Alcohol & Drug Abuse PSYCHIATRIC SERVICES. September 1996 Vol. 47 No. 9 917 Closing the Gap Between Alcoholism Research and Practice: The Case for Pharmacotherapy Eduardo Meza, M.D. Henry R. Kranzler, M.D. T he last two decades have wit- nessed an unprecedented growth in knowledge about the diagnosis and treatment of addictive disorders (1). However, despite the sophistication attained by researchers, clinical ap- plication of these developments has been limited (2). To illustrate some potential impediments to the clinical application of research findings, in this column we consider recent de- velopments in the pharmacotherapy of alcoholism and the potential inter- action of these developments with traditional psychosocial treatment ap- proaches. The acceptability and applicability of novel treatment modalities depend on a host of factors, such as the tools used in the dissemination of research results, where the results are present- ed or published, the investigators’ reputations, and the settings in which the findings are to be applied (2). Even when new knowledge is widely and adequately disseminated, clini- cians’ theoretical orientation or their specific skills may not be compatible with the new information. Further- more, to enhance treatment effective- ness, research results should also be communicated to paraprofessional staff providing care to individuals with substance use disorders (3). The authors are affiliated with the Alcohol Research Center in the department of psy- chiatry at the University of Connecticut School of Medicine, 263 Farrnington Av- enue, Farmington, Connecticut 06030. Send correspondence to Dr. Kranzler. Richard J. Frances, M.D., is editor of this column. One approach to the dissemination of research findings to clinicians is through the publication of practice guidelines. The American Psychiatric Association’s Practice Guidelines for the Treatment of Patients With Sub- stance Use Disorders: Alcohol, Go- caine, Opiokls (4) represents a recent effort of this type. Such guidelines usually summarize an extensive liter- ature; however, their impact on clini- cal practice is currently unknown. Guidelines may be biased by the pro- fessional orientation of the authors and sources consulted, thus limiting the acceptability and generalizability of the recommendations (5). Pharmacotherapy of alcoholism A role has been proposed for virtually all major neurotransmitter systems in the control of alcohol consumption and in the acute and long-term effects of drinking, including alcohol depen- dence (6). Particular attention has been paid to the serotonergic, opioid- ergic, dopaminergic, noradrenergic, and glutamatergic systems (7-13). Agents specifically affecting the sero- tonergic, opioidergic, and dopamin- ergic systems, and less specific agents such as tricyclic antidepressants and lithium, have been the most widely used in studies investigating the out- come ofalcoholism treatment (14). Of these, dopaminergic agonists and an- tagonists have received comparative- ly less attention due to the adverse ef- fects associated with some of these agents (for example, tardive dyskine- sia with neuroleptics) or the abuse po- tential of others (for example, am- phetamines) (14). As our understanding of the neuro- biological processes underlying alco- hol use disorders grows, medications are increasingly being viewed as im- portant therapeutic options for this substantial public health problem (15,16). The strategy that has been used in this effort represents a shift from approaches based mainly on aversive or deterrent interventions such as disulfiram (17) to agents that target the direct reduction of alcohol consumption (18,19). Despite recent advances in the pharmacotherapy of alcoholism, re- search in this area has been compli- cated by extensive interactions among neurotransmitter systems, the involvement of multiple receptor subtypes, and the absence of agents that are specific to these receptor subtypes. Further, marked differ- ences in research samples between studies (for example, outpatients, in- patients, and samples with different levels of severity of dependence) make it difficult to generalize from ex- isting data. Finally, guidelines do not yet exist for the application of impor- tant methodological features of ran- domized controlled trials in alco- holics, such as the need for standard- ized psychosocial interventions and compliance monitoring. Nonetheless, recent findings mdi- cate that opioid antagonists reduce risk of relapse to heavy drinking in al- cohol-dependent subjects. Further- more, some medications that are widely used for treatment of depres- sion and anxiety disorders are also useful in alcoholics with these disor- ders. The consistency of these find-