By Katherine Spitz,Akron Beacon Journal

The treatment plan used to be simple, if not easy: A recovering alcoholic was to follow the 12 steps of Alcoholics Anonymous and steer clear of any drugs that affect mental state.

Today, physicians and addiction researchers look at the alcoholic in a different way and consider the use of drugs that AA founders Bill Wilson and Dr. Robert Smith never dreamed of.

At least half of the nation’s 8 million alcoholics also suffer from a mental illness, which can be treated with antidepressants, anti-anxiety drugs and other medications. And new drugs have come out that address the craving for alcohol itself.

Dr. Victoria Sanelli, medical director of the Ignatia Hall Acute Alcohol and Drug Treatment Center of Ohio’s Summa Health System, says the issue of treating alcoholics with drugs is a complicated one.

Most people, she says, understand that prescription anti-depressants and other drugs sometimes can help the recovering alcoholic. But there are those who take a traditional no-drugs stance.

“There are still some hard-liners who say you shouldn’t be on any of that stuff,” she says.

AA cautions alcoholics about using drugs to deal with the “aches and discomforts of everyday living.” But its pamphlet “The AA Member – Medications & Other Drugs,” published in 1984, also provides examples of alcoholics who need to use strong medications under medical supervision.

Sanelli routinely has to figure out whether a patient’s mental health problems or the alcohol dependence came first: Is a newly detoxed alcoholic anxious because he or she is without alcohol or because there is an underlying anxiety disorder?

“There is disagreement as to whether we should make them stop (drinking) first and then treat them for depression and anxiety or treat it all at the same time,” she says.

Sanelli prefers to delay prescribing mood-managing drugs to a newly recovering alcoholic. That way, she says, it’s easier to determine if the symptoms will pass naturally after the first weeks of recovery.

But for some alcoholic patients, the anxiety or depression won’t abate without a course of psychotropic drugs. Patients with a genetic predisposition to a mood disorder will need to be on medication for the rest of their life.

Tina, a middle-aged alcoholic who asked that her last name be withheld to protect her privacy, understands well the connection between alcoholism and mental disorders.

She has had a rocky sobriety the past several years and at the same time has been treated medically for depression.

“Alcohol helps with the depression,” she says, “because you drink yourself into oblivion.”

At the same time, the drinking makes everything worse.’

“I’d get real depressed when I drank,” she says.

Dr. Robert Liebelt, a former director of Ignatia Hall who’s now addiction medicine director for the Summit County Alcohol, Drug and Mental Health Board, estimates that 50 percent to 60 percent of people who have alcohol problems also have psychiatric problems.

Liebelt says he and his colleagues are working on a plan that will require certain agencies that receive funding from the alcohol, drug and mental health board to add specialized drug and psychiatric testing to new clients.

Under the plan, a patient who wants help for alcohol addiction would automatically be screened for mental health problems. And a person who needs mental health services would be screened for a substance abuse problem.

The plan, Liebelt says, will be presented to the board in August.

Anti-craving drugs – acamprosate or naltrexone – are another approach to treating alcoholics.

Sanelli says she rarely prescribes them. Her patients, who receive treatment and go to Alcoholics Anonymous meetings, don’t seem to require them, she explains.

However, according to the Journal of the American Medical Association, which on May 6 published long-awaited results to a national study comparing different ways of treating alcoholism, the majority of the nation’s alcoholics don’t get treatment for their addiction.

The journal-published research, known as COMBINE, was a four-year study of 1,400 abstinent alcoholics, none of whom had major mental health problems. One of the findings was that there are several effective ways to treat alcoholics, including a system in which a primary care physician provides short, frequent “medical management” sessions with a patient and prescribes naltrexone.

Dr. Robert Anthenelli, an addiction psychiatrist and nationally known researcher who directs the Substance Dependence Program at the Cincinnati Veterans Affairs Medical Center, says the study’s findings present hope and broader options for those who are alcohol dependent.

“What this (study) hopefully will lead to,” he says, “is that people understand that there are multiple ways and multiple modalities to treat alcohol dependence.”

The drugs can mesh very well in a treatment plan that includes AA meetings, Anthenelli says, but they also provide an option for someone who refuses traditional treatment strategies.

The success of naltrexone with medical management is nothing to discount, says internist Dr. Paul Lecat. But he’s not ready to start writing many prescriptions.

“You can argue with certainty that there is a benefit,” Lecat says. “The question is, is that amount of benefit worth the risk, the cost? For some people, it probably will be. I think you can say the drugs are an option.”

Sanelli says the question of using medications to treat alcoholism is part of a much larger issue.

Whether an alcoholic is on a prescription medication or not, he or she needs to shoot for much more than not drinking, she says.

“Just being abstinent is what we refer to as a dry drunk,” Sanelli says.

“It’s about emotional stability. For recovery, we’re also looking at improvement of relationships, self-esteem and spirituality.”

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