Alcoholism Treatment in the United States An Overview - some 14 million Americans have an alcohol problem; treatment efforts are described

Alcohol Research & Health, Spring, 1999 by Richard K. Fuller, Susanne Hilles-Sturmhofel

On any given day, more than 700,000 people in the United States receive alcoholism treatment in either inpatient or outpatient settings. For many of those patients, detoxification--with or without pharmacotherapy--is the first step of treatment. The major behavioral approaches currently used in alcoholism treatment include cognitive-behavioral therapy, motivational enhancement therapy, and Alcoholics Anonymous (AA) or related 12-step programs. Clinical studies, such as the Project MATCH trial, have compared the effectiveness of these approaches. Overall, that study detected no significant differences among the three treatments in patient outcome, although certain treatment methodologies may be most appropriate for patients with certain characteristics. Pharmacotherapy with aversive or anticraving medications may supplement behavioral treatment approaches. Brief interventions that are delivered by primary health care providers also have been shown to reduce drinking levels, particularly in nondependent drinker s. KEY WORDS: addiction care; drug therapy; treatment research; United States; behavior therapy; cognitive therapy; Alcoholics Anonymous; motivational interviewing; treatment outcome; inpatient care; outpatient care; detoxification; aftercare; comparative study; patients; predictive factor; anti AOD (alcohol and other drug) craving agents; anti AOD abuse agents; intervention; literature review

According to the 1992 National Longitudinal Alcohol Epidemiologic Survey, a national household survey, approximately 7.5 percent of the U.S. population (about 14 million Americans) abuse and/or are dependent on alcohol (Grant et al. 1994). Furthermore, according to the 1993 National Drug and Alcoholism Treatment Unit Survey, more than 700,000 people receive alcoholism treatment on any given day (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1997). Of those people, 13.5 percent receive treatment in either a residential or hospital (i.e., inpatient) setting, and 86.5 percent are treated on an outpatient basis. The approaches currently used in the treatment of alcohol problems generally have been developed based on three sources of information: (1) the experiences of recovering alcoholics and the professional staff treating them, (2) research on human behavior, and (3) studies of potential medications (i.e., pharmacological research).

Most treatment programs encourage patients to attend regular Alcoholics Anonymous (AA) meetings or similar self-help groups that are based on a 12-step philosophy. Many treatment programs also use relapse prevention techniques to help patients acquire the skills necessary to prevent a relapse after achieving initial abstinence. This approach is derived from therapeutic methods developed by behavioral psychologists. Cognitive-behavioral therapy (CBT) is based on learning theory principles, which posit that human behavior is largely learned and that learning processes can be used to change problem behaviors.

In addition to 12-step programs and behavioral therapies, one pharmacological agent, disulfiram (Antabuse(r)), has been available and used in alcoholism treatment since the late 1940s. In 1994 the U.S. Food and Drug Administration (FDA) also approved the medication naltrexone ([ReVia.sup.TM]) for alcoholism treatment based on the results of randomized clinical trials. To date, however, naltrexone is not widely used, although pharmacotherapy has shown promising results in improving treatment outcome.

This article summarizes some of the characteristics and recent findings of alcoholism treatment research. It introduces the two general treatment settings (i.e., inpatient and outpatient) and reviews recent research on currently used alcoholism treatment approaches. These approaches include detoxification to manage alcohol withdrawal, nonpharmacological treatment methods, pharmacotherapy, and brief interventions that are designed to be delivered by primary care physicians rather than alcoholism treatment specialists. For more in-depth information on these topics, the reader is referred to subsequent articles in this issue.

BASIC CHARACTERISTICS OF ALCOHOLISM TREATMENT RESEARCH

Until recently, few controlled clinical studies had evaluated and compared the efficacy of various treatment approaches, particularly of AA and other 12-step programs that are currently the cornerstone of alcoholism treatment in the United States. Several factors may contribute to the paucity of controlled research on the efficacy of AA. First, AA became a central component of most treatment programs before stringent study designs and criteria for assessing treatment outcome were introduced as standard procedures for determining alcoholism treatment efficacy. Second, researchers in the past have been deterred from studying AA for several reasons: AA programs can vary tremendously from group to group in the type and number of attendees as well as in the meeting style; furthermore, no standard definition of an AA member exists, and studying AA without perturbing its characteristics, such as the anonymity of its members, is difficult. Third, practitioners may be reluctant to enroll their patients in clinical stu dies of alcoholism treatments if the practitioners believe that the treatment to be evaluated is inferior to the traditional approaches already used. This reluctance is not limited to alcoholism treatment but also occurs in other treatment areas, such as breast cancer therapy. For example, when researchers first initiated clinical trials of lumpectomy (i.e., removal of only the tumor tissue rather than the entire breast) for breast cancer, many physicians considered it unethical to have their patients receive an operation that was potentially less effective.