422 subjects initially diagnosed as having alcohol dependency, only 25% of these could still be diagnosed as alcohol-dependant one year later. Among the others, 27% were in partial remission, 12% had risk use, 18% low risk use and 18% were abstinent. Stable remission rates were observed in 30% of these subjects at 5 years. This study also argues in favour of the newer dimensional approach elaborated in the DSM 5. One potentially interesting treatment option is oriented toward reducing alcohol intake. In a study by Rehm and Roerecke (2013), they modelled the impact of reduced consumption in a typical alcoholic patient who drinks 8 glasses of alcohol per day (92 g of pure alcohol). If he decreases his alcohol intake by just one glass per day (12g of alcohol per day), his one-year mortality risk falls from 180/100,000 to 120/100,000; if he decreases his intake by two glasses per day (24g), this risk falls to 95/100,000, roughly half his baseline risk. These observations have resulted in integrating reduced consumption as an option into the treatment guidelines of several national institutions such as the National Institute for Clinical Excellence (NICE, UK), European Medicines Agency, as well as the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Decreasing stigmatisation of alcohol use disorder through public service announcements, in addition to more flexible physician attitudes concerning personal alcohol intake objectives may be key in getting increased numbers of patients into treatment programmes. In one study in Great Britain, 50% of patients in treatment for alcohol use disorder would prefer an initial objective of reduced consumption. A recent addition to the pharmacotherapy arsenal is nalmefene, which has been recently released as a medication to aid in reducing alcohol consumption. It is a strong p. and opioid receptor antagonist and a partial K opioid receptor agonist. Opioid receptor antagonism is associated with reduced reward in relation to alcohol use, thus helping patients in reducing their consumption. Patients are instructed to take one nalmefene tablet two hours prior to each drinking occasion. Nalmefene therapy is to be accompanied by a specific psychosocial programme called BRENDA. BRENDA consists of a biopsychosocial evaluation, restitution of the evaluation to the patient, an empathetic approach that responds to patient needs, offering direct advice and adjusting goals and treatment programmes as the patient makes progress. Nalmefene has been associated with decreased heavy drinking days in two clinical trials. Overall, the treatment is well tolerated; adverse effects are fairly mild and short-lived. In conclusion, an approach that integrates reduced alcohol consumption makes sense from both a public and personal standpoint. Medications such as nalmefene have shown efficacy in association with a biopsychosocial approach to help patients attain their personal objectives with respect to alcohol use. (C) L'Encephale, Paris, 2014.
