When a determination has been made that an individual is drink-ing excessively, the nature, setting and intensity of the interven-tion must be determined in order to address the specific treatment needs of the patient. Among heavy drinkers without evidence of alcohol dependence, a brief intervention aimed at the reduction of drinking may suffice. In contrast, among alcoholics, there are typically a variety of associated disabilities, so it is necessary to address both the excessive drinking and problems related to it. Consequently, alcoholism treatment is best conceived of as mul-timodal. Table 35.3 provides an overview of the goals of alcohol-ism treatment. It should be noted that while total abstinence is a primary goal of treatment for persons with alcohol dependence, moderate drinking can be considered as a goal for persons with alcohol abuse.
Figure 35.1 describes a process for the management of patients with alcohol abuse and dependence. The algorithm is written from the perspective of a community-based or consul-tation/liaison psychiatrist who does not necessarily have spe-cialized training in addiction medicine. Following the initial
assessment, using a screening test like the CAGE or AUDIT, the patient is referred to either a diagnostic evaluation with a likely treatment recommendation or a brief intervention with further monitoring. Brief interventions are characterized by their low intensity and short duration. They typically consist of one to three sessions of counseling and education. They are intended to provide early intervention, before or soon after the onset of alco-hol-related problems. Brief interventions seek to motivate high risk drinkers to moderate their alcohol consumption, rather than promote total abstinence with specialized treatment techniques. They are simple enough to be delivered by primary care prac-titioners and are especially appropriate for psychiatric patients whose at-risk drinking meets criteria for alcohol abuse rather than dependence.
If the patient’s screening results and diagnostic evaluation provide evidence of alcohol dependence, the next step is to differ-entiate between mild and more severe levels of physical depend-ence to determine the need for detoxification. If withdrawal risk is low, the patient may be referred directly to outpatient therapy. If the withdrawal risk is moderate or high, outpatient or inpatient detoxification is indicated.
There are a number of potentially life-threatening condi-tions for which alcoholics are at increased risk. The presence of any of the following requires immediate attention: acute alco- hol withdrawal (with the potential for seizures and delirium tre-mens), serious medical or surgical disease (e.g., acute pancreati-tis, bleeding esophageal varices) and serious psychiatric illness (e.g., psychosis, suicidal intent). In the presence of any of these emergent conditions, acute stabilization should be the first prior-ity of treatment.
The presence of complicating medical or psychiatric con-ditions is an important determinant of whether detoxification and rehabilitation are initiated in an inpatient or an outpatient setting. Other considerations are the alcoholic’s current living circum-stances and social support network. Women with children are sometimes unwilling to enter residential treatment unless their family needs are taken care of. Homeless people may be eager to enter residential treatment even when their medical or psychiat-ric condition does not warrant it.
In the alcoholic patient whose condition is stabilized or in the patient without these complicating features, the major focus should be on the establishment of a therapeutic alli-ance, which provides the context within which rehabilitation can occur. The presence of a trusting relationship facilitates the patient’s acknowledgement of alcohol-related problems and encourages open consideration of different treatment op-tions. In addition to participation in structured rehabilitation treatment, the patient should be made aware of the widespread availability of Alcoholics Anonymous (AA) and the wide di-versity of its membership.
Residential settings include hospital-based rehabilitation programs, freestanding units and psychiatric units. With the growth of managed care in the 1990s, there has been a dramatic reduction in the average length of stay for residential treatment and a shift in emphasis to less costly outpatient treatment set-tings. There is no consistent evidence that intensive or inpatient residential treatment provides more benefit than less intensive outpatient treatment, but for certain kinds of patients residential treatment may have advantages (Finney and Monahan, 1996). In many populations, outpatient programs produce results compara-ble to those of inpatient programs.
Another approach to patient placement and treatment matching is based on the notion that patients should initially be matched to the least intensive level of care that is appropriate, and then stepped up to more intensive treatment settings if they do not respond.
Despite treatment, some alcoholics relapse repeatedly. For many emergency department personnel, the multiple recidivist al-coholic has come to personify the disorder. For clinicians involved in the delivery of alcoholism rehabilitation services, these individ-uals’ apparent unresponsiveness to treatment may contribute to frustration and a sense of futility. Presently, long-term residential treatment appears to be the only option for alcoholics who do not respond to more limited efforts at rehabilitation. Unfortunately, the availability of such care in many states is limited as a conse-quence of the effort to deinstitutionalize psychiatric patients.
Finally, the importance of continuing care by means of af-tercare groups, and other mutual help organizations cannot be overestimated.