Icap blue book

MODULE 17:
ALCOHOL DEPENDENCE AND TREATMENT
Summary:

• Alcohol dependence is a clinical condition clearly defined by specific diagnostic criteria.
• The term “alcohol dependence” is not interchangeable with “alcohol abuse”; not all those who abuse alcohol are or may become dependent. • Treatment is an appropriate approach to addressing alcohol dependence. Of the range of treatment approaches that are available, not all are appropriate for all individuals or in all cultural contexts. • The provision of treatment services is an integral part of any comprehensive strategy around alcohol. Treatment must be tailored to the needs of different groups and be culturally appropriate. • Where traditional approaches and venues are not available or where resources are lacking, alternative measures can be effective for prevention and treatment. • For the Blue Book index page.


Most people who consume alcohol do so without suffering adverse consequences. However,
individuals with abusive or excessive patterns of drinking may be at elevated risk for alcohol
problems. These problems cover a broad range of social and health outcomes. Those who abuse
alcohol include a smaller sub-population of individuals who are “alcohol-dependent” or
“alcoholic.”
Alcohol abuse and alcohol dependence

It is important to note that the terms “alcohol dependence” and “alcohol abuse” are not
interchangeable (Harford & Muthen, 2001). Individuals may drink abusively and to excess,
causing harm to themselves and others without being dependent. Alcohol abuse covers a broad
range of patterns and outcomes, while alcohol dependence is characterized by a number of
specific diagnostic criteria (American Psychiatric Association, 1994; World Health Organization,
1994).
The distinction between abuse and dependence is an important one from the perspective of
policy, prevention, and treatment. Measures that may be applied to many who drink excessively
and abusively may be inadequate for dependent individuals. Conversely, measures that
specifically address alcohol dependence are largely inappropriate for the majority of those whose
drinking is problematic.
Abusive drinking patterns, related problems, and various prevention and policy measures are
covered in other Blue Book modules that address specific populati; ), particular drinkingand ), and outcomes (e.g., and This module deals specifically with the
diagnosed condition of “alcohol dependence,” approaches to its treatment, and policy
implications.
Defining alcohol dependence The view of alcohol dependence as a separately recognized disorder first appeared in the 1960s as the “disease concept of alcoholism” (Jellinek, 1972, 2002). In the 1970s, the “alcohol dependence syndrome” was described, along with the cognitive, behavioral, and physiological changes associated with it (Edwards, 1986; Edwards & Gross, 1976; Edwards & Lader, 1990). Several views exist on the etiology of alcohol dependence (Peele, 1985). There is evidence that in some individuals, alcohol dependence is a manifestation of underlying traits that include a genetic predisposition (Bierut et al., 2002; Cloninger, 1999; Cloninger, Bohman, & Sigvardsson, 1981; Crabbe, 2002; Walters, 2002). Alcohol dependence is often associated with other conditions, such as depression and anxiety, and there is compelling evidence to support a strong familial component (Davids et al., 2002; Schuckit, Kelsoe, Braff, & Wilhelmsen, 2003). It is also widely recognized that alcohol dependence can occur as a result of the cultural and social influences on an individual (Heath, 1986; Jung, 2000). Similarly, culture plays an important role in how dependence is viewed within a society (Bennett, Janca, Grant, & Sartorius, 1993; Bennett, Miller, & Woodall, 1999; Grant & Ritson, 1990; Gureje, Vazquez-Barquero, & Janca, 1996). A medical perspective on alcohol dependence has allowed evidence-based diagnostic criteria to be developed to assist in identifying dependent individuals. This model of alcohol dependence has increasingly gained currency around the world and is accepted as the basis for its classification and diagnosis through the International Classification of Disease, ICD (World Health Organization, 1994) and the Diagnostic and Statistical Manual of Mental Disorder, DSM (American Psychiatric Association, 1994). Alcohol dependence is classified as one of several substance-related disorders involving psychoactive substances, including alcohol. According to the ICD-10, the dependence syndrome is a “cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state” (World Health Organization, 1994). A similar definition in DSM-IV requires the presence of at least three of the following six symptoms within a 12-month period for a positive diagnosis of alcohol dependence: 1. Tolerance: increasing amounts of alcohol are needed to produce the desired effect in a given individual. Where the threshold for tolerance lies varies from one individual to another. 2. Withdrawal from the absence of alcohol is characterized by a number of physiological symptoms—most commonly tremor, anxiety, sweating, agitation and restlessness, nausea, and diarrhea. Depression and sleep disorders are also common Further drinking generally relieves the symptoms. 3. Salience of drinking, meaning that a dependent individual’s drinking occupies higher priority than other interests or obligations. Typically, hobbies and interests, once important, have been put aside to make room for a greater focus on drinking. 4. Craving refers to an individual’s compulsion to drink, triggered by any number of external cues or “primed” by the first drink or two. 5. Dependent individuals have impaired control over their drinking and difficulty setting limits on their consumption. At the same time, they tend to be acutely aware of the need to curb their drinking. 6. “Continued use despite harm” is also critical, in that the individual is aware of the adverse effects, yet continues to drink. Certain drinking patterns are characteristic of alcohol dependence, primarily those that have been
described as the “narrowing of the drinking repertoire.” These patterns are rigid and not easily
changed by external influence. The dependent individual’s drinking pattern is driven by
considerations such as avoiding the symptoms of withdrawal. However, certain drinking patterns
may also lead to the development of alcohol problems culminating in dependence (Cloninger et
al., 1981; Cloninger, Sigvardsson, & Bohman, 1996). Heavy steady chronic drinking at
sufficiently high levels can lead to the physiological changes that result in alcohol dependence.

Approaches to treatment

For individuals who are diagnosed with alcohol dependence, treatment may be appropriate and
can take on a variety of forms. Careful consideration should be given to which approach is most
fitting, most likely to elicit the desired effect, and most compatible with a particular culture
(Room, 1998; Schmidt & Room, 1999). The effectiveness of different approaches to treatment
hinges upon the cultural setting in which they are applied and the prevailing societal views on
dependence and priorities. In general, treatment is administered with the goal of allowing the
affected individual to resume normal functioning.
There are various approaches to treating alcohol problems. They can be divided into two groups,
depending on the severity of the problem: (1) treatment approaches directed at alcohol-dependent
individuals and severe problem drinkers, and (2) approaches that target those who are not yet
dependent, but are at high risk. The choice of which treatment is appropriate depends to a large
extent on the severity of the problems being addressed. Some individuals may require only minor
behavioral modifications to address emerging problems. For those whose drinking patterns have
resulted in more serious and established negative consequences, more intensive secondary and
tertiary prevention may be needed.
A variety of treatment approaches exists, each of them appropriate for particular individuals and
less so for others (Babor et al., 2003; Babor & Del Boca, 2003; Enoch & Goldman, 2002). They
include behavior modifications, support groups, as well as pharmacological treatment. Some
treatment has as its goal abstinence from alcohol, while other approaches seek to change the
pattern of drinking to one that is moderate and compatible with a healthy and balanced lifestyle.
Whatever the final goal, most treatment comprises three stages: detoxification to minimize
withdrawal, rehabilitation, and maintenance. Which approach and end result is best for a
particular individual should be determined on a case-by-case basis (Kadden, Longabaugh, &
Wirtz, 2003; Longabaugh & Wirtz, 2003, 2001).
The following is an overview of some of the commonly used approaches to treatment of alcohol
dependence.
Self-help or mutual help groups aspire to abstinence from alcohol. They include Alcoholics
Anonymous (AA), developed in the United States, in which an individual submits to a higher
power in the process of “recovery” (Humphreys, 2003). AA members make a fresh resolve each
day not to drink. Other similar groups exist with modifications that make them appropriate for different cultures. These include the Swedish Links movement, the Croix Bleu, and others (Gossop, 1995). A dominant approach in some countries of Southern and Central Europe—e.g., in Italy and Croatia—relies on Clubs for Alcoholics in Treatment, CATs (Hudolin, 1964; Hudolin, 1984). Unlike AA, these are often integrated into the social health services system and rely heavily on the family as integral to the self-help group. Self- and mutual help groups exist as both residential and non-residential programs. Early identification and brief intervention emphasizes that it is possible for individuals to modify their problematic drinking patterns (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Bien, Miller, & Tonigan, 1993). Inherent in this approach is the notion that it is possible for individuals to learn to drink responsibly, especially if they are diagnosed early and before problems have become severe. Brief interventions have been tested across cultures and have been found to be widely effective at reducing problematic drinking. They have also been successfully applied in the treatment of diverse populations, including young people with problem drinking patterns. Another advantage of this approach is that it is quick and efficient to administer and can therefore be implemented in settings where resources may be scarce. A detailed discussion of this approach Motivational interviewing centers on the idea that individuals with problematic drinking patterns may recognize the negative aspects of their behavior, but need assistance in making the decision to change. This is achieved through motivational techniques to encourage the patient to set realistic and attainable goals, using positive feedback to encourage and sustain progress and change. The approach is oriented toward drinkers with problems, but not severe dependence, and its final goal is a changed drinking pattern rather than abstinence. The community reinforcement approach includes behavioral techniques designed to support the individual in overcoming dependence. In general, it is most appropriate for those who are alcohol-dependent or have severe problems. The approach identifies high-risk situations that encourage and contribute to the individual’s problematic drinking and endows the patient with skills aimed at problem solving and at avoiding such situations. Skills include vocational training, recreational activities, marriage counseling, and avoiding situations where the risk for drinking and drunkenness is high. The patient is also taught skills to avoid relapse. Psychological therapy and aversion therapy are also used to reduce problematic drinking (Parks, Marlatt, & Anderson, 2001). Aversion therapy relies on associating alcohol with highly negative contexts (e.g., nausea induced by various medications, such as the drug Antabuse) or other negative cues. Other methods include teaching social skills to deal with stressors and to facilitate problem solving or developing skills aimed at reducing or controlling drinking (e.g., refusing or just sipping drinks). Psychotherapy is employed as an approach for general drinking problems and also for alcohol dependence. Pharmacotherapy is also commonly used to assist individuals with alcohol dependence by easing the symptoms of withdrawal and easing craving. Disulfiram (Antabuse), naltrexone, and acamprosate are among the most common drugs used for treatment (Drummond, 2001; O'Malley & Froehlich, 2003; Rubio, Ponce, & Manzanares, 2002; Soyka & Chick, 2003). The effectiveness of various treatment approaches has been assessed in populations of individuals with drinking problems and those with alcohol dependence. According the data, the most successful approaches include brief intervention and motivational enhancement, followed by pharmacotherapy and skills therapy. Various self- and mutual help approaches, despite their
popularity, are less effective and, according to some research, no more effective than no
treatment. Counseling approaches have been shown to be the least effective means of addressing
treatment.
It should be noted, however, that many treatment approaches may be combined with others,
enhancing their overall effectiveness. Clearly, the sooner a problem can be identified and
addressed, the greater are the chances for success. Patients’ relapse into earlier behaviors remains
the main obstacle to the effectiveness of treatment.
Considerations for policy and prevention

Many problems related to alcohol abuse (and dependence) are associated with trauma and injury.
As a result, for many individuals suffering from these consequences, the emergency room and
trauma departments at hospitals are a point of first contact with health care providers. Thus,
emergency rooms offer an important point of access to patients and opportunity for treatment
(Hungerford & Pollock, 2003).
Assessing admitted patients for alcohol dependence and increased risk for dependence has proven
an effective approach to reducing problems. Assessment can be accompanied by psychiatric
assistance and followed up through social workers. In addition, the provision of brief
interventions has shown reduced injuries requiring emergency treatment, shorter hospital stays,
and reduced alcohol consumption following the visiting et al., 2002; Moyer, Finney, Swearingen, & Vergun, 2002).
In addition to emergency rooms, other venues can also be used to provide brief interventions for
individuals who abuse alcohol (Fernandez Garcia et al., 2003). Doctor’s offices and general
health services are a useful venue, but not accessible in many parts of the world. Use can be made
of the resources available within a particular community, including the training of non-medical
personnel to provide assessm).
Where it is not possible to prevent the emergence of problems or to arrest them at a less advanced
stage of development, approaches for dealing with dependence, including treatment, are needed.
As a starting point, it should be recognized that alcohol dependence is a manifestation of a
clinical condition, not criminal behavior. Punitive measures and incarceration may temporarily
put the affected individuals out of circulation, but have not been shown to have an impact on
changing behavior.
Treatment may be the only viable solution for many of these individuals and, therefore, the
provision of treatment services is an essential part of a comprehensive and effective alcohol
policy. It has been shown that different groups of individuals require different approaches to
treatment. Aside from cultural differences in how alcohol problems in general and dependence in
particular are perceived, appropriate treatment for women may be different from that offered to
men (Acharyya & Zhang, 2003; Ashley, Marsden, & Brady, 2003), and young people also require
separate approaches.
Treatment services are clearly a necessary component of any healthcare system. Ideally, they
should cover a range from assessment to therapy and follow-up care. How these services they are
integrated into the system varies from country to country, depending on local priorities and
resources. Adequate healthcare includes ensuring that treatment opportunities and facilities are
available, and also educating health care professionals about alcohol dependence. Those
providing health care should be able to recognize symptoms of dependence and direct individuals
to appropriate further care.
Cost is clearly a consideration, especially for countries where health care is inadequate or where
priorities need to be set clearly, not only with regard to alcohol, but around health issues in
general. However, as effectiveness studies have shown, some of the less extensive and thus costly
approaches, including early identification and brief intervention are actually among the most
effective. They can be administered through a variety of less formal channels and do not hinge
upon access to health providers.
It is also important to bear in mind that alcohol dependence, like alcohol abuse, does not affect
only the dependent individual but also his or her family and others. Children of alcohol-
dependent individuals are more likely to experience behavioral problems and the general stress of
dealing with a dependent individual takes a heavy toll on the immediate surroundings in a variety
of different ways. It is important, therefore, to make available the necessary support structure
Included in this support structure is a role for the community as a whole, including employers,
families , and educators, not only the health sector. Offering a broad support network can assist in
both prevention and treatment.

Conclusion

Alcohol dependence is a condition clearly defined by diagnostic criteria. While alcohol
dependence includes abusive drinking patterns, it is not interchangeable with alcohol abuse and,
indeed, not all those who abuse alcohol are dependent. This distinction is an important one from
the point of view of prevention, treatment, and policy.
In addressing alcohol dependence, it is important to clearly define the population in question and
to develop approaches that best fit its needs. Prevention and treatment are heavily influenced by
cultural views on dependence and this should to be taken into account. While the availability of
adequate treatment services is key to balanced approaches to alcohol dependence, how these are
developed and implemented depends to a large extent on resources that may be present and on the
cultural context.
POLICY OPTIONS: Alcohol Dependence and Treatment
In developing policies and approaches, several key components need to be taken into consideration.
While some may be necessary under most conditions, others may not be appropriate or may be
difficult to implement in all cases. The list below offers a menu of areas that need to be addressed,
based on effective approaches that have been implemented elsewhere. Specific examples are provided
section of the ICAP Blue Book.

Screening and identification
Availability of screening tools to identify dependent individuals.
• Specialized instruments, such as AUDIT, MAST, CAGE.

Trained professionals who can administer instruments and identify dependent individuals.
Professionals can include:
• Health workers (nurses, doctors) in general practice and emergency rooms.
• Reliance on other professionals where medical personnel is unavailable—e.g., health and social
Education
Education of professionals to diagnose dependence.
• Professional trained to offer assistance and treatment. • Attention to individual needs, culture, gender, goals for treatment outcome (i.e., abstinence or
Education of patients to change behavior.
• Information about drinking patterns and outcomes.
• Skills for coping and avoiding relapse.
Access to treatment
Availability of a range of treatment options.
• Offer access to various treatment approaches.
• Match patient with most appropriate treatment(s). • Range of treatment services targeting particular populations (e.g., young people, women, the
Provision of services
• Services include assessment, therapy, and follow-up care—both non-residential and residential. • Resources and services as integral part of healthcare system, with qualified personnel. • Where resources are unavailable, greater reliance on alternative approaches, such as through general practitioners, nurses, social workers, pharmacists, and others. • Treatment and intervention available through employers, educators, community. • Access to support structure through involvement of broader community. • Support for those affected by dependent individuals (e.g., children, family).
Special considerations
• Recognition of dependence as a medical condition, not criminal behavior. • Emphasis on sustainable behavior change. • Avoid stigmatization of dependent individuals.
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