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: 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 these symptoms.
3. Salience of drinking: 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: an individual’s compulsion to drink,
triggered by any number of external cues or "primed" by the first
drink or two.
5. Impaired control: an
individual's lack of control over drinking and difficulty setting consumption limits.
At the same time, a dependent individual tends to be acutely
aware of the need to curb his or her drinking.
6. Continued use despite harm: continued
harmful drinking despite awareness of the adverse effects.
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.
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.
.
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.
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.
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
assessment or counseling 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.
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.
