Inpatient versus Outpatient Treatment.People with mild to moderate withdrawal symptoms are usually treated as outpatients and assigned to support groups, counseling, or both. Inpatient treatment in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse is recommended for patients with a coexisting medical or psychiatric disorder and those who may harm themselves or others, who have not responded to conservative treatments, or who have a disruptive home environment. A typical inpatient regimen includes a physical and psychiatric work-up, detoxification, treatment with psychotherapy or cognitive-behavioral therapy, and an introduction to Alcoholics Anonymous. Because of the high cost of inpatient care, its advantages over outpatient care are currently being questioned. One study compared employed alcoholics who were either hospitalized, treated as outpatients with compulsory attendance at AA meetings, or allowed to choose their own treatment optionincluding none at all. After two years, everyone experienced fewer job problems, but those in the inpatient group had significantly fewer rehospitalizations and remained abstinent longer than people in the other two groups. Another study analyzing drug and alcohol treatment programs found that 75% of inpatients completed therapy compared to only 18% of outpatients. Other studies, however, have shown no difference in results between inpatient and outpatient programs, and in one, the costs for AA were 45% lower than other outpatient options. Studies have attempted to uncover characteristics that might make people more likely to drop out of either outpatient or inpatient programs. One study found that people who drop out of outpatient treatments are more apt to be female, young, unskilled, or have more than one addiction. Another reported that those who leave inpatient treatment against medical advice tend to have jobs, to be college educated, and have a history of leaving treatment.
Psychotherapy and Cognitive-Behavioral Therapy.The two usual forms of therapy for alcoholics are cognitive-behavioral and interactional group psychotherapy based on the Alcoholics Anonymous 12-step program. In one study, all treatment approaches were, on average, equally effective as long as the individual program was competently administered. Those with fewer psychiatric problems, however, did best with the AA approach. This confirms an earlier study in which researchers categorized alcoholics as either Type A or Type B. Type A individuals became alcoholic at a later age, had less severe symptoms or fewer psychiatric problems, and had a better outlook on life than those with Type B. The people in the Type A group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy. Type B people became alcoholic at an early age, had a high family risk for alcoholism, more severe symptoms, and a negative outlook on life. This group did poorly with interactional group therapy but tended to do better with cognitive-behavioral therapy. This difference in response to the two forms of treatments held up after two years. Interactional Group Psychotherapy (12-Step Program). Alcoholics Anonymous (AA), founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well-known program for helping people with alcoholism. It offers a very strong support network using group meetings open seven days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation. AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends.
Cognitive-Behavioral Therapy. Cognitive-behavioral therapy uses a structured teaching approach and may be better than AA for severe alcoholism. People with alcoholism are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. For example, patients might write a history of their drinking experiences and describe what they consider to be risky situations. They are then assigned activities to help them cope when exposed to "cues"places or circumstances that trigger their desire to drink. Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team; this gave them the opportunity to practice coping skills, develop supportive relationships, and engage in healthy alternative activities. In one study of patients with both depression and alcoholism, this therapeutic approach achieved 47% abstinence rates after six months compared to only 13% abstinence in patients who received standard treatments and relaxation techniques.
Medications to Aid in Abstinence.Disulfiram. Disulfiram (Antabuse) causes distressing symptoms, including flushing, headache, nausea, and vomiting, if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and last from half an hour to two hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for one to two weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. Studies have not shown the use of disulfiram to have any effect on staying abstinent, although one study found that the total number of drinking days was less in people who took the drug. The drug may also be more effective in married patients or those with other family members or caregivers, including AA "buddies", close by and vigilant to ensure that they take it. Naltrexone. Naltrexone (ReVia) appears to block the pleasurable effects of alcohol and reduce cravings. When used with counseling or support groups, studies indicate that it may be very effective for people with low- to medium-risk for alcohol dependency. In one 10-week program, patients who had been abstinent only 37% of the time increased this rate to 89%, and the average number of drinks consumed when they did drink dropped from 9.5 to 2.5. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.
Acamprosate. Acamprosate (Campral) calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). In one European study, 18% of patients were still abstaining after a year compared to only 7% who did not take the drug. Acamprosate is fully effective after about a week of treatment. It may cause occasional diarrhea. At this time it is available only in Europe but is being tested in America. It should be used along with counseling. Combination therapy with naltrexone or disulfiram may be possible.
Antidepressant and Anti-anxiety Drugs. Depression is common among alcohol-dependent people and can lead to a higher relapse rate. Antidepressants may be helpful, particularly those that maintain elevated levels of serotonin in the brain, since alcoholism has been associated with low serotonin levels. Two studies have reported higher rates of abstinence, fewer heavy drinking days, and fewer drinks in severe alcoholics who took fluoxetine (Prozac), the most common antidepressant in a class known as serotonin reuptake inhibitors (SSRIs). Other SSRIs include sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Another small study reported that people given the tricyclic antidepressant desipramine (Norpramin, Pertofrane)whether or not they exhibited other symptoms of depressionhad fewer drinking days and a longer period between relapses than those not taking the drug. A unique anti-anxiety drug, buspirone (BuSpar), may also be beneficial for alcoholics, particularly if they also suffer from anxiety. The drug has few side effects and a low potential for abuse. It not only reduces anxiety, but also appears to have modest effects on alcohol cravings. In one study, alcoholics who took it had a slow return to alcohol consumption and fewer drinking days than those not on the drug.
Other Drugs. Isradipine, a calcium channel blocker, reduced cravings more effectively than naltrexone and the antidepressant paroxetine (Paxil)drugs used to maintain abstinence. Calcium channel blockers are used to treat high blood pressure and can have serious side effects, which should be discussed with a physician. Another drug being investigated for withdrawal and abstinence is gamma-hydroxybutyric acid (GHB). In one small study, 58% of subjects remained abstinent during a six-month period. The drug has a number of potentially very serious side effects, however.