What does the evidence tell us?
Reprinted from the "Treatments: What Works?" issue of Visions Journal, 2015 15 (4), pp. 23-25
A journal article by leading researchers on alcohol and public health estimates that 4% of the world’s total burden of disease is attributable to alcohol.1 Alcohol consumption is related to more than 60 different medical conditions, including breast cancer and coronary heart disease. Specifically, those who consume more alcohol than is recommended are at a heightened risk of developing an alcohol-attributable disease.
Looking at these statistics, we can clearly see that alcohol use is a substantial issue. This is why effective treatment of alcohol disorders is critically important.
Established treatments for alcohol use disorders
Problems associated with alcohol use can be thought of on a continuum—from no issues at one end of the spectrum to dependence on the other end of the spectrum. Because of this wide range of issues, alcohol use treatment must cater to an assortment of individual needs. Also, the type of treatment that works for one person may not necessarily work for another person. For this reason, it is important to offer many different types of treatment, accessible in many ways (e.g. inpatient, outpatient, support groups, etc.).
Some experts have categorized alcohol treatment into three broad categories: 1) brief intervention, 2) mutual help groups, and 3) specialized treatment programs (e.g., withdrawal management, medications, etc.).1 Brief intervention is generally aimed at those people who have minimal alcohol dependency, or are just at the onset of experiencing any alcohol related issues.1 Mutual self-help groups could include Alcoholics Anonymous, which is seen as a sort of substitute for more formal types of treatment, where clinicians are generally involved. Finally, specialized treatment programs aim to manage withdrawal and potential future relapse.
According to the Alcohol Use Disorders Identification Test (AUDIT)2 instrument, a screening tool used to identify those with harmful and hazardous drinking, there are three distinct divisions of alcohol use: hazardous/risky drinking, harmful drinking, and alcohol dependence.1
Brief intervention is aimed at individuals who score low in terms of alcohol dependence or are just beginning to show signs of alcoholism (i.e., hazardous/risky drinkers). Brief intervention is based on motivational interviewing where clients are presented with objective feedback from a general practitioner or counselor, for example that is based on the information provided by the individual. CARBC has developed a number of paper-based screening tools such as the Alcohol Reality Check questionnaire that asks such questions as how much alcohol you have had in the past week, how many times you have combined alcohol with other risky activities (e.g., operating machinery, mixing with other drugs, etc.). This feedback is given with the hopes of increasing a persons’ awareness of their alcohol consumption and the associated risks. Rather than requiring abstinence, this method instead promotes clients to self-monitor their alcohol intake.1
Brief intervention is considered useful because it acknowledges that individuals enter treatment with differing levels of alcohol dependence and therefore differing levels of therapy needs. However, brief intervention is most appropriate for those clients whose alcohol use is characterized as “harmful” rather than full alcohol dependence.1 Full dependence may require more intense forms of treatment, specifically specialized treatment programs covered later in this article. Brief intervention allows clinicians to make a positive impact in minimal sessions, therefore maximizing the effectiveness for clients who only attend one or two sessions.
Mutual help or self-help groups
Self-help organizations for problem alcohol use have been around for decades. The most widely known group is Alcoholics Anonymous (AA) and its 12-step group approach. The AA 12 steps centre around abstaining from alcohol use, admitting being powerless over alcohol, and relying heavily on belief in God/a higher power. Not only are clients following set steps with goals at each one, but the ongoing personal and emotional support through being a part of a group of non-judgmental and supportive individuals is also important. AA is inclusive such that anyone can join and it’s a free-of-charge, ongoing program where you can choose to attend as many or as few meetings as you like. Furthermore, clients pair themselves with a sponsor who they feel they would be compatible with, someone who has also experienced addiction and can provide support and advice for the client between meetings, as addiction is a constant battle.
Due to the spiritual aspect of AA as well as the notion of participating in a group and sharing personal stories, the guiding principles of the AA program may not suit everyone. They do however cater to individuals at any stage of treatment or non-treatment; as well as the full spectrum of risky drinkers through to those with more serious alcohol dependence.
Of course, 12-step AA groups are just one type of mutual self-help group. There are also secular groups such as LifeRing or SMART, which are peer-run recovery groups for individuals who are either directly affected (i.e., the substance user) or indirectly affected (i.e., family member of substance user) by alcohol.
There is research that suggests participation in self-help groups (i.e., SMART Recovery, Secular Organization for Sobriety, and twelve-step groups such as AA and NA) may be associated with reduced alcohol consumption, fewer alcohol-related outcomes (e.g., Alzheimers, diabetes, obesity, cardiovascular disease, etc.) and better psychological functioning.3 However, a more recent review of the evidence shows that AA groups may simply benefit individuals by encouraging them to begin or continue at a treatment program.4
Specialized treatment options
Withdrawal management (also known as “detox” or “rehab”)
Withdrawal management can be either medicated or not medicated, inpatient or outpatient, depending on the severity of the withdrawal symptoms. If the client is experiencing symptoms such as seizures or delirium tremens, they will likely receive benzodiazepines such as lorazepam to moderate these effects of alcohol withdrawal.5 Interestingly however, studies have found no difference in the effectiveness of inpatient (i.e., being formally admitted to a hospital) versus outpatient treatment,6,7 even though inpatient treatment is much more costly. Generally, especially if the client is experiencing severe withdrawal symptoms, specialized treatment is most useful for those clients at the top end of the spectrum of alcohol use problems (i.e., alcohol dependence).
Medication options have been shown to be beneficial in treating alcohol use disorders. Specifically, a 2014 study investigated the effects of two pharmacological drugs administered for 12-week periods: acamprosate (e.g., Campral) and naltrexone (e.g., Revia or Depade; oral and injection). The authors found that both acamprosate and oral naltrexone were related to reduced return to drinking.8
New online, mobile resources
Today, a very high percentage of people now solely access information from their laptops and their smartphones, so newer developments in treatment cleverly include online options for substance use intervention. This lets users access the information from anywhere, remain anonymous and integrate it into their everyday lives. Furthermore, the large proportion of people who would have experienced barriers to accessing treatment before, whether the barriers were physical, financial or motivational, now have the ability to receive online alcohol treatment.
Researchers investigated a Web-based personalized feedback intervention called CheckYourDrinking.net and found that participants were drinking less alcohol 3 and 6 months after the program had ended, however by 12 months post-intervention the participants had returned to their regular drinking habits.9
There are other online tools such as e-check-up-to-go, a personalized online prevention intervention app. While these online resources are accessible and relatively cheap for the average working person, it must be noted that in order to access them, one must have a computer or smartphone. Many people with alcohol use disorders experience concurrent issues such as poverty or lack of stable housing and/or food, thus these people would likely not have access to the online tools. Furthermore, these interventions and tools are designed to help individuals with less severe alcohol use much like the population that brief intervention targets (i.e., hazardous/risky drinkers), thus cannot replace more intense forms of treatment such as inpatient care.
As a whole, the multiple options for substance use treatment cater to a wide range of needs. Furthermore, treatments are not mutually exclusive and it is important to match your own values, needs and resources with your alcohol use treatment. The type of treatment that works for one person may not necessarily work for another person, and so offering many different types of treatment is important.
About the author
Chantele is a Research Associate at the Centre for Addictions Research of BC in Victoria. She has a master’s degree in Social Psychology and has been at the Centre for over two years. Her main project has been a collaborative effort between CARBC and the BC Ministry of Health to estimate substance use treatment need in the province
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Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. The alcohol use disorders identification test: Guidelines for use in primary care (2nd eds.). World Health Organization, Department of Mental Health & Substance Dependence.
Humphreys, K., Wing, S., McCarty, D. et al. (2004). Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy. Journal of Substance Abuse Treatment, 26(3), 151-165.
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Cunningham, J.A., Wild, T.C., Cordingley, J. et al. (2010). Twelve-month follow-up results from a randomized controlled trial of a brief personalized feedback intervention for problem drinkers. Alcohol and Alcoholism, 45(3), 258-262