Alcoholic Subtype Predicts Treatment Response

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There are different types of diabetes, different types of Herpes Simplex and different types of Alcoholism.  The different types of disease demonstrate different causes, different disease progressions and different responses to treatment.

Backin the 1980s, Dr Cloninger noted that there were two different patterns of inheritance of alcoholism.  There was the alcoholic who developed his disease slowly.  He may have drank heavily as a young adult but did not become clinincally alcoholic until his mid-30s or 40s.  First degree family members of this person would have a 30-40% chance of being alcoholic.  If they did develop alcoholism, the presentation was similar in that it developed relatively later.

However, if you were a male who was drinking alcoholically by your early 20s, than you had a 90% chance of having a son with the same early onset of alcoholism.  Clearly, there seemed to be two different abnormalities being passed on that predisposed to alcohol abuse.  

The two groups were better characterized in the 90s.  The older onset, or Type One, had isolated alcohol problems.  They tended to work more and develop problems after the age of 25.  Type two alcoholics, on the other hand, were drinking heavily before age age 25.  They had more psychiatric problems, more conduct issues and more use of illicit drugs.

The different types of patterns suggest there might be separate abnormal physiologies that led alcoholism.  It is still unclear what the exact nature of these abnormalities are.    Abnormalities of seratonin receptors have been postulated  to be one source of disease but this is still being worked out.  However, the important question remains:  Should we treat both types of alcoholism the same way.

The short answer is no.

A famous alcohol treatment study, the COMBINE study, was done looking at treatment responses to naltrexone.  Naltrexone was found to have some mild benefit.  However, when the population was separated by type- type ones had a more significant benefit and type twos had no benefit.

By the early 90s, it had been demonstrated that anti-depressants had no benefit in treating alcoholism unless there was an independent diagnosis of depression.  But that was also wrong.  More recent research shows that that Zoloft helps reduce  alcohol use in type ones.  However, alcohol use goes up in type twos when they were given this medication.  I cannot tell you how many young alcoholics are prescribed this type of medication without any thought that the drug might be causing harm.  Ongoing alcohol use has always been blamed on the alcoholic, blaming anything else, we are told, is shirking responsibility.  However, maybe we should blame the mediciation.  After all, bipolar gets worse with Zoloft so why should we doubt that this problem can get worse too.

Zofran, in the low doses that are used for craving, has been found to be more helpful for type two alcoholics and of uncler benefit for type oness.  Perhaps this demonstrates that abnomal seratonin and/or abnormal learning is more of an issue with type two alcoholism.

My biggest question is whether this disease sub-type can be generalized to other classes of drug use.  Is a young opiod abuser with anti-social tendencies going to react the same way as an older user.  I await the results of clinical trials and the results of my own office observations

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