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A Randomized Trial of Treatment Options for Alcohol-Abusing Workers
Abstract
Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options.
We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period.
All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment.
Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.
... In fact, Raspe (2009) encourages better evidence for effectiveness of the German rehabilitation system. In terms of the determinants of return to work, the focus often lies on specific diagnoses such as musculoskeletal disorders (Krischak et al., 2013; Bloch / Prins, 2001; Mau, 2006; Gallagher et al., 1989), cancer (Spelten et al., 2002) or alcohol dependency (Buschmann-Steinhage / Zollmann, 2008; Walsh et al., 1991). Bloch / Prins (2001) consider in their longitudinal country comparative study patients with lower back pain. ...
... The authors report in their findings that 18 % of alcohol dependent patients are gainfully employed subject to statutory social security for twelve months on average within two years after the pertinent medical rehabilitation. Walsh et al. (1991) contribute to the debate on the effectiveness of different treatment options for alcohol-abusing workers. In a design of random assignment of patients to three possible rehabilitation programs, the authors compare the groups with respect to their job performance and drinking and drug use in the course of a two-year follow-up period. ...
... The assignment occurs to the following treatment options: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings and a choice between these options. In terms of the measures of job performance such as hours missed from work, problems with supervisors, warning notices, drinking on the job, and absenteeism because of drinking, Walsh et al. (1991) do not find any significant differences among the treatment groups. However, results concerning the measures of drinking and drug use such as average daily number of drinks, number of drinking days per month, serious problems, intoxication, blackouts, definite alcoholism and cocaine use are not univocal. ...
The authors examine the labor market reintegration after medical rehabilitation by analyzing a large representative administrative panel data set for Germany. The research design focuses on socio-demographic group differences in before-after differences in days with unemployment benefits, days in employment, and labor income of participants in medical rehabilitation. The mean before-after differences indicate that the number of days with unemployment benefits is larger and the number of working days and labor income are smaller after the rehabilitation than before. Our regression analysis further reveals that the before-after differences in labor market outcomes differ significantly between socio-demographic groups.
... Troisi, II, Joseph R. "Perhaps More Consideration of Pavlovian-Operant Interaction May Improve the Clinical Efficacy of Behavioral-Based Drug Treatment Programs," Psychological Record 63 no. 4 (2013): 863-94. 48 The question then becomes, "Is adherence to dogma more important than offering another proven and well-documented aid to sobriety?" Adherence to dogma does not equal sobriety. ...
... This automatic response to a cue sets an operant chain in motion that terminates in use of the drug of choice that suggests the utility of cue exposure therapy (CET) (Troisi 2013). 48 ...
Challenges the current paradigm regarding addiction as a chronically relapsing brain disease (Brain Disease Model of Addiction BDMA). Creates a more plausible paradigm encompassing early trauma induced emotional dysregulation through the limbic system coopting the normal frontal and prefrontal cortex as the executive decision maker. Separates the software "mind" from the "hardware" brain and addresses treatment options.
... Nor are the two reports isolated. A randomized study conducted by Walsh et al. (1991) that was voluntary in nature, demonstrates that participants who personally chose AA fared significantly worse when compared to those who chose from an array of other treatments, including inpatient care. Kownacki and Shadish (1999) conducted a meta-analysis of "21 controlled studies of AA, with emphasis on methodological quality" (p. ...
... The primary factor that differentiates many of these reports from prior studies lies in the selfselection process, post treatment for addiction. Contrary to the findings of Walsh et al. (1991), they demonstrate that AA is more likely to work for those who attend AA on their own volition and are actively immersed in the program for extended periods. Kelly et al. (2011) report that, "increasingly rigorous research conducted in the past 15 years supports the notion that AA participation is associated with better short and long-term outcomes and may be a cost-effective treatment adjunct" (p. ...
This study expands the role of transpersonal psychology in the treatment of addiction and offers a revised theoretical model that is, in effect, a spiritual alternative to the Twelve-step approach. First, the current transpersonal model of addiction is deconstructed based on three of its core suppositions: (a) that Twelve-step programs are spiritual rather than religious, (b) that they are philosophically congruent with transpersonal theory, and (c) that they are the most effective treatment for addiction. Next, aspects of two major theoretical trends in transpersonal studies, the integral and the participatory perspectives, are then implemented as foundational supports for extending the traditional transpersonal model of addiction beyond its current boundaries. Addiction research from different fields and disciplines is also referenced to ensure that the model is effective, appropriate, and relevant.
... First, the green cluster in Figure 2 refers to remedial EAP orientations. A wealth of research is concerned with the remedial functions of EAPs, including multiple types of post-event interventions (both spiritual and material EAP support), such as alcohol treatment/management (Walsh et al., 1991), weight reduction (Clancy et al., 2018), smoking cessation (Street & Lacey, 2018) and drug/substance abuse interventions (Waehrer et al., 2016). These programmes are executed to minimize the dysfunctional effects of personal and job-related problems that have already occurred. ...
Scholars across disciplines (e.g., medicine and health, human resource management, organizational behaviour) have paid increasing attention to employee assistance programmes (EAPs) over the past 40 years. Our study systematically reviewed 327 EAP studies published in peer‐reviewed journals from 1980 to December 2021. We provided both descriptive and thematic analyses of this body of literature. We revealed that existing research has not paid sufficient attention to the role of multiple stakeholders, the importance of context and the strategic nature of EAPs, all of which are critical to EAP effectiveness. To fill these gaps, we develop an integrated conceptual model for EAP research that highlights the stakeholder perspective, strategic human resource management and contextual approach. We argue that EAPs cannot yield desirable outcomes without three forms of ‘strategic fit’: the internal fit between EAPs and a bundle of HR strategies; the organizational fit between EAPs and business strategies; and the environmental fit between EAPs and the environmental contexts. We suggest that employees and other diverse stakeholders should proactively engage in the EAP process to achieve mutual gains.
... Despite the vitality of these groups for more than 50 years and the acceptance of AA as an effective treatment for alcoholism by the professional and lay communities, there is little systematic evidence of their effectiveness (Emrick & Aarons, 1991). Unfortunately, relatively few randomized studies have been conducted to test the effectiveness of treatments for alcohol problems and a still smaller number have randomly assigned participants to A A (Brandsma, Maultsby, & Welsh, 1980;Ditman, Crawford, Forgy, Moscowitz, & Macandrew, 1967;Walsh et al., 1991). Fortunately, in recent meetings sponsored by the National Institute of Alcohol Abuse and Alcoholism, investigators have begun to encourage the use of randomized trials to test the benefits of AA (T. ...
The article focuses on the validity of measures of service delivery; any attempt to establish a linkage between service and outcomes follows the assumption that services have been given and received. Claims relating to the benefits of attending self-help groups on the mental health functioning of individuals with depression or manic depression were examined in the context of a well-controlled study and a validated measure of individual attendance. A test was conducted to probe the conjecture that the greater the degree of involvement in self-help groups, the greater the improvement in functioning. Additional questions related to individual patterns of attendance, generalization of the intervention's effects, and migration from “home” to other meeting sites.
... Recent studies suggested a significant dose-and time-dependent effect of alcohol consumption on AF genesis, and the high AF risk is also associated with long-term alcohol abuse, even in those without co-existing cardiovascular diseases [39][40][41][42]. Unfortunately, the success rate of rehabilitation from chronic alcohol abuse for those wishing to stop drinking is low, at between 5% and 30% [43,44]. Although AF is a growing public health concern, the currently available treatment strategies, including anti-arrhythmic drugs and atrial ablation, for alcohol-related AF remain suboptimal, largely due to the lack of understanding of the underlying mechanisms. ...
Long-term alcohol consumption leads to cardiac arrhythmias including atrial fibrillation (AF), the most common alcohol-related arrhythmia. While AF significantly increases morbidity and mortality in patients, it takes years for an alcoholic individual undergoing an adaptive status with normal cardiac function to reach alcoholic cardiomyopathy. The underlying mechanism remains unclear to date. In this study, we assessed the functional role of JNK2 in long-term alcohol-evoked atrial arrhythmogenicity but preserved cardiac function. Wild-type (WT) mice and cardiac-specific JNK2dn mice (with an overexpression of inactive dominant negative (dn) JNK2) were treated with alcohol (2 g/kg daily for 2 months; 2 Mo). Confocal Ca2+ imaging in the intact mouse hearts showed that long-term alcohol prolonged intracellular Ca2+ transient decay, and increased pacing-induced Ca2+ waves, compared to that of sham controls, while cardiac-specific JNK2 inhibition in JNK2dn mice precluded alcohol-evoked Ca2+-triggered activities. Moreover, activated JNK2 enhances diastolic SR Ca2+ leak in 24 h and 48 h alcohol-exposed HL-1 atrial myocytes as well as HEK-RyR2 cells (inducible expression of human RyR2) with the overexpression of tGFP-tagged active JNK2-tGFP or inactive JNK2dn-tGFP. Meanwhile, the SR Ca2+ load and systolic Ca2+ transient amplitude were both increased in ventricular myocytes, along with the preserved cardiac function in 2 Mo alcohol-exposed mice. Moreover, the role of activated JNK2 in SR Ca2+ overload and enhanced transient amplitude was also confirmed in long-term alcohol-exposed HL-1 atrial myocytes. In conclusion, our findings suggest that long-term alcohol-activated JNK2 is a key driver in preserved cardiac function, but at the expense of enhanced cardiac arrhythmogenicity. Modulating JNK2 activity could be a novel anti-arrhythmia therapeutic strategy.
... Parallel organizations with varying ideologies and approaches have been developed in a number of other countries such as Danshukai in Japan, Kreuzbund in Germany, Croix d'Or and Vie Libre in France, Abstainers Clubs in Poland, Family Clubs in Italy, and Links in the Scandinavian countries (Room 1998;Humphreys et al. 2004). Several large-scale, well-designed studies (Walsh et al. 1991;Ouimette et al. 1999) suggest that AA can have an incremental effect when combined with formal treatment, and AA attendance alone may be better than no intervention. ...
This book is about alcohol policy: why it is needed, how it is made, and the impact it has on health and well-being. It is written for both policymakers and alcohol scientists, as well as the many other people interested in bridging the gap between research and policy. It begins with a global review of epidemiological evidence showing why alcohol is not an ordinary commodity, and it ends with the conclusion that alcohol policies implemented within a public health agenda are needed to reduce the enormous burden of harm it causes. The core of the book is a critical review of the cumulative scientific evidence in seven general areas of alcohol policy: pricing and taxation; regulating the physical availability of alcohol; modifying the environment in which drinking occurs; drink-driving countermeasures; marketing restrictions; primary prevention programmes in schools and other settings; and treatment and early intervention services. The final chapters discuss the current state of alcohol policy in different parts of the world, the detrimental role of the alcohol industry, and the need for both national and global alcohol policies that are evidence-based, effective, and coordinated. This book shows that opportunities for evidence-based alcohol policies that better serve the public good are clearer than ever before, as a result of accumulating knowledge on which strategies work best.
... Parallel organizations with varying ideologies and approaches have been developed in a number of other countries such as Danshukai in Japan, Kreuzbund in Germany, Croix d'Or and Vie Libre in France, Abstainers Clubs in Poland, Family Clubs in Italy, and Links in the Scandinavian countries (Room 1998;Humphreys et al. 2004). Several large-scale, well-designed studies (Walsh et al. 1991;Ouimette et al. 1999) suggest that AA can have an incremental effect when combined with formal treatment, and AA attendance alone may be better than no intervention. ...
This book is about alcohol policy: why it is needed, how it is made, and the impact it has on health and well-being. It is written for both policymakers and alcohol scientists, as well as the many other people interested in bridging the gap between research and policy. It begins with a global review of epidemiological evidence showing why alcohol is not an ordinary commodity, and it ends with the conclusion that alcohol policies implemented within a public health agenda are needed to reduce the enormous burden of harm it causes. The core of the book is a critical review of the cumulative scientific evidence in seven general areas of alcohol policy: pricing and taxation; regulating the physical availability of alcohol; modifying the environment in which drinking occurs; drink-driving countermeasures; marketing restrictions; primary prevention programmes in schools and other settings; and treatment and early intervention services. The final chapters discuss the current state of alcohol policy in different parts of the world, the detrimental role of the alcohol industry, and the need for both national and global alcohol policies that are evidence-based, effective, and coordinated. This book shows that opportunities for evidence-based alcohol policies that better serve the public good are clearer than ever before, as a result of accumulating knowledge on which strategies work best.
... In conditions with detoxication only and detoxications combined with 12-step program, it was 23% and 49%, respectively. Other longitudinal studies comparing AA twelve-step program with outpatient treatment also showed its effectiveness (Humphreys & Moos, 1996;Pisani, Fawcett, Clark, & McGuire, 1993;Walsh et al., 1991). ...
Background and aims
Sexuality is natural to human life and inseparable from it, yet some individuals develop compulsive sexual behavior (CSB). Many individuals with CSB seek treatment in free self-support groups based on the twelve-step program. This program was extensively studied in substance abuse disorders (e.g., Alcoholics Anonymous), but little is known about its efficiency in CSB.
Methods
We “assesed” questionnaire data on sociodemographical-, psychological-, and recovery-related factors from 97 male participants of Sexaholics Anonymous (SA) programs in Israel.
Results
Our results indicated that advancement in the SA program, measured as a current step of the program, is significantly related to lower levels of sexual-related overall sense of helplessness, avoidant help-seeking, self-control, overall CSB, and sexual suppression. It is also related to the higher well-being.
Discussion
This is the first study to examine psychological factors of CSB recovery process in twelve-step groups, and future research is needed to replicate our results within a longitudinal study.
... The giving and receiving of nonclinical, nonprofessional help to achieve long-term recovery from SUD is central to the approach (Fiorentine & Hillhouse, 2000;Moos & Moos, 2005;Phillips et al., 2014). MA approaches are effective in promoting engagement with healthcare (Moos & Moos, 2005;Phillips et al., 2014;Fiorentine & Hillhouse, 2000;Walsh et al., 1991). ...
Chronic hepatitis C virus (HCV) infection is associated with liver disease, including cancer. Novel therapy options make cure possible. People with history of injecting drugs have high HCV prevalence. Groups are effective at promoting health engagement. Thirty-eight people in Narcotics Anonymous completed a pilot survey. All were abstinent but had engaged in risk behavior for HCV. Forty-two percent thought it was difficult to engage for HCV therapy, 65% stated it was hard to access novel treatments, and 97% considered that people in Narcotics Anonymous should find out information about novel HCV therapy. Groups present an important option for promoting engagement in HCV.
... A noteworthy finding was that inpatients had fewer days incarcerated and/or in residential treatment in the follow-up periods than either intensive or standard outpatients. The finding is similar to the results of Walsh et al. (1991), who found clients randomly assigned to inpatient treatment had fewer subsequent inpatient treatment days than did clients randomly assigned to attend AA or their choice of treatment. In fact, Walsh et al. found the cost of outpatient treatment only 10% less than inpatient treatment when the additional residential treatment received by outpatients was taken into account. ...
This study compared inpatient, intensive outpatient, and standard outpatient treatment settings for persons with alcoholism and tested a priori hypotheses about the interaction of setting with client alcohol involvement and social network support for drinking. Participants (N = 192) were assigned randomly in cohorts to 1 of the 3 settings. The settings did not differ in posttreatment primary drinking outcomes, although inpatients had significantly fewer jail and residential treatment days combined than outpatients. Clients high in alcohol involvement benefited more from inpatient than outpatient care; the opposite was true at low alcohol involvement levels. Network drinking support did not moderate setting effects. Clients low in cognitive functioning also appeared to benefit more from inpatient than outpatient care. Improved outcomes might he achieved by matching degree of alcohol involvement and cognitive functioning to level of care.
... Questi dati rendono ragione del perché, in tutti i paesi industrializzati, si siano adottate politiche per il contrasto dell'abuso di alcol, e perché i luoghi di lavoro siano il teatro privilegiato dei programmi di prevenzione, con un ruolo fondamentale giocato dal Medico del Lavoro (41,149,175,178,204). La riduzione del consumo di alcolici sul lavoro potrebbe, da sola, determinare un risparmio in vite umane e in infortuni sul lavoro superiore a quello che si è ottenuto negli ultimi dieci anni per tutti gli interventi di prevenzione condotti nei luoghi di lavoro. ...
Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers.
A written document expressing agreement was produced following discus-sions between doctors, lawyers, bioethicists and social partners.
There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consump-tion alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be vio-lating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspec-tors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved. Conclu-sions: The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.
... Thus, although the overall effec tiveness of inpatient care generally is accepted (Finney and Moos 1991;Walsh et al. 1991), concerns exist that this more costly approach has been applied to many patients who did not require this level of care. Moreover, aside from the actual dollar costs of treatment, other costs with potential clinical implications may be associated with inappropriate patienttreatment matching. ...
The proliferation of managed health care systems as a means of controlling rising health care costs has stimulated efforts to subdivide the heterogeneous population of alcoholics into more homogeneous subgroups based on their needs for specific levels of treatment. The American Society of Addiction Medicine (ASAM) has developed a set of criteria aimed at helping clinicians select from four levels of care the one most appropriate for each patient. The ASAM criteria are designed around six criteria dimensions reflecting the severity of the patients' alcohol-related problems. Although the ASAM criteria currently are the most widely used placement criteria for alcoholism treatment and reimbursement, they also have been criticized in several respects. Moreover, they still require outcome validation to ensure that application of the criteria improves treatment outcome.
... 6) retient 14 études qui comparent l'efficacité du traitement résidentiel par rapport au traitement externe. Sept de ces études ne trouvent aucune différence significative entre les deux modalités de traitement , cinq études constatent une légère supériorité du traitement résidentiel (Chick et coll., 1988;;Timko et coll., 1994, Mckay et coll.,1995bWalsh et coll., 1991;Wanberg et coll., 1974) et deux études montrent une efficacité accrue du traitement externe (Fink et coll., 1985;McKay et coll., 1995a). Les cinq études qui constatent une efficacité accrue du traitement interne se distinguent des neuf autres par les aspects suivants : 1) l'assignation au hasard à une modalité de traitement n'a pas été u ...
Objective: Saudi Arabia is actively working to improve citizens' quality of life and achieve comprehensive development, with a specific focus on combating drug abuse. Strict measures, including legislative policies, have been implemented to prevent, treat, and rehabilitate individuals involved in drug abuse. The emphasis is on creating a drug-free work environment for government employees, enhancing workplace safety, and improving overall performance through regular and random drug tests. Clear guidelines and protocols ensure transparency and fairness in policy implementation. Methods: The study adopts a descriptive-analytical methodology, shedding light on the description and analysis of the actual reality of drug control and its impact on the development process within the country. The study relies on a range of primary and secondary sources, as well as scientific publications. Results: The suggestion of conducting drug tests for employees may stir controversy due to privacy concerns and potential impact on employee integrity. To ensure the fair achievement of this goal, policies should include clear procedures for handling results and provide opportunities for rehabilitation and reemployment. Implementing drug testing policies requires enhancing transparency, clearly stating objectives and procedures to employees, confirming their rights, and specifying measures taken in case of positive results. Harmony between policies and legislation is necessary, emphasizing employee rights and striking a balance between security and individual dignity. Suggestions: The social impact on an employee undergoing drug testing and showing positive results should be considered. Individuals using drugs often face discrimination and exclusion, and to avoid this, coherent legislative policies should be developed to balance the interests of the work environment with the rights and privacy of employees. This will help avoid injustice and negative effects on individuals who need support and assistance in changing their behavior.
Background
The Canadian Society of Addiction Medicine La Societe medicale canadienne sur l’addiction Policy Committee created a task force to conduct a systematic review examining the effectiveness of involuntary treatment for individuals with substance use disorders (SUDs).
Methods
We followed Preferred Reporting Items for Systematic Reviews & Meta-analyses (PRISMA) guidelines and searched 2 databases for peer-reviewed articles assessing the effectiveness of involuntary treatment modalities for substance use disorders from inception to July 2021. Effectiveness was defined as any SUD-related outcome, including treatment retention, post-treatment substance use frequency, overdose mortality, improvement in functioning, or other patient-centred outcomes. Involuntary treatment was defined as any modality not fully motivated by the individual’s volition to seek treatment.
Results
Forty-two studies met the review criteria, with 354,420 participants. Most studies were from the United States, Canada, and China: most measured substance use changes, criminal recidivism, and retention in treatment. Only 7 studies comparing involuntary to voluntary intervention reported improved outcomes in the involuntary group, with most for retention in treatment and only one showing a reduction in substance use. Six out of 7 studies comparing different involuntary interventions occurred in the context of prison or probation. No studies compared the involuntary treatment to no treatment. Only 11 described evidence-based treatment for SUDs, while 5 diagnosed and co-treated psychiatric comorbidity and 11 discussed the motivation for treatment.
Conclusions
There is a lack of high-quality evidence to support or refute involuntary treatment for SUD. More research is needed to inform health policy.
Contexte
Le comité d’orientation de la Canadian Society of Addiction Medicine La Societe medicale canadienne sur l’addiction a créé un groupe de travail chargé d’effectuer une étude systématique sur l’efficacité du traitement non volontaire des personnes souffrant de troubles liés à l’utilisation de substances (TLUS).
Méthodes
Nous avons suivi les directives PRISMA et cherché dans deux bases de données des articles évalués par des pairs sur l’efficacité des modalités de traitement non volontaire des troubles liés à l’utilisation de substances, depuis sa création jusqu'à juillet 2021. L’efficacité a été définie comme tout résultat lié aux troubles liés à l’utilisation de substances, y compris la rétention du traitement, la fréquence de l’utilisation de substances après le traitement, la mortalité par overdose, l’amélioration du fonctionnement ou d’autres résultats centrés sur le patient. Le traitement non volontaire est défini comme toute modalité qui n’est pas entièrement motivée par la volonté de l’individu de se faire soigner.
Résultats
42 études ont répondu aux critères d’examen, avec 354 420 participants. La plupart des études provenaient des États-Unis, du Canada et de la Chine: la plupart mesuraient les changements dans la consommation de substances, la récidive criminelle et la rétention en traitement. Seules sept études comparant l’intervention non volontaire à l’intervention volontaire ont fait état de meilleurs résultats dans le groupe non volontaire, la plupart concernant la rétention en traitement et une seule montrant une réduction de la consommation de substances. Six des sept études comparant différentes interventions non volontaires ont eu lieu dans le contexte de la prison ou de la probation. Aucune étude n’a comparé le traitement non volontaire à l’absence de traitement. Seules 11 études décrivaient un traitement basé sur des preuves pour les TLUS, tandis que cinq études diagnostiquaient et traitaient la comorbidité psychiatrique et 11 études discutaient de la motivation pour le traitement.
Conclusions
Il y a un manque de preuves de haute qualité pour soutenir ou réfuter le traitement non volontaire des TLUS. Des recherches supplémentaires sont nécessaires pour éclairer la politique de santé.
Background:
Although our understanding about neurobiology of opioid dependence and availability of pharmacological treatment has gone a long way in the last few decades, psychosocial interventions play a pivotal role in the prevention of relapse owing to reasons such as less treatment-seeking behavior and poor penetrance of opioid substitution treatment. There are many studies assessing psychosocial factors in alcohol and nicotine dependence, yet the availability of such studies for opioid dependence is sparse. This study aimed at evaluating the association of relapse in opioid dependence with various psychosocial factors.
Materials and methods:
This was a cross-sectional study with two groups of opioid dependence patients: In abstinence (N = 28) and relapse (N = 33). Psychosocial variables such as high-risk situations, coping behavior, stressful life events, self-efficacy, and social support were assessed in the two groups and analyzed for the association with opioid relapse.
Results:
This study reports that more high risk situations (odds ratio [OR] =1.58; 95% confidence interval [CI] =1.22-2.03; P = 0.017), especially negative mood state and undesirable stressful life events (OR = 2.08; 95% CI = 1.28-3.37; P = 0.05) were significantly associated with higher odds of relapse in patients of opioid dependence. Further, higher self-efficacy (OR = 0.92; 95% CI = 0.87-0.96; P = 0.017) was significantly associated with lower odds of relapse.
Conclusion:
Psychosocial factors such as high risk situations, undesirable stressful life events, and self-efficacy were significantly associated with relapse in opioid dependence. Hence, practice of a holistic, multimodal, and individualized treatment plan addressing these factors might help in reducing the relapse rates in them.
This chapter describes the requirements and priorities of service systems designed to treat persons with substance use disorders. Research and theory are reviewed to inform policymakers, program administrators, and treatment providers about the best ways to organize or to expand treatment services using a public health systems approach, which is concerned primarily with how services contribute to the health and welfare of a population. The requirements of a service system include sound policies (especially stable financing); appropriate structural features, such as facilities and trained personnel; and services that are effective, accessible, affordable, and integrated. The priorities for establishing such a system will depend on the assessment of population needs, as well as needs-based planning and the support of mutual help organizations. It is concluded that a public health approach to the development of treatment systems provides a useful way of responding to the changing needs of the population in relation to substance use disorders.
The alcohol treatment field has seen considerable change over the past 30 years. Some of this has been evidence based, and some has been largely politically driven, particularly in the pursuit of containing health care costs. On the positive side, a shift in policy from a limited number of treatment services catering only for the small minority of severely dependent drinkers, to more community orientated services with a greater emphasis on early identification and intervention, is to be broadly welcomed. However, in some places a move towards services catering for early stage ‘at-risk’ drinkers has been at the expense of losing services for those with more severe alcohol problems. While the evidence in favour of matching treatments to individual needs is still at a relatively early stage of development, and clear evidence of matching effects is not yet available, clinical practice needs to be guided by pragmatic principles by which more intensive treatments are provided to more complex patients, and/or in a stepped care paradigm. It must be concluded that, despite a large research effort in evaluating intensive versus less intensive alcohol interventions, there is still a long way to go in developing pragmatic clinical trials that evaluate effectiveness and cost-effectiveness of treatment in a way that can best advise practitioners in the typical treatment setting. On the positive side, research has begun to address fundamental health economic issues that are highly relevant to the rational funding of treatment services. Important in this is the development of health economic analysis in randomized controlled trials. The assessment of the impact of treatment availability on the prevalence of alcohol-related harm also represents a significant advance. Nevertheless, treatment research cannot occur in a vacuum. Research needs to take account of the funding environment in which treatment takes place. Further, treatment research needs to provide answers to the key issues facing commissioners of health care. With the gradual improvement in the quality of treatment research over the past three decades and the development of more advanced health economic methods to evaluate treatment, the treatment research community is in a much better position than ever before to provide evidence to guide the rational development of treatment services for alcohol use disorders. While many differences between health care systems exist in different countries, the evidence points to the need for a wide spectrum of services to cater for different needs. The development of low-threshold community-based services should not occur at the expense of more specialized services for more severe alcohol use disorders. Similarly, a treatment system that provides only specialist services for the minority of severe cases misses a significant public health opportunity to reduce the prevalence of alcohol use disorders through early, brief interventions.
Background:
Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted.
Objectives:
To evaluate whether peer-led AA and professionally-delivered treatments that facilitate AA involvement (Twelve-Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets.
Search methods:
We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and bibliographies of included studies.
Selection criteria:
We included randomized controlled trials (RCTs), quasi-RCTs and non-randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non-coerced adults with AUD.
Data collection and analysis:
We categorized studies by: study design (RCT/quasi-RCT; non-randomized; economic); degree of standardized manualization (all interventions manualized versus some/none); and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random-effects meta-analyses to pool effects wherever possible.
Main results:
We included 27 studies containing 10,565 participants (21 RCTs/quasi-RCTs, 5 non-randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12-step program variants. We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear. AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high-certainty evidence). This effect remained consistent at both 24 and 36 months. For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI -4.36 to 10.43; 4 studies, 1999 participants; very low-certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; low-certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; low-certainty evidence). For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI -0.30 to 1.50; 2 studies, 136 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD -0.17, 95% CI -1.11 to 0.77; 1 study, 1516 participants; moderate-certainty evidence) and percentage days heavy drinking (PDHD) (MD -5.51, 95% CI -14.15 to 3.13; 1 study, 91 participants; low-certainty evidence). For alcohol-related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD -2.88, 95% CI -6.81 to 1.04; 3 studies, 1762 participants; moderate-certainty evidence). For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low-certainty evidence). AA/TSF (non-manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) For the proportion of participants completely abstinent, non-manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow-up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low-certainty evidence). Non-manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD -1.76, 95% CI -2.23 to -1.29; 1 study, 93 participants; very low-certainty evidence) and PDHD (MD 2.09, 95% CI -1.24 to 5.42; 1 study, 286 participants; low-certainty evidence). None of the RCTs comparing non-manualized AA/TSF to other clinical interventions assessed LPA, alcohol-related consequences, or alcohol addiction severity. Cost-effectiveness studies In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate-certainty evidence).
Authors' conclusions:
There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.
This chapter debunks the common myth about 12-step programs and discusses the research findings on them. It provides practical tips for facilitating involvement in 12-step programs. It also covers the role of religion and spirituality in addiction treatment and recovery. Practical tools about integrating religion and spirituality in recovery are presented.
Unhealthy alcohol use is a leading causes of preventable death in the United States. Reducing unhealthy alcohol use should be a high priority for health care providers. Well-validated screening instruments are available, and behavioral counseling interventions delivered in primary care can reduce risky drinking. For people with alcohol use disorder, treatment programs with or without medication can reduce consumption and promote abstinence. To overcome barriers to implementation of screening for alcohol use and subsequent delivery of appropriate interventions in primary care settings, support systems, changes in staffing or roles, formal protocols, and additional provider and staff training may be required.
Forty years ago there was only one drug addiction treatment center in the United States. By the late 1980s, there were approximately 9000 treatment programs serving nearly 600,000 addicts at any given time.1 The recent decrease in overall drug use, coupled with our recent economic troubles, has significantly slowed the growth of treatment programs—nevertheless, specialized inpatient or outpatient treatment programs are still widely available.
The aim of this chapter is to give you practical information to help you choose a program. The process of finding help involves trying to match your own needs and preferences to the huge number of potential programs available to you, so you can get help in a way that makes you most comfortable.
Background
The Norwegian Knowledge Centre for the Health Services was asked by Helse SørØst
RHF (South-Eastern Norway Regional Health Authority) to review Research about the effects of long-term institutional treatment of patients with substance abuse compared with short-term outpatient treatment.
Objective
The objectives were to assess the effectiveness of; 1) long-term treatment of patients
with substance abuse compared to short-term treatment and 2) to estimate the costeffectiveness of long-term treatment compared to short-term treatment.
Methods
We searched systematically for systematic reviews, randomised controlled trials and
cohort studies in international databases. We appraised and synthesized studies that
met our inclusion criteria.
Results
We included one systematic review and five studies, three cohort studies and two
health economy evaluations in our review. Although residential treatment may offer
some specific advantages, the conclusion here is that improvement among day
treatment clients was not significantly different from that of residential treatment
clients. Few baseline predictors were prospectively related to relapse at 12 and 18
months. Results from health economic evaluations suggest that outpatient and
short-term residential treatments might be cost effective compared to long-term residential
treatment.
Conclusion
Our systematic review gave no compelling evidence to support long term treatment
over short term interventions for drug addiction. However, it was emphasized that
the results must be interpreted carefully, because of low quality of economic studies.
Results from new research may alter our conclusions.
This chapter focuses on alcohol-related disorders which, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5), includes different severities of Alcohol Use Disorder and three types of alcohol-induced disorders (i.e., Alcohol Intoxication, Alcohol Withdrawal, and Alcohol-Induced Mental Disorders). These disorders are part of a larger group of substance-related disorders defined by 10 classes of psychoactive substances, including alcohol. The following conditions are classified as alcohol-induced: Alcohol Intoxication, Alcohol Withdrawal, and Other Alcohol-Induced Mental Disorders. Additional research is required before medications are likely to play a meaningful role in the postwithdrawal treatment of alcohol dependence. In addition, the opioid antagonist naltrexone, which is capable of yielding a modest effect overall in reducing drinking behavior, appears to be of considerable value in some individuals.
This chapter describes the requirements and priorities of service systems
designed to treat persons with substance use disorders. Research and theory
are reviewed to inform policymakers, program administrators, and treatment
providers
about the best ways to organize or to expand treatment services using a public health systems perspective, which is concerned primarily with how services contribute to the health and welfare of a population. The requirements of a service system include sound policies (especially stable financing); appropriate structural features, such as facilities and trained personnel; and services that are accessible, affordable, and integrated. The priorities for establishing such a system will depend on the assessment of population needs, as well as needs-based planning and the support of mutual help organizations. It is concluded that a public health approach
to the development of treatment systems provides a useful way of responding to the changing needs of the population in relation to substance use disorders.
Abuse substances may interact with their targets in the central nerve system, the peripheral nerve system, and/or the end organs such as heart or vascular system to cause indirect or direct, acute or chronic change of the cardiovascular system. Withdrawal of the abuse substances may also effect both the central and the peripheral nerve system to cause change of the cardiovascular system. Treatment mostly is supportive besides acutely lavage, hemodialysis, and specific antagonist.
Common causes of trauma to the brain result from accidents and in many cases not using a helmet or wearing a seat belt. These traumatic injuries can lead to extradural or subdural hematomas. Tumors/neoplasms are another nonvascular cause of disease in the brain. They are more common as one ages. Tumors may be intrinsic gliomas and metastatic. Extrinsic tumors are also common from meningiomas or metastatic lesions. Meningitis is the most common cause of infection to the nervous system and it can be caused by many organisms. Infections in the brain are also common sources of pathology in the brain following infections in the nasal sinuses, middle ear, or following compound skull fractures.
The historical role of inpatient treatment for alcoholism is reviewed in terms of its advantages and disadvantages. The factors that have forced a change in the utilization of inpatient treatment include increasing recognition of the heterogeneity of alcoholic patients, negative outcome studies, and cost-containment efforts. The clinical domains that warrant inpatient treatment are outlined, and decisions of treatment placement are necessarily guided by the factors of acuteness, ability, safety, and stabilization.
Workplace programs to prevent and reduce alcohol-related problems among employees have considerable potential. For example, because employees spend a lot of time at work, coworkers and supervisors may have the opportunity to notice a developing alcohol problem. in addition, employers can use their influence to motivate employees to get help for an alcohol problem. Many employers offer employee assistance programs (EAPs) as well as educational programs to reduce employees' alcohol problems. However, several risk factors for alcohol problems exist in the workplace domain. Further research is needed to develop strategies to reduce these risk factors.
This study investigated whether selected patients have better outcomes with inpatient than outpatient treatment. There were 93 inpatients and 80 outpatients with alcohol dependence who were evaluated at treatment entry to a private healthcare setting. Patients with multiple drinking-related consequences were less likely to return to significant drinking in the first 3 months after treatment ended if they had attended inpatient compared to outpatient treatment. Thus, inpatient appeared to have some advantage over outpatient treatment in the early recovery period for patients with multiple drinking-related consequences. The gap between inpatient and outpatient costs was also reduced when computed as a cost-effectiveness ratio, although treatment costs continued to remain proportionally higher with inpatient than outpatient treatment.
Objective: Attempts to balance escalating health care costs with resource downsizing have prompted alcohol treatment directors in the U.S. Navy to consider reducing the standard length of stay in treatment. The objectives of this study were to (1) determine whether a 4-week inpatient treatment program is as effective as a 6-week; program, and (2) explore the potential for matching patients to a 4- or 6-week program according to the severity of their condition at intake. Method: A total of 2.823 active-duty alcohol-dependent inpatients (2,685 men, 138 women) at 12 Navy treatment facilities participated in the evaluation. All facilities conducted a 6-week program until data had been collected for 1,380 participants; they then switched to a ii-week program (n = 1,443). Background information and clinical profile were obtained when patients entered treatment; 1-year outcome data (e.g., alcohol use, behavior problems, job performance, quality of life) were obtained from participants, work supervisors and aftercare advisors. Hierarchical multiple regression analysts were used to assess the effect of length of stay on outcome and to examine patient-program interactions. Results: The single best predictor of success at 1 year was months of aftercare attendance. Program membership failed to explain any of the observed differences in the criterion measures, once the effects of other predictors had been taken into account. Severity of condition and patient-program interactions were likewise nonsignificant. Conclusions: It was concluded that a reduction in length of stay from 6 weeks to 4 weeks in the Navy's inpatient alcohol treatment program would not have an adverse effect on outcome.
Modern concepts of addictive disorders emphasize the compulsive and relapsing drug-taking behaviors rather than tolerance and physical dependence. As with any chronic disorder, long-term treatment is necessary and medications may aid in the rehabilitative process. Specific medications have been demonstrated to be helpful for psychiatric disorders coexisting with addiction. Medications have also been demonstrated in controlled studies to aid in the rehabilitation of patients dependent on nicotine, alcohol, or opiates. Thus far, no medication has been clearly demonstrated to benefit patients suffering from abuse or dependence on cocaine, cannabinoids, nonalcohol sedatives, or hallucinogens.
Although 12-Step is increasingly utilized as a recovery resource and is viewed by many addiction specialists as an integral component of treatment and long-term recovery, questions regarding participation and effectiveness of 12-Step programs for women and ethnic minorities have been raised. Utilizing data from the Los Angeles Target Cites Evaluation Project (n = 356), participants in adult outpatient alcohol and drug treatment were followed for 24 months and rates of 12-Step participation and effectiveness were assessed for all gender and ethnic groups. Contrary to reports that 12-Step is more appropriate for European-American males, statistical analyses reveals that women and ethnic minorities are equally likely to attend 12-Step programs, and to recover In conjunction with such participation as European-American males. Although 12-Step may not appeal to all seeking to cease alcohol and drug use, the clinical implications for treatment providers and other addiction specialists points to the benefits of Integrating 12-Step components into traditional treatment programs and recommending 12-Step participation for clients of all gender and ethnic groups.
Alcohol dependence and harmful alcohol use account for a substantial burden of disease and disability in both developed and developing countries. This article reviews current knowledge about the treatment and secondary prevention of alcohol-related problems from a public health perspective. The article begins with a review of conceptual issues relevant to the therapeutic management of persons with alcohol-related problems. After describing diagnostic criteria and clinical assessment techniques for alcohol use disorders, the scientific basis for three types of intervention are reviewed: (1) Preventive interventions designed for nondependent high-risk drinkers, (2) formal treatment for problem drinkers and alcohol-dependent persons, and (3) mutual help organizations for alcoholics and their families. The article concludes with a discussion of the effect of treatment services on population rates of alcohol-related problems.
This chapter summarizes years of substantial change as Medicaid moved largely from fee for service to a managed care environment. Numerous questions have arisen regarding this momentous shift. In particular, it has been suggested that managed care provided incentives for providers to "cherry pick" clients with low substance abuse severity. Beginning with definitions of substance abuse treatment and managed care, the chapter provides detailed historical information on a state-by-state and year-by-year basis regarding the movement away from Medicaid fee for service and towards assorted managed care programs. States adopted numerous Medicaid innovations chiefly via various waiver mechanisms. The chapter provides comprehensive listings in text and tables showing these transitions with emphasis on changes pertinent to chemical dependency care. Building on this carefully assembled (and unlikely to be found elsewhere) record, the chapter examines impact of managed care transition on severity of Medicaid clients in treatment for substance abuse. Using hierarchical linear models, it is concluded that Medicaid managed care led, if anything, to slight increase in severity of substance abuse treatment clients.
This chapter first discusses the prevalence of alcohol use and the patterns of alcohol use in different countries worldwide. Criteria for alcohol use disorders (AUDs; alcohol abuse and dependence) are described. The acute and chronic effects of alcohol on the human peripheral and central nervous system are outlined. Unintentional and intentional injuries due to alcohol use are a considerable part of the disease burden of alcohol use, and comprise traffic accidents, alcohol poisoning, cancer, and liver disorders. Chronic heavy alcohol use is associated with negative health effects such as gastrointestinal abnormalities, and with structural and functional brain abnormalities. These negative health effects are higher when heavier alcohol use is present. Negative effects on cognitive functions have been reported for heavy alcohol use, but results are less evident for moderate alcohol use. The potential beneficial effects of light alcohol use (mostly defined as a maximum of 7 drinks per week, spread evenly) are suggested to have some health benefits. Risk factors associated with AUDs are discussed at the genetic, psychological, and environmental level. Effective -psychosocial and pharmacological interventions for AUDs are outlined. © 2012 Springer Science+Business Media, LLC. All rights reserved.
Although uncontrolled studies have yielded mixed findings, 26 controlled comparisons have consistently shown no overall advantage for residential over nonresidential settings, for longer over shorter inpatient programs, or for more intensive over less intensive interventions in treating alcohol abuse. Predictor data suggest that intensive treatment may be differentially beneficial for more severely deteriorated and less socially stable individuals. The outcome of alcoholism treatment is more likely to be influenced by the content of interventions than by the settings in which they are offered. Third-party reimbursement policy should discourage the use of intensive residential models for addressing alcohol abuse when more cost-effective alternatives are available and should reinforce the use of research-supported treatment methods regardless of setting. Such policy priorities run directly counter to the current practices and financial interests of many for-profit providers.
Despite the significant advances of the past 20 years, serious questions have been raised about the value of alcoholism treatment outcome research due to the purported invalidity of alcoholics' self-report data for which biological measures of alcohol consumption have been suggested as a solution. The literature does not support widespread skepticism of alcoholics' self-reports or the existence of a systematic underreporting bias except when alcoholics have a positive blood alcohol level. Available evidence shows good reliability and validity for reports of hospital/jail stays and frequency of drinking/abstinence; good reliability and modest agreement with collateral informants for measures of problem severity and alcohol dependence symptoms. For amount consumed, reliability is good for outpatient but not for inpatient or residential alcoholics and validity in the form of agreement with collateral reports is not good except in problem drinkers at followup. Unfortunately, currently available biological markers do not solve the problems of measuring alcohol consumption in outcome studies. Markers correlate only modestly with self-reported consumption, are affected by factors other than alcohol consumption, show large individual differences in response to variations in alcohol intake, have an overly long half-life in certain cases, provide a specific but not very sensitive indicator of poor outcome, and may present compliance problems especially among chronic alcoholics. Nonetheless, markers can be used as part of a convergent validity approach and as a measure of negative alcohol-related health consequences. Suggestions for current practices in the field and for future research directions are provided.
The comparative effects of alcoholism treatment programmes were examined by randomly assigning 113 male and female detoxified alcoholics to either: a 6‐week inpatient programme, a 6‐week outpatient programme or a single confrontational interview. On a variety of outcome measures, that included both levels of drinking and general functioning taken 6 and 18 months after intake, no treatment appeared to be consistently more effective than another. Furthermore, those who stayed in treatment did not show significantly more long‐term improvement than those who refused or dropped out of treatment.
Abstinent subjects felt more often than drinkers that they had achieved the goals they had set themselves and by the final follow‐up there were many positive differences in apparent lifestyle.
Although individual drinking patterns were unstable, on average, almost half the subjects located had either abstained or were drinking moderately. Patient and treatment variables combined explained up to 57% of the variance in amount drunk after treatment, with patient variables providing the strongest associations.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Compared the effect of intensive inhospital (IH) treatment with that of incommunity (IC) treatment. Results indicate that in terms of overall adjustment and of other specific adjustments, IH treatment had a greater effect than a program of short term IC therapy. However, the IC treatment was effective for some patients, and both IH and IC treatments were relatively ineffective for other patients. A 2nd finding supports a process model rather than an abstinence model as a criterion of recovery: successful adjustment cannot be judged on the basis of abstinence alone. Results also argue for further efforts to identify the kinds of problems that can best be treated with a particular form of therapy. (19 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In recent years there has been a large increase in the number of theoretical papers and empirical studies which focus upon the cognitive processes involved in addiction. This paper is intended simply to illustrate selected theories and concepts and to highlight some of the avenues of research which are helping to change our models of addiction. The main conceptual framework is that which has come to be known as social learning or cognitive social learning theory but concepts of self awareness, perceptual narrowing and self-handicapping are also described. Implications for the understanding of craving, loss of control, treatment and relapse are also considered.
A review of 384 studies of psychologically oriented alcoholism treatment showed that differences in treatment methods did not significantly affect long-term outcome. Mean abstinence rates did not differ between treated and untreated alcoholics, but more treated than nontreated alcoholics improved, suggesting that formal treatment at least increases an alcoholic's chances of reducing his drinking problem.
The Michigan Alcoholism Screening Test and a shortened 13-item version can reliably be used as self-administered questionnaires.
The test-retest reliability of the Iowa Alcoholic Stages Index is found consistent with the process model of alcoholism.
Two groups of alcoholics received either one counseling session or several months of in- and outpatient treatment. One year later there were no significant differences in outcome between the two groups.
Increases in cocaine use have created a new and challenging cohort of problem drinkers with dual or multiple addictions. As part of a randomized trial comparing alternative alcoholism treatments at a 10,000-employee industrial plant, we interviewed 224 new alcoholic clients of an employee assistance program (EAP); 40% used cocaine during the 6 months just prior to EAP intake. Compared to employees reporting no recent cocaine use, the cocaine users were younger, less often married and reported heavier drinking and more alcohol-related problems, on the job and off. Even after controlling for demographic and occupational factors, and drinking indicators, cocaine users reported more binges (being drunk 24 hours or more), more blackouts (marginally significant, p = .06), more absenteeism and more warnings about unacceptable job performance. Alcoholic EAP clients who use cocaine appear to engage in riskier drinking and to have more trouble on the job than do those who report no cocaine use, and this seems to be a difference specifically attributable to their use of cocaine.
We used data from 21 states that participated in the 1985 Behavioral Risk Factor Surveillance System to compare state-specific per capita self-reported alcohol consumption and the prevalence of three drinking behaviors with state-specific per capita sales. The correlation coefficient for per capita sales and per capita self-reported consumption for the 21 states was 0.81. Per capita sales were also significantly correlated with the prevalence of self-reported heavier drinking, binge drinking, and drinking and driving; the corresponding correlation coefficients were 0.74, 0.59, and 0.51. These findings suggest that states with higher per capita sales of alcohol also have higher rates of self-reported consumption and drinking patterns suggestive of high-risk behavior.
We compared the effectiveness, safety, and costs of outpatient (n = 87) and inpatient (n = 77) detoxification from alcohol in a randomized, prospective trial involving 164 male veterans of low socioeconomic status. The outpatients were evaluated medically and psychiatrically and then were prescribed decreasing doses of oxazepam on the basis of daily clinic visits. The inpatient program combined comprehensive psychiatric and medical evaluation, detoxification with oxazepam, and the initiation of rehabilitation treatment. The mean duration of treatment was significantly shorter for outpatients (6.5 days) than for inpatients (9.2 days). On the other hand, significantly more inpatients (95 percent) than outpatient (72 percent) completed detoxification. There were no serious medical complications in either group. Outcome evaluations completed at one and six months for 93 and 85 percent of the patients, respectively, showed substantial improvement in both groups at both follow-up periods. At one month there were fewer alcohol-related problems among inpatients and fewer medical problems among outpatients. However, no group differences were found at the six-month follow-up, nor were differences found in the subsequent use of other alcoholism-treatment services. Costs were substantially greater for inpatients (3,665 per patient) than for outpatients (388). We conclude that outpatient medical detoxification is an effective, safe, and low-cost treatment for patients with mid-to-moderate symptoms of alcohol withdrawal.
The origins of contemporary workplace programs to provide constructive assistance to employees with alcohol problems are described. The transformation from industrial alcoholism programming to employee assistance programming is delineated in terms of a seven-component "core technology." The high degree of reported success of these programs is described with general findings from a survey of 480 private-company sites. Increasing rates of self-referral for assistance with alcohol problems are described in terms of factors facilitating such referrals. Basic research knowledge is summarized, together with a projection of new studies considered to be critical for maximizing the effectiveness of alcoholism intervention as it relates to workplace programs. Throughout the chapter the large-scale impact of workplace programming is emphasized, with an urgency for greater attention to be paid to these activities by the alcohol problem research community.
The comparative effects of alcoholism treatment programmes were examined by randomly assigning 113 male and female detoxified alcoholics to either: a 6-week inpatient programme, a 6-week outpatient programme or a single confrontational interview. On a variety of outcome measures, that included both levels of drinking and general functioning taken 6 and 18 months after intake, no treatment appeared to be consistently more effective than another. Furthermore, those who stayed in treatment did not show significantly more long-term improvement than those who refused or dropped out of treatment. Abstinent subjects felt more often than drinkers that they had achieved the goals they had set themselves and by the final follow-up there were many positive differences in apparent lifestyle. Althought individual drinking patterns were unstable, on average, almost half the subjects located had either obstained or were drinking moderately. Patient and treatment variables combined explained up to 57% of the variance in amount drunk after treatment, with patient variables providing the strongest associations.
In recent years there has been a large increase in the number of theoretical papers and empirical studies which focus upon the cognitive processes involved in addiction. This paper is intended simply to illustrate selected theories and concepts and to highlight some of the avenues of research which are helping to change our models of addiction. The main conceptual framework is that which has come to be known as social learning or cognitive social learning theory but concepts of self awareness, perceptual narrowing and self-handicapping are also described. Implications for the understanding of craving, loss of control, treatment and relapse are also considered.
Although employee assistance programs appear to be spreading rapidly, much remains to be discovered about how they should proceed. A critical review of the literature undergirding these programs reveals wide gaps in knowledge about the relative efficacy of a variety of alternative strategies. In particular, empirical data on the question of where to refer employees for treatment of drinking problems are urgently needed. As medical scientists with ties to industry, occupational health professionals can play a decisive role in the articulation of central research questions and in the design and implementation of key studies that will begin to yield the blueprint for an efficient and effective system of care for alcohol problems.
Six-month outcomes for alcohol misusers assigned to extended inpatient hospitalization and to partial hospitalization were comparable for alcohol consumption and social and vocational roles. However, the subjective well-being of partial hospital patients was greater and their treatment costs were lower.
Most job-based alcoholism policies and programs incorporate a strategy of constructive confrontation. Data from two national samples of over 600 managers in a large corporation were collected to assess the effectiveness of this strategy with both problem drinkers and other problem employees. Results showed that supervisors of problem drinkers took more actions than did supervisors of employees with other problems. Work performance of problem-drinking employees improved more than that of other problem employees. Oral discussions containing both constructive and confrontational topics were positively associated with employees accepting help and with better work performance following intervention for both samples of employees. However, more severe forms of discipline--written warnings, suspensions or discharges--were negatively associated with work performance following intervention in both samples. The results suggest that (1) the strategy is most effective when repeated discussions balance both constructive and confrontational elements, and (2) the presence of the alcoholism policy encouraged supervisors to take more actions with problem drinkers, legitimated those actions and made the threat of discipline more credible.
The literature on the validity of self-reported alcohol consumption and alcohol problems was reviewed. Studies done in this area were analyzed by type of sample, by specific behaviour which was validated and by criterion chosen as the standard to which the behaviour would be compared. Despite the usual conclusion of validity studies that self-reports are basically valid, variation exists depending upon what is being validated and how its accuracy is measured. Recent reports of consumption are validated more easily than drinking patterns measured in drinking practices surveys (as evidenced by coverage rates of surveys to sales statistics ranging from 40-60%). In addition, collateral reports by significant others do not necessarily yield better information on consumption. In the area of alcohol problems, only a few, highly‘visible’problems can realistically be validated. Thus, the reporting of drinking driving arrests can be better validated than tremors or other physical manifestations. It is concluded that more emphasis should be placed on developing new ways to validate alcohol consumption and alcohol problems so that researchers can continue to refine their data collection techniques in order to maintain confidence in their findings.
Employee assistance or counseling programs have proliferated rapidly in American industry. They originated during the 1940s to help problem-drinking employees, and expanded in the 1970s in efforts to assist with a range of personal problems interfering with performance on the job. Existing programs vary widely on strategic and structural dimensions, yet research on basic questions has lagged far behind actual innovation.
Broadening the base of treatment for alcohol problems
- Idem
Matching individuals with interventions Handbook of alcoholism treatment approaches: effective alternatives
- Wr Miller
Evaluation of a day treatment for alcoholics
- McLachlan
24 National Council on Alcoholism.. Criteria for the diagnosis of alcoholism
- National Council on Alcoholism
Coercion in alcohol treatment In: Institute of Medicine Broadening the base of treatment for alcohol problems
- Cm Weisner
Alcoholism and treatment
- Dj Armor
- Jm Polich
- Hb Stambul
26 American Psychiatric Association Diagnostic and statistical manual of mental disorders
- D C Washington