The 10th Special Report to the U.S. Congress on Alcohol and Health (2000) notes that more than seven hundred thousand people in the United States receive treatment for alcoholism daily. In Treating Alcoholism: The Illness, the Symptoms, the Treatments (Washington, DC: not dated) the NIAAA lists three stages of treatment:
- Detoxification, or managing acute intoxication and withdrawal to overcome the effects of drunkenness, safely rid the body of alcohol, and help the body adjust to the absence of alcohol.
- Correcting health problems that may have been brought on or aggravated by heavy drinking.
- Altering long-term behavior so that drinking patterns are not reestablished.
Some physicians prescribe the drug disulfiram (Antabuse) for daily use. If combined with alcohol, this drug produces violent headaches, nausea, and other discomforts. Many doctors, however, question the effectiveness of Antabuse, believing it to be more of a psychological than a physical agent. In other words, patients taking Antabuse who believe they will become sick if they drink alcohol tend to become ill. This drug has been marketed since 1948.
Approved by the U.S. Food and Drug Administration (FDA) in 1994, naltrexone (ReVia) has been shown to be very effective with low- and medium-risk alcohol-dependent patients when used in primary-care-based alcohol intervention programs. Naltrexone lowers the "high" associated with drinking and diminishes the craving.
Acamprosate is now being used effectively in Europe. Acamprosate was approved for use in the United States by the Food and Drug Administration (FDA) in July 2004. In Pharmacotherapy for Alcohol Dependence (Rockville,
TABLE 4.10
Estimated economic costs of alcohol abuse, 1992 and 1998
| Economic cost | 1992 ($ millions) |
1998 (projected) ($ millions) |
| Health care expenditures | ||
| Alcohol use disorders: treatment, prevention, and support | 5,573 | 7,466 |
| Medical consequences of alcohol consumption | 13,247 | 18,872 |
| Total | 18,820 | 26,338 |
| Productivity impacts | ||
| Lost productivity due to alcohol-related illness | 69,209 | 87,622 |
| Lost future earnings due to premature deathsb | 31,327 | 36,499 |
| Lost productivity due to alcohol-related crime | 6,461 | 10,085 |
| Total | 106,997 | 134,206 |
| Others impacts on society | ||
| Motor vehicle crashes | 13,619 | 15,744 |
| Crime | 6,312 | 6,328 |
| Fire destruction | 1,590 | 1,537 |
| Social welfare administration | 683 | 484 |
| Total | 22,204 | 24,093 |
| Total costs | 148,021 | 184,636 |
| aThe authors estimated the economic costs of alcohol abuse for 1992 and projected those estimates forward to 1998, adjusting for inflation, population growth, and other factors. | ||
| bPresent discounted value of future earnings calculated using a 6-percent discount rate. | ||
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Agency for Health Care Policy and Research, 1999), researchers reported that both naltrexone and acamprosate can be effective in the treatment of alcoholism. They found that the drugs can help reduce cravings, decrease the frequency with which a person drinks, minimize relapse, and, in some cases, improve abstinence rates. The combination of two or more medications given simultaneously may be even more efficient. Results of a recent study showed that monthly injections of naltrexone in patients who are seeking treatment, combined with biweekly low-intensity psychosocial therapy, resulted in a 25% decrease in the number of days patients drank heavily (Garbutt et al., "Efficacy and Tolerability of Long-Acting Injectable Naltrexone for Alcohol Dependence," Journal of the American Medical Association, April 6, 2005).
The main side effect of Acamprosate is mild diarrhea, which usually goes away after a few days. By contrast, Antabuse can be toxic if the patient drinks enough alcohol, while naltrexone can cause liver damage if prescribed in too high a dose.
A Long-Term Process
In 1996 Dr. George E. Vaillant of Harvard Medical School and Brigham and Women's Hospital in Boston announced the results of a long-term study of recovering alcoholics. The study followed the lives and drinking patterns of problem drinkers for fifty years. Researchers found that relapse was common after two years of sobriety but was rare after five years. While 56% of the abusers in the study achieved two years of sobriety, 41% of them relapsed. Generally, an alcoholic needs to live free of symptoms for five years before he or she can be considered recovered, although alcoholism can return even after five years.
Treatment Settings
Many types of long-term treatments are available for alcohol dependence, including both inpatient and outpatient treatment programs. These programs can involve psychological approaches, medications, or a combination of the two. The 10th Special Report to the U.S. Congress on Alcohol and Health notes that a broad range of therapies are currently available to treat alcohol dependence, including social-skills training, motivational enhancement, behavior contracting, cognitive therapy, marital and family therapy, aversion therapy, and relaxation training. Complete abstinence from alcohol and other drugs is the main goal of these treatments.
Jane Ellen Smith, in "The Community Reinforcement Approach to the Treatment of Substance Use Disorders" (The American Journal on Addictions, 2001), describes a program that has repeatedly proven successful. The Community Reinforcement Approach (CRA) is a cognitive-behavioral treatment for all substance-use disorders. It is founded on the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. When used with alcoholics, the goal is to rearrange multiple aspects of an individual's "community" so that a sober lifestyle appears more rewarding to the alcoholic than a lifestyle including alcohol dependence.
A variation of CRA, called Community Reinforcement Family Training (CRAFT), has also been developed. This program works with family members and significant others to motivate individuals who refuse to seek treatment to do so.
Research in treatment for alcoholism has also led to an important advancement called the "brief intervention." This approach is used with patients who are at-risk or problem drinkers, but who may not be alcohol dependent. With this approach, the health-care provider identifies patients who are problem drinkers, provides them with feedback and advice on their drinking, and works toward doctor-patient agreement on an appropriate course of action to stem the problem.
In past decades treatment for alcohol abuse and dependence occurred most often within hospitals and treatment facilities (inpatient treatment). In recent years inpatient treatment has changed dramatically. The length of stay has dropped sharply, often as a result of pressure from the health insurance industry to cut costs. Admissions to state facilities for alcohol-only treatment dropped 24% between 1992 and 2002, according to the government's Treatment Episode Data Sets (TEDS, as it is called, only covers admissions to facilities that receive state funding). However, there was a rise in people receiving assistance in outpatient treatment programs. Clients are also more likely to be addicted to other drugs along with alcohol, so treatment has shifted focus from alcohol-only dependence to dependence on alcohol and other drugs. Admissions to state facilities for drug treatment with a secondary diagnosis of alcohol dependence rose by nearly 50% between 1992 and 2002.
Alcoholics Anonymous
In 1935 two alcoholics started a group called Alcoholics Anonymous, which effectively laid the foundation for the modern self-help movement (including Alcoholics Anonymous, Al-Anon, Alateen, Overeaters Anonymous, Gamblers Anonymous, etc.). Alcoholics Anonymous (AA) groups are self-governed and independent of formal alcoholism-treatment facilities. Meetings are conducted by recovering alcoholics, without regard to formal counseling training and experience. As of January 2002, AA had nearly 2.1 million members in more than 103,000 groups. Participation in AA or in treatment programs based on the Twelve Steps of AA is the dominant approach to alcoholism treatment in the United States today (10th Special Report to the U.S. Congress on Alcohol and Health).
Critical elements of the AA program include fellowship meetings, with members expected to attend ninety meetings in ninety days during the early recovery period; a sponsor system in which newly recovering alcoholics are linked with an established member for assistance and advice; and the Twelve-Step philosophy, which spells out a series of activities, or steps, that alcoholics must undertake in their recovery process.
Al-Anon and Alateen are similar programs for the families of alcoholics. At Al-Anon meetings, families learn how to deal with alcoholic family members and their own feelings about these people. Al-Anon members also work to break their own codependent behaviors—the cycle of denial, anger, and unconscious facilitation of their family members' alcoholism. Alateen groups offer support for the children of alcoholics. Families Anonymous is generally designed to offer support for the parents of alcohol-or drug-dependent children.
Project MATCH—Patient-Treatment Matching
Caregiving professionals recognize that no single treatment is successful for everyone suffering from alcohol abuse and dependence. For many years, based on the outcomes of more than thirty studies, professionals have suggested that treatments for alcoholism should be matched to the particular characteristics of the patients. The characteristics to be considered include psychiatric and sociopathic problems, severity of alcohol involvement, cognitive impairment, and level of social support.
In 1989 the NIAAA began a study called Matching Alcohol Treatments to Client Heterogeneity (Project MATCH) to determine if the outcome of treatment is affected by matching patients to certain treatments. The study recruited 1,726 patients, of whom 75% were men and 25% women; 15% were minorities. The patients were divided into two groups: those who were recruited directly from the community on an outpatient basis, and those who had just completed an inpatient or intensive day hospital treatment (the "aftercare" group). Each patient was randomly assigned to one of three treatments (all of which were conducted by qualified therapists):
- Twelve-Step Facilitation (TSF)—Twelve weekly sessions that explained Twelve-Step principles and introduced the first five steps. Patients were encouraged to join Alcoholics Anonymous and become involved in its activities, in addition to the TSF program.
- Cognitive-Behavioral Therapy (CBT)—Twelve weekly sessions in which therapists taught skills that could help patients cope with situations and moods that are known to trigger relapses.
- Motivational Enhancement Therapy (MET)—Four sessions over a span of twelve weeks in which therapists used motivational psychology techniques. Patients were encouraged to consider their situations and how alcohol had affected their lives, develop a plan to stop drinking, and implement the plan.
Patient characteristics were studied to evaluate whether treatments that were appropriately matched to a patient's needs produced better outcomes than treatments that were not matched. By the late 1990s, the data were analyzed and the results showed that patient-treatment matching had little effect on the outcomes. In all the programs, patients decreased their drinking days per month to six, compared with twenty-five before treatment. While almost all patients reported both heavy drinking and recurrent problems when they entered the project, only 50% reported these problems one year after treatment.
Only four patient characteristics (out of a potential twenty-one characteristics) showed any differences in outcome when matched with particular programs:
- Alcohol dependence—In the aftercare group, individuals highly dependent on alcohol benefited more from the Twelve-Step treatment than from cognitive-behavioral treatment. The reverse was true for patients with low alcohol dependence.
- Psychopathology—In the outpatient group, individuals without mental and behavioral disorders benefited more from the Twelve-Step treatment than from cognitive-behavioral treatment.
- Anger—In the outpatient group, individuals with high levels of anger benefited more from the motivational enhancement treatment than from the other two treatments.
- Social Network Support for Abstinence—Individuals without strong social support networks benefited more from the Twelve-Step treatment than from motivational enhancement therapy.
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