Modalities of alcoholism treatment in Korea include withdrawal treatment, detoxification, education, behavioral approaches, psychotherapy (PT), pharmacotherapy, individual therapy, and group therapy including Alcoholics Anonymous (AA) according to the severity of the disorder, availability of facilities, motivation and patient's or family's choice ().
Comparison of current treatment modalities of alcoholism between Korea and the United States
A consensus on the status of alcoholism treatment in Korea has been reached primarily by the Korean Academy of Addiction Psychiatry (KAAP) from presentations at conferences, questionnaire surveys, and discussions among experts. Based on the highlights of such consensus that there is a need for standardized and evidence-based treatment methods, the KAAP and the Alcohol Project Supporting Committee (APSC) established treatment guidelines in 2011 (6
). In this section, current treatment modalities of alcoholism based on the treatment guidelines and the consensus of experts in Korea (6
) is described.
The treatment of alcohol withdrawal
Korean clinicians assess risks of alcohol withdrawal by evaluating the patient's current drinking pattern, the presence of withdrawal symptoms, use of other related substances, and the presence of comorbid physical or psychiatric disorders. Then if needed, pharmacotherapy is recommended in an outpatient clinic or in an inpatient ward.
Benzodiazepines such as chlordiazepoxide and lorazepam are mainly used to treat alcohol withdrawal in Korea. Particularly for elderly patients or patients with severe liver diseases, recent brain damage, respiratory failure, or undetermined physical conditions, lorazepam is primarily used. Administration regimens include symptom-triggered therapy, loading dose therapy, and fixed-schedule therapy. For severe withdrawal cases, 6-12 mg of lorazepam is orally administered daily and maximally 20 mg per day. Generally, after the resolution of withdrawal symptoms, benzodiazepines are reduced and subsequently terminated. It may be used as a prophylactic agent for alcohol withdrawal in Korea.
For all patients experiencing withdrawal, in order to prevent Wernicke Korsakoff syndrome, 100-300 mg of thiamine is administered orally prior to the administration of carbohydrates. For cases of poor food intake, in addition to oral administration, thiamine may be injected intramuscularly; but for patients with blood coagulation diseases, intramuscular injection is avoided. Thiamine is administered for approximately 1-3 months and terminated. Nonetheless, continuous oral administration may be recommended for cases of continuous drinking. In addition, supportive care such as correction of dehydration and electrolyte imbalance, environmental support (to minimize stimulation and reduce anxiety), vitamin and nutritional support, and supportive PT, may be administered.
Anticonvulsant agents are not recommended for the prevention of withdrawal symptoms, and are generally not used in addition to benzodiazepines. Nonetheless, for the patients who are being treated for seizure disorder or bipolar disorder, regardless of the presence of withdrawal symptoms, anticonvulsant agents are maintained.
Antipsychotic agents lower the seizure threshold and thus increase the risk of seizures. Therefore, they are not used alone to treat hallucination, delirium, or anxiety due to alcohol withdrawal. Nonetheless, for patients whose symptoms are unresponsive to sufficient benzodiazepines, antipsychotic agents may be administered in conjunction with benzodiazepines for the treatment of hallucination, delirium, and anxiety induced by alcohol withdrawal.
Pharmacological treatment of chronic alcoholism
The drugs of first choice to treat alcoholism are naltrexone and acamprosate in Korea. For hospitalized patients, medications to treat alcoholism are not required, and it is difficult to evaluate their effectiveness in the setting. The prerequisite to drug treatment is alcohol treatment in an outpatient-based setting. However, drugs may be administered after the detoxification period to assess compliance and the side effects of drugs.
Acamprosate is a gamma-aminobutyric acid (GABA) agonist and glutamate antagonist. It is most effective for patients with an abstinence goal, rather than preventing excessive drinking in non-abstinent patients. Acamprosate is contraindicated in patients with renal insufficiency or severe hepatic failure. Its main side effects are diarrhea and somnolence. The treatment must be started during the abstinence period. The therapeutic dose is from 1,332 mg to 1,998 mg per day according to the patient's weight. It is recommended that acamprosate should be maintained for a minimum of 6 months to 1 yr in Korea.
Namkoong et al. (8
) conducted an 8-week multi-center randomized, double-blind, placebo-controlled study to assess the effectiveness of acamprosate in Korean alcohol dependence. Acamprosate failed to show any treatment advantages over the placebo in the study. This is contradictory to the previous reports (9
) which proved the effectiveness of acamprosate treatment. The sample characteristics (i.e., a more severe form of alcohol dependence, a lower level of social support, a short interval between the last drink and the first medication), the dosage issues of acamprosate, the short period (8 weeks) of study, and the various concomitant psychosocial treatments, may all explain the negative findings of the study.
Naltrexone is an opioid antagonist and reduces the rewarding effect of alcohol. It is more effective for preventing relapse to heavy or problem drinking and reducing high levels of alcohol consumption than for maintaining abstinence from alcohol. It is contraindicated for patients with acute hepatitis, severe liver failure, or who are on opioid medication such as codeine, morphine, oxycodone, and methadone. Patients with significant depression or more severe alcohol dependence respond less well to naltrexone. It may be administered after the alcohol withdrawal symptoms, and is safe to use during the drinking period or the withdrawal period. Its side effects are nausea, vomiting, anorexia, headache, dizziness, fatigue, and anxiety. The therapeutic dose of naltrexone is 25-100 mg. It is recommended that naltrexone should be maintained for a minimum of 6 months to 1 yr in Korea.
Namkoong et al. (12
) conducted a 10-week open-label study on the drug compliance of naltrexone in 93 Korean outpatients with alcohol dependence. The estimated compliance measured by the Medication Event Monitoring System (MEMS) was observed to be 80.4%±20.6%. The treatment outcome such as percentage of days abstinent, percentage of heavy drinking days, and mean alcohol amount consumed per drinking occasion was consistently correlated with the estimate of compliance.
Kim et al. (13
) conducted a 12-week prospective study on the efficacy of naltrexone, and the genotype in 32 Korean subjects with alcohol dependence. The results showed that the time to the first relapse of the Asp40 variant genotype group (G carrier, A/G or G/G) was observed to be significantly longer than that of the Asn40 genotype group (A/A) (hazard ratio [A/A vs G carrier]=13.623, P
=0.014). This is the first study reported in Asia, and its results are in accordance with the European studies. Since the frequency of the Asn40 genotype is high among the Asian populations, it is proposed that naltrexone may be an effective treatment for Korean alcohol dependence.
), gabapentin (15
), baclofen (16
), and aripiprazole (17
) may reduce the recurrence of alcohol use disorders. Nevertheless, further studies including randomized controlled trials are required in Korea. They are not recommended as first-choice drugs in Korea.
Psychosocial treatment of chronic alcoholism
Psychosocial interventions or treatments imply non-drug treatments that have been widely applied to treat alcohol use disorders. Psychosocial interventions have been used by diverse therapists in the primary care setting, outpatient clinics, hospitals, residential institutions, and other diverse treatment environments for individual patient or groups.
Psychosocial treatment methods such as individual PT, group therapy (or group PT), family therapy, cognitive behavior therapy (CBT), cue exposure therapy, 12-step facilitation therapy, self-help group therapy, and community-based treatment (via therapeutic communities, crisis interventions, halfway houses, and community residential facilities) have been carried out in Korea. These are carried out primarily in the form of inpatient treatment rather than outpatient treatment in Korea. Among these psychosocial treatments, 12-step facilitation therapy, cognitive behavior therapy, and coping skills training have been primarily used. In addition, when required, parallel drug treatments have been performed.
According to the Korean addiction treatment guidelines, psychosocial intervention including group therapy, motivation enhancement therapy, CBT (coping skills training, exploration of high-risk situations, therapy to prevent recurrence, behavioral couples therapy, etc.), continuous intensive case management, rehabilitation programs at residential institutions, regular participation in AA meetings, and individual psychodynamic therapy are recommended. Psychoeducational intervention is also recommended as a form of adjuvant treatment.
Intensive inpatient treatment
The intensive inpatient treatment program of alcohol dependence in Korea usually provides a 2 or 3-step program that takes 6-10 weeks to complete in a closed ward. Step 1 comprises 1-2 weeks of detoxification and basic education. This is followed by 4-8 weeks of intensive education (Step 2). Some mental hospitals provide 2 weeks of intensive education in a closed or semi-closed ward (Step 2) and 6 weeks in an open ward (Step 3). These programs include 12-step alcohol treatment, CBT, art therapy, group PT, individual PT, self-help therapy, meditation and medication.
Outpatient individual and group PT
In Korea, individual PT for alcoholism generally has a supportive PT mode and consists of sessions every 2 to 4 weeks lasting 15 to 30 min per session in a standard outpatient setting. Group PT has a cognitive-behavioral PT mode and consists of weekly group meeting, each lasting 60-90 min, usually administered by 1 psychiatrist and 1 nurse or social worker. Group members have the opportunity to obtain peer support and experts' comments and to model their behavior after that of others in the group.
Kim et al. (18
) performed a long-term comparative trial with an aim of evaluating the effectiveness of continuing group PT for Korean outpatients with alcohol dependence. This study, which was undertaken for 6 yr, was a quasi-experimental trial with 177 alcohol-dependent patients who had completed 10-week inpatient alcohol treatment program each. Group PT was a cognitive-behavioral PT mode, and individual PT was a supportive PT mode in an outpatient setting. Abstinence rates of the combined PT group (outpatient individual PT plus group PT, n=94) were significantly higher relative to those of the outpatient individual PT-only group (comparison group, n=83) (log rank [Mantel-Cox], chi-squared=22.58, df=1, P
<0.001). Outpatient group PT was a significant predictive factor for the alcohol abstinence rate (B=-0.710, df=1, P
<0.001, Exp [B]=0.492, [95% confidence interval (CI): 0.355-0.680]), and even after controlling for confounding factors, outpatient group PT was a significant predictive factor for the alcohol abstinence rate (B=-0.671, df=1, P
<0.001, Exp [B]=0.511, [95% CI: 0.366-0.715]). Our findings indicate that for patients with alcohol dependence, who had completed the inpatient alcohol treatment, outpatient group PT appears to be an effective form of continuing care or aftercare within the context of an outpatient service system in Korea.
AA was started in 1935 by a New York stockbroker (William Wilson) and an Akron, OH, physician (Robert Smith) in the United States (19
). It is a mutual movement world-wide, which states that the "primary purpose is to stay sober" and aid other alcoholics to achieve abstinence from alcohol. Its objective is to effect enough change in the thought process of alcoholics "to bring about recovery from alcoholism" through a transcendent awakening. Such transcendent awakening is achieved by adhering to the Twelve Steps. In addition, sobriety is furthered by volunteering for AA and regular AA meeting attendance or contact with AA members (20
In Korea, the first AA meeting was held by an Irish priest at a Catholic church in 1983. As of October 2011, 182 meetings have been organized in various locations nationwide. AA in Korea operates actively, and the organization's of the 16th AA Korea International Convention was held in December 2011 (http://www.aakorea.co.kr/
Jung et al. (21
) performed a randomized controlled trial with an aim of evaluating the effects of brief intervention to promote insight among the 41 Korean alcohol-dependent patients who had been admitted to an alcohol treatment center. Patients in the intervention group (IG), while focusing on insight enhancement, participated in the five sessions of brief individual intervention. The IG showed significant improvement (P
<0.05) in the distribution of insight level and in the insight score. However, the control group did not show such significant improvement. As insight has a positive effect on the motivation for treatment, and may play a critical role in the recovery process, this brief form of intervention focused on the insight enhancement may be an effective modality to improve the insight among alcohol-dependent patients.
Virtual reality therapy
Lee et al. (22
) conducted an age, education, alcohol consumption matched trial with the object of evaluating the effects of a virtual reality training program (VRTP) in Korean male alcohol-dependent inpatients. This is the first multisensory stimulation virtual reality therapy for alcohol-dependent patients. The virtual reality therapy (VRT) consisted of a succession of scenes that were associated with relaxation, simulating a high-risk situation (virtual alcohol cues) and then an aversive stimulation. Alcohol-dependent patients were exposed to such sequence of 10 VRTP sessions (VRTP group, n=20) and CBT sessions (CBT group, n=18). The VRTP group displayed a larger reduction in craving, when compared to the CBT group (F=8.73, P=0.01). There was a complete increase in EEG alpha power in Fp2-A2 (z=2.91, P
<0.01) and F8-A2 (z=3.80, P
<0.01) in the pattern of the change of 16 EEG leads in the VRTP group, between the pre-intervention and the 10th VRTP session, but not in the CBT group.