Trends In Treatment And Prevention

From the time of Benjamin Rush, two central treatment methods were established, based on the psychiatric treatment methods of the late 1700s: (1) "asylum" in a supportive environment away from drink and companion drinkers and (2) "moral treatment," consisting of a civil, respectful consideration for the recovering person (Johnson & Westermeyer, 2000). Both methods persist today and remain as two standard treatment strategies. They were not and are not inevitably successful. Consequently, other methods have been tried.

One of these methods was the substitution of one drug for another. For example, laudanum (combined alcohol and opiates) was once prescribed for alcoholism. Morphine, and later heroin, was recommended for opium addiction during the mid-1800s. This approach is not extinct, as exemplified by the frequent recommendation in the 1970s that alcoholics substitute cannabis smoking for alcohol. Currently, methadone is used for chronic opiate addicts who have failed attempts at drug-free treatment. Despite aversive selection factors, methadone maintenance patients tend to do well as long as they comply with treatment.

Detoxification became prevalent in the mid-1900s. Public detoxification facilities, established first in Eastern Europe, spread throughout the world. For many patients, this resource offers an entree into recovery. For others, "revolving door" detoxification may actually produce lifelong institutionalization on the installment plan (Gallant et al., 1973). The problem of the treatment-resistant public inebriate exists today in all parts of the United States.

The so-called Minnesota Model of treatment developed from several sources: a state hospital program (at Wilmar) and a later private program (at Hazelden), supplemented by the first day program for alcoholism (at the Minneapolis Veterans Administration Hospital). The characteristics of this "model" have varied over time as treatment has evolved and changed, and definitions still differ from one person to the next. However, characteristics often ascribed to the model include the following:

1. A period of residential or inpatient care, ranging from a few weeks to several months.

2. A focus on the psychoactive substance use disorder, with little or no consideration of associated psychiatric conditions or individual psychosocial factors.

3. Heavy emphasis on AA self-help concepts, resources, and precepts, such as the "12 steps" of recovery.

4. Referral to AA or another self-help group on discharge from residential or inpatient care, with minimal or no ongoing professional treatment.

5. Minimal or no family therapy or counseling (although family orientation to AA principles and Al-Anon may take place).

6. Negative attitudes toward ongoing psychotherapies and pharmaco-therapies for substance use disorder or associated psychiatric disorder.

At the time of its evolution in the 1950s and 1960s, this model served to bridge the formerly separate hospital programs and self-help groups—a laudable achievement. However, if it is applied rigidly in light of current knowledge, some patients (who might otherwise be helped) will fail in or drop out of treatment. Nowadays, many treatment programs employ aspects of the old "Minnesota Model," integrating them flexibly with newer methods in a more individualized and patient-centered manner.

The workplace has been a locus of prevention, early recognition, referral for treatment, and rehabilitation. Following World War II, Hudolin and coworkers in Yugoslavia established factory- and farm-commune-based recovery groups, with ties to treatment facilities. Over the last two decades, alcoholism counselors have worked in similar "employee assistance programs" in the United States.

More sophisticated methods of pharmacotherapy have appeared recently, although these remain few in comparison with other areas of medicine. Safe detoxification is possible through increased basic and clinical appreciation of withdrawal syndromes. Disulfiram, naltrexone, buprenorphine, and methadone may be selectively prescribed as maintenance drugs in the early difficult months and years of recovery. Other medications are currently being investigated for use in special circumstances.

Recognition of comorbid conditions accompanying substance abuse has led to concurrent treatment for affective disorders, anxiety disorders, eating disorders, and pathological gambling. For certain chronic conditions (e.g., mild mental retardation, borderline intelligence, organic brain syndrome, or chronic schizophrenia), substance abuse treatment, rehabilitation, and self-help procedures need to be modified. Intensive outpatient programs, conducted during the day, evening, or weekend, assist certain patients to recover when other measures fail. These intensive outpatient programs are modeled after similar psychiatric programs. Much of the treatment time is spent in groups of various sizes, although individual and family sessions may occur as well. Staffing is typically multidisciplinary, with counselors, nurses, occupational and recreational therapists, psychologists, psychiatrists, and social workers. Monitoring of recovery in several contexts and by several sources (e.g., at work, by licensing agencies or unions, in the family, and with medical resources) appears to enhance outcome (Westermeyer, 1989).

Preventive techniques first applied to the gin epidemic are still useful today: control over hours and location of sales, taxes or duties to increase cost, changing of public attitudes via the mass media, education, and abstinence-oriented religion (Smart, 1982). The prolonged Asian opium epidemic demonstrated that laws alone are ineffective unless accompanied by socially integrated treatment; recovery programs; compulsory abstinence in identified cases; police pressure against drug production, commerce, and consumption; and follow-up monitoring. Experience with anti-alcohol prohibition laws in Europe and North America demonstrated the futility of outlawing substance use that was supported by many citizens. Adverse results from the Prohibition era in the United States included increased criminality associated with bootlegging alcohol, lack of quality control (e.g., methanol and lead contaminants), and development of unhealthy drinking patterns (e.g., surreptitious, rapid, without food, and in a deviant setting). Public interest groups such as MADD may aid in reducing certain alcohol- and drug-related problems. The United States has expended several 10's of billions of dollars since 1970 to reduce the supply of and demand for drugs. But mortality from hepatic cirrhosis, alcohol-related accidents, and suicide continue at an unprecedented level, especially among young American males. Work still remaining includes our learning from history (our own as well as that of others) to honing that aspect of statecraft aimed at eliminating our endemic substance abuse.


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Alcohol No More

Alcohol No More

Do you love a drink from time to time? A lot of us do, often when socializing with acquaintances and loved ones. Drinking may be beneficial or harmful, depending upon your age and health status, and, naturally, how much you drink.

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