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  Monday, April 12, 2004

A Controversial Approach to Alcohol Treatment

In keeping with the alcohol related theme, latest Current Opinion in Psychiatry offers a literature review of a controversial approach to the treatment of alcoholism - controlled drinking.

The traditional treatment of alcoholism views that excessive alcohol use is a progressive disease in which the ingestion of even small amounts of alcohol can lead to a loss of control. Over time, the alcoholic's excessive use of alcohol results in physical deterioration as well as emotional and social problems. The primary goal of treatment in the US has focused on abstinence or complete cessation of alcohol use as a means of interrupting the path of self-destructive behavior.

Despite the dominance of an abstinence-focused treatment approach, the authors point out that 'there is an increasing tide of treatment alternatives that emphasize goals other than abstinence. This class of treatments or interventions goes by a host of names including, but not limited to, controlled drinking, reduced-risk drinking, moderated drinking, and asymptomatic drinking.'

The controversial idea of controlled drinking has been around for over 50 years and the debate was sparked by a report published in the UK in the 1960's by Davies and followed by numerous arguments and studies both pro and con.  It did, however, set the stage for several subsequent confirmatory reports on controlled drinking. Developments in the last 3 years have made it clear that there was a need to define what constitutes a controlled-drinking intervention. It was concluded that any treatment strategy or intervention that addressed an alcohol-related problem and which did not require abstinence as a treatment/intervention goal should be included. Thus, not only should interventions targeting either treatment-seeking alcohol dependent individuals or problem drinkers be considered but also interventions that address alcohol-related problems such as binge drinking in college students.

Controlled drinking strategies

One of the more successful techniques described by the authors is behavioral self-control training. (BSCT) This generally consists of (1) self-monitoring of drinking and urges to drink; (2) specific goal setting; (3) rate control of alcohol consumption and drink refusal; (4) behavioral contracting in which reward and consequences for goal adherence are specified; (5) identification and management of triggers for excessive drinking; (6) functional analysis of drinking behavior; and (7) relapse prevention training. BSCT is the most intensely studied controlled-drinking treatment approach, with more than 30 studies published to date. A meta-analysis of randomized controlled trials published between 1984 and 1997 indicated that BSCT was superior, relative to alternative non-abstinence interventions and no intervention, on measures of alcohol consumption and drinking-related problems. The analysis also suggested that BSCT outcomes tended to be superior to abstinence-oriented interventions, but not significantly. A recent related study looked at augmenting BSCT with the opioid antagonist naltrexone to decrease craving and the likelihood of heavy drinking as well as reduce consumption in early problem drinkers.

In addition to traditional Alcohol Anonymous programs, the authors describes a number of other interventions or programs:

Guided self-change (GSC) which is a brief cognitive-behavioral motivational intervention designed to assist problem drinkers to recognize and use their own personal strengths to resolve drinking problems . GSC typically targets problem drinkers with either identifiable alcohol use problems or those with mild-moderate alcohol dependence but without severe alcohol consequences or withdrawal symptoms

Moderation-oriented cue exposure (MOCE) which is a variant of cue exposure treatment for alcohol dependence and is specifically designed to train moderation of alcohol consumption. In general, cue exposure is based on the assumption that cues associated with alcohol consumption acquire the capacity to elicit conditioned responses that bear a functional relationship to craving for alcohol.

Harm reduction in the area of controlled drinking has been conceptualized as an attempt at 'meeting people where they are' with respect to their motivation to change high-risk behavior. Rather than focusing on the elimination of high-risk behaviors, the harm reduction approach tends to favor reducing the harm or risk of harm.

The use of computers in treatment has been shown to produce some interesting results. It was noted above that a computer-based version of BSCT could produce substantial reductions in the drinking behavior of heavy drinkers.  A computer-based intervention called the Drinker's Check Up (DCU) has been developed. The DCU is a brief motivational intervention designed to assist clients with a goal of moderation or abstinence. This computerized treatment was designed for use with at-risk drinkers and alcohol-dependent individuals that are ambivalent about changing their drinking. The treatment is widely available, either on the Internet as a web-based application or in a PC version.

There are a number of self-help organizations dedicated to helping individuals with alcohol-related problems with Alcoholics Anonymous (AA) being the oldest, there are a number of alternatives including: Self Management and Recovery Training, (SMART); Women for Sobriety; Men for Sobriety; Secular Organization for Sobriety (SOS); Rational Recovery (RR); and Moderation Management (MM). Of these programs, only Moderation Management supports moderation or controlled drinking.

The authors conclude that while this review describes some changes and new possibilities in the approaches to the treatment of alcohol abuse/addicition, the concept of controlled drinking tends to have a "disruptive effect on the social, political and economic factors that impact contemporary treatment research and service delivery." There is growing evidence that for some individuals this may be a viable treatment, yet for many, the concept of a "priming effect" is unfortunately a very real issue and abstinence may be the only form of treatment for those individuals.

Current Opinion in Psychiatry: Volume 17(3) May 2004 pp 175-187

9:53:12 PM    comment []

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