Alcohol Abuse Treatment: What do we do now?

The most appropriate decisions related to alcohol abuse treatment can only occur by matching individuals with their treatment needs. The individual’s screening results should differentiate between mild and more severe levels of physical dependence to determine whether detoxification should be part of an individual's early alcohol abuse treatment. If their withdrawal risk is low, it may be appropriate to refer them to an outpatient treatment setting. If the risk for withdrawal is moderate to high, outpatient or inpatient detoxification may be indicated as an absolute imperative for effective alcohol abuse treatment.

There are a large number of life-threatening factors that must be considered in order to determine if alcoholics are at increased risk. Any of the following factors may warrant immediate attention: acute alcohol withdrawal (with the potential for seizures and delirium tremens), serious psychiatric illness (e.g. psychosis, suicidal intentions or behavior), serious medical or surgical disease ( e.g. acute pancreatitis, bleeding esophageal varices). If you notice the presence of any of these emergent problems, acute stabilization should be the first priority for the individual’s alcohol abuse treatment.

The presence of these complicating medical and psychiatric issues is a key determinant in whether an individual receives alcohol abuse treatment in an inpatient or outpatient alcohol rehabilitation setting. Other circumstances include the patient’s current living circumstances and whether they have a social support network. Women with children are frequently unwilling to enter alcohol rehabilitation in residential settings if other family members need to be taken care of. Homeless people may be very willing to enter residential placement even when their medical and psychiatric needs do not warrant it.

After an individual’s acute medical and psychiatric conditions have stabilized, and if they do not have any of the previously referred to conditions, the focus needs to then be on the establishment of a therapeutic alliance. The presence of a trusting relationship will make the alcoholic's consideration of various alcohol abuse treatment options more viable. In addition to participation in a structured alcohol rehabilitation program, the individual should be made aware of the availability of Alcoholics Anonymous (AA) as well as its wide diversity of membership.

Another key factor in determining the optimum alcohol rehabilitation setting is that you should always consider matching the individual with the most appropriate alcohol abuse treatment at the lowest level of intensity required, and then having the alcoholic step up to the next higher level of intensity if the lower level does not work adequately. This approach is consistent with the American Society of Addiction Medicine (ASAM) criteria, which states that inpatient treatment should not be required unless an individual has failed in outpatient alcohol treatment. Matching individuals with appropriate alcohol rehabilitation options includes matching alcoholics guided by theoretically derived hypothesis. This strategy relies upon research evidence that suggests that certain kinds of treatments are more likely to provide improved outcomes for different individuals over other alternatives. An example may be the assignment of individuals with ASPD to cognitive behavioral treatment based upon evidence that these individuals may have better outcomes with more structured alcohol rehabilitation therapy.

The matching of individuals with optimum alcohol abuse treatment continues to attract significant attention, and there appears to be some evidence suggesting that alcoholics with certain characteristics (e.g. severe dependence, high levels of anger, social networks that support drinking) may respond slightly better to certain types of specific therapy (e.g. 12-step programs, motivational enhancement, cognitive behavioral therapy etc.). One study looking at individuals in alcohol rehabilitation programs in both inpatient and outpatient settings found that in certain areas related to their health, employment, family, and psychiatric needs, those provided with alcohol rehabilitation that met their needs in each of these particular areas showed the greatest improvements after discharge. These findings and others may suggest the importance of incorporating a range of alcohol abuse treatment services within specialized alcohol rehabilitation facilities to meet the diverse psychosocial needs of alcoholics.

Despite their efforts at alcohol rehabilitation, some alcoholics repeatedly relapse. For many medical and mental health professionals, the multiple recidivist alcoholic seems to personify the disorder. Clinicians involved in the delivery of alcohol abuse treatment frequently find the individual’s apparent unresponsiveness to treatment a significant source of frustration about the apparent futility of alcohol rehabilitation. Currently, long-term care in residential treatment appears to be the only option these alcoholics respond well to, rather than the more limited alcohol rehabilitation efforts. Unfortunately, the availability of these intensive residential types of services in many states is limited due to cost considerations and the efforts at the deinstitutionalization of psychiatric patients.

Finally, the importance of continuing care through aftercare groups and other mutual support organizations such as Alcoholics Anonymous (AA) cannot be overestimated for individuals in need of alcohol abuse treatment. The use of these resources as well as some of the newer pharmacological and non-pharmacological alcohol abuse treatment options have been developed in the past two decades and will be discussed on subsequent pages of this series.

From DSM-IV-TR Mental Disorders: Diagnosis, Etiology and Treatment by Michael B. First and Allan Tasman

Additional Information and webpage by Paul Susic MA Licensed Psychologist Ph.D. Candidate (Health and Geriatric Psychologist)

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