ALCOHOL DEPENDENCE

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.

Treatment approaches

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.

Implications 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.

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.

Conclusions

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.