Location and intensity of treatment Specialist treatments

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The main treatment response to alcohol use disorders continues to be delivered by specialists. There has been extensive research on the location and intensity of specialist treatment. An early influential study was that of Edwards et al.(7) in which 100 alcohol-dependent men referred to the Maudsley Hospital in London were randomized to receive either intensive specialist treatment, including inpatient care in an alcoholism treatment unit, or one session of counselling. At 1-year follow-up there was no difference in outcome between the two treatments. It was concluded that the reliance on intensive treatments up to that time was called into question by the findings. This controversial study gave rise to considerable debate and several studies have subsequently investigated the same issues. Another British study attempted to replicate the Edwards study and found only modest differences between advice only and extended treatment in a randomized controlled trial at 2 years's follow-up.(8) There were, however, no differences between treatments in abstinence rates or alcohol consumption level during follow-up.

In a larger study in the United States, 227 employees identified as abusing alcohol were randomized to one of three options: compulsory inpatient treatment, compulsory AA attendance, or a choice of these two options.(9) At 2-year follow-up there were no differences between the groups in terms of work-related outcome measures. However, on seven drinking-related measures the inpatient group had the best, and the AA group the poorest outcome, with the choice group having an intermediate outcome. The compulsory AA group was more likely than the others to require subsequent inpatient treatment. However, the length of inpatient treatment does not appear to influence outcome significantly. (1. H)

Studies comparing inpatient versus outpatient alcohol detoxification have generally found the two approaches to be equally effective. For example, Hayashida et al.'(1,2) randomized 164 male military veterans to inpatient and outpatient detoxification. At 6 months's follow-up no differences in outcome were found between the two groups. Indeed, outpatient detoxification is generally regarded as the treatment of choice for the majority of patients. (!, It should be noted, however, that studies comparing inpatient and outpatient treatment (including detoxification) have tended to exclude patients with particularly poor prognosis (e.g. poor social circumstances, severe psychiatric or physical comorbidity, those at risk of harm to themselves or others). Hence, the clinician needs to interpret the research evidence with caution in the usual clinical setting. However, it is probably safe to assume that in 'uncomplicated' alcohol dependence there is no evidence of an advantage of inpatient over outpatient treatment.

Another important specialist treatment approach used widely in the private or non-statutory treatment sector is residential treatment based upon the Minnesota Model originally developed in the Hazelden Clinic in Minnesota, using an approach closely allied to the AA movement. These approaches, often described as 12-step programmes after the 12 steps of AA, have not generally been subjected to randomized controlled trials.(1 .I.6,) One trial in Finland, however, found a higher rate of abstinence at 12 months's follow-up in the Hazelden treatment group compared with traditional residential psychiatric treatment not involving the Minnesota Model approach (26.3 per cent vs. 9.8 per cent). (1Z) However, the higher abstinence rate was not supported by corresponding reduction in markers of heavy drinking (g-glutamyl transferase, mean cell volume).

It is also important to note that the self-help movement of AA, which was founded in the United States in 1935, is a major provider of help and support for people with alcohol use disorders, with more than 73 000 groups worldwide. (1J> Indeed, a higher proportion of problem drinkers attend AA than formal alcohol treatment programmes/!9) Although this approach is largely unevaluated, because of the difficulty of using conventional randomized controlled trials in this setting, there is evidence that regular AA attendance is associated with better outcomes in those with a high level of alcohol dependence. (2,21) Regular AA attenders are, of course, self-selected.

Overall, the majority of studies that have compared intensive specialist treatment with less intensive treatment have not supported the use of more intensive approaches, with a few important exceptions. However, three points are important to note. Little attention has been paid to the issue of matching effects in these studies: do patients with more severe or complex problems benefit more from intensive treatments, as would seem intuitively reasonable? Second, many of the studies have had important methodological limitations, not least being small sample sizes that increase the risk of type 2 error. Third, as noted above, more complex cases tend to be excluded from research trials, which limits the generalizability of the existing research base. With improved methodology now available and an awareness of the possibility of matching effects, this issue is far from closed.

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Beat The Battle With The Bottle

Beat The Battle With The Bottle

Alcoholism is something that can't be formed in easy terms. Alcoholism as a whole refers to the circumstance whereby there's an obsession in man to keep ingesting beverages with alcohol content which is injurious to health. The circumstance of alcoholism doesn't let the person addicted have any command over ingestion despite being cognizant of the damaging consequences ensuing from it.

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