Specialized Treatment for Persons with Alcohol Dependence

In countries with well-developed health-care systems, the range of agencies and professional service providers involved in specialist treatment of alcohol-related pro­blems is extensive. In addition to the medical sector, which encompasses psychiatric services and specialist treatment units, treatment is also delivered by social and welfare agencies, workplace programs, and court-mandated pro­grams for persons convicted of drunk-driving.

Some of the key issues that treatment research has addressed with increasing scientific rigor include the most effective detoxification measures, the impact of different treat­ment settings, whether some therapeutic modalities are better than others, the effects of treatment intensity, and factors that influence long-term outcomes.

Detoxification. As noted above, many patients with a history of chro­nic drinking (especially those with poor nutrition and prior experience of an abstinence syndrome) experience withdrawal symptoms, and for some patients alcohol with­drawal can be life-threatening. It is generally assumed that successful management of the alcohol withdrawal syndrome provides a basis for subsequent efforts at rehabilitation. Administration of thiamine and multivita­mins is a low-cost, low-risk intervention that prevents alcohol-related neurological disturbances and is typically combined with supportive care and treatment of con­current illness, including fluid and electrolyte repletion.

Social detoxification, which involves the nonpharmacological treatment of alcohol withdrawal has been shown to be effective. It consists of frequent reassurance, moni­toring of vital signs, personal attention, and general nursing care. Increasingly, detoxification is being done on an ambulatory basis, which is much less costly than hospital-based detoxification. A variety of medications have been used for the treatment of alcohol withdrawal, but the benzodiazepines, especially diazepam and chlordi- azepoxide, have largely supplanted all other medications because of their favorable side-effect profiles.

Optimal Treatment Settings for Rehabilitation. Following detoxification, a variety of programmatic ele­ments and therapeutic modalities have been incorpo­rated into service settings designed to treat the patient’s alcohol-related problems, promote abstinence from alco­hol, and prevent relapse. Service settings are an important component of treatment for alcohol problems, not only because they control access to treatment, but also because the setting often determines the climate (sometimes called the milieu), the resources and the professional staff pro­viding treatment.

Alcohol treatment is typically provided in outpatient hospital settings, but it can also be delivered in psychiatric clinics, social service agencies, and health­care settings. Treatment is also delivered in residential settings, which include hospital-based rehabilitation pro­grams, freestanding units, and psychiatric units.

In most comparative studies, outpatient programs have been found to produce outcomes comparable to those of residential programs. This conclusion, however, should be tempered by a consideration of the kinds of problem drinkers who are appropriate for each type of pro­gram (Finney etal, 1996). Some studies comparing outpa­tient with residential treatment have not controlled for the possibility that patients who choose outpatient set­tings are less severely alcohol-dependent, less physically ill, or less psychiatrically impaired.

Residential treatment may be indicated when motivation is weak to continue treatment, when patients are psychotic, depressed, or suicidal, and when there are medical complications. Other factors that affect the choice of treatment setting include patients’ social stability, the severity of their symptoms, and the ability of a program to respond to individual needs.

An obstacle to ambulatory treatment is the higher rate of attrition usually encountered among more severely impaired alcoholics. An obvious question is whether some treatment settings are more cost-effective than others. In general, the research evidence on the cost-effectiveness of different treatment modalities has consistently found that the more expensive modalities do not necessarily produce better treatment outcomes.