Alcoholism
Description
An in-depth report on the causes, diagnosis, and treatment of alcoholism.
Alternative Names
Alcohol dependence, Alcohol abuse
Treatment for Alcoholism
Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. One study reported that the main reasons alcoholics do not seek treatment are:
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Lack of confidence in successful therapies
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Denial of their own alcoholism
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Social stigma attached to the condition and its treatment
The alcoholic patient and everyone involved should fully understand that alcoholism is a disease. Furthermore, the responses to this disease (need, craving, fear of withdrawal) are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as are treatments for other life-threatening diseases, such as cancer, but that treatment is the only hope for a cure.
Interventions by family members, employers, and therapists can be very effective in motivating a person to quit and in reducing drinking over the short term. Even brief interventions from a primary care doctor and self-help information can be helpful in reducing harmful drinking. Studies report, however, that only regular follow-up and reinforcement will sustain quit rates and possibly even improve survival rates.
Personal Intervention Meetings.
The best approaches for motivating a patient to seek treatment are interventional group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this approach, each person affected offers a compassionate but direct and honest report describing specifically how he or she has been hurt by their loved one's alcoholism. The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and consistently demand that the patient seek treatment. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation.
Employer Intervention.
Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if they do not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers. Studies suggest that such interventions are effective at helping the worker at least to cut back on drinking.
Overall Treatment Goals
The ideal goals of long-term treatment by many doctors and organizations such as Alcoholics Anonymous (AA) are total abstinence. Patients who secure total abstinence have better survival rates, mental health, and marriages, and they are more responsible parents and employees than those who continue to drink or relapse. To achieve this, the patient aims to avoid high-risk situations and replace the addictive patterns with satisfying, time-filling behaviors.
Because abstinence is so difficult to attain, however, many professionals choose to treat alcoholism as a chronic disease. In other words, patients should expect and accept relapse but should aim for as long a remission period as possible. Even merely reducing alcohol intake can lower the risk for alcohol-related medical problems.
AA and other alcoholic treatment groups are greatly worried by treatment approaches that do not aim for strict abstinence, however. Many people with alcoholism are eager for any excuse to start drinking again. There is also no way to determine which people can stop after one drink and which ones cannot.
Evidence strongly suggests that seeking total abstinence and avoiding high-risk situations are the optimal goal for people with alcoholism.
Inpatient Versus Outpatient Treatment
A number of treatment options now exist for alcoholism. It is first important to determine whether inpatient or outpatient care would best benefit the individual. Inpatient care is performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. It is recommended for the following people:
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Those with a coexisting medical or psychiatric disorder
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Those with delirium tremens
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Those who may harm themselves or others
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Those who have not responded to conservative treatments
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Those who have a disruptive home environment
Some -- but not all -- studies have reported better success rates with inpatient treatment of patients with alcoholism. In those studies, patients who were hospitalized for treatment had fewer complications and re-hospitalizations, and longer abstinence rates, than patients treated as outpatients. However, newer studies strongly suggest that alcoholism can be effectively treated in a doctor’s office.
The new approach to outpatient treatment uses “medical management” -- a disease management approach that is used for chronic illnesses such as diabetes. With medical management, patients receive regular 20-minute sessions with a health care provider. The provider monitors the patient’s medical condition, medication, and alcohol consumption.
An important 2006 study in the
Journal of the Medical American Association
(
JAMA
) found that medical management can successfully treat alcoholism when it is combined with either:
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Drug treatment with naltrexone (ReVia, Vivitrol), or
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Behavioral counseling with a therapy technique called combined behavioral intervention (CBI)
The study did not find any benefit for another drug, acamprosate (Campral), either used alone or in combination with naltrexone.
Inpatient Treatment Options.
A typical inpatient regimen may include the following stages:
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A physical and psychiatric work-up for any physical or mental disorders
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Detoxification -- this phase involves initiating abstinence, managing withdrawal symptoms and complications, and ensuring that the patient remains in treatment
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On going treatment with medications in some cases
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Psychotherapy, usually cognitive-behavioral therapy
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An introduction to Alcoholics Anonymous
Outpatient Treatment Options.
People with mild to moderate withdrawal symptoms are usually treated as outpatients. Treatments are similar to those in inpatient situations and include:
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Psychotherapy or counseling
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Medications that target brain chemicals involved in addiction
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Social support groups such as Alcoholics Anonymous
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Cognitive therapies
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Quitting smoking (smoking interferes with the brain’s recovery from alcoholism)
After-Care and Work Therapy.
After-care employs services that help alcoholics maintain sobriety. For example, in some cities, sober-living houses provide residences for people who are trying to stay sober. They do not offer formal treatment services, but the people living there offer each other support and maintain an abstinent environment. A 2002 study reported that work therapy improved the outcome for homeless veterans who were being treated for substance abuse.
Factors That Predict Success or Failure After Treatment
A 2001 analysis of studies reported that 25% of people were continuously abstinent following treatment, and another 10% used alcohol moderately and without problems. Even among the remaining group, alcohol consumption was reduced by an average of 87%. Most studies strongly suggest that intensive and prolonged treatment is important for successful recovery, whether the patient is treated within or outside a treatment center.
Certain factors play a role in success or failure. Patients from low-income groups tend to have worse results in general. Their difficulties are often intensified by lack of insurance, low self-esteem, and minimal social support.
Treating People Who Have Both Alcoholism and Health Problems
Severe alcoholism is often complicated by the presence of serious medical illnesses. People with alcoholism should try at least to maintain a healthy diet and take vitamin supplements. Such deficiencies are a major cause of health problems in people with alcoholism. Women are particularly endangered.
A program called integrated outpatient treatment (IOT) may be specifically helpful for medically ill alcoholics. The patient visits a clinic once a month and receives both intensive alcohol treatment and a physical check-up, which includes tracking factors, such as liver function, that are affected by drinking. One study showed that IOT significantly increased abstinence and the number of treatment visits. IOT may even improve survival rates. Interestingly, however, drinking also significantly decreased in a comparison group of patients who were treated only for their medical conditions.
Treating People Who Have Both Alcoholism and Mental Illness
Treatment for patients with both alcoholism and mental illness is particularly difficult. The greater the psychiatric distress a person is experiencing, the more the person is tempted to drink, particularly in negative situations.
There has been some concern that self-help programs, such as Alcoholics Anonymous (AA), are not effective for patients with dual diagnoses of mental illness and alcoholism, because the focus of the organization is on addiction, not psychiatric problems. Studies, however, have reported that they are also effective in many of these patients. (AA may not be as helpful for people with schizophrenia and schizoaffective disorder.) In one study, individuals with a dual diagnosis achieved better abstinence rates after being treated only for alcoholism compared to patients treated for the mental disorder as well. (Cognitive-behavioral therapy was used for both groups.)
Newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are proving to be very useful complements to AA or counseling sessions. Anti-anxiety medications are also available for people with anxiety.
People with alcoholism and more severe problems such as schizophrenia or severe bipolar disorder may need more intense help. One 2002 study also suggested that women and men with dual diagnoses may need different treatment approaches. Women were more bothered by their psychiatric problems and with social relationships than men were and were more likely to have a history of abuse. Women also had fewer episodes of criminal activity.
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Review Date: 12/3/2006
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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