The natural history of alcoholism over four years after treatment

How Much Is Too Much? Patterns of Drinking During Alcohol Treatment and Associations With Post-Treatment Outcomes Across Three Alcohol Clinical Trials

OBJECTIVE

This secondary data analysis examined patterns of drinking during alcohol treatment and associated drinking outcomes during the first year following treatment. The goal was to provide clinicians with guidance on which patients may be most at risk for negative long-term outcomes based on drinking patterns during treatment.

METHOD

This study was an analysis of existing data (N = 3,851) from three randomized clinical trials for alcohol use disorder: the COMBINE Study (n = 1,383), Project MATCH (n = 1,726), and the United Kingdom Alcohol Treatment Trial (n = 742). Indicators of abstinence, non-heavy drinking, and heavy drinking (defined as 4/5 or more drinks per day for women/men) were examined during each week of treatment using repeated-measures latent class analysis. Associations between drinking patterns during treatment and drinking intensity, drinking consequences, and physical and mental health 12 months following intake were examined.

RESULTS

Seven drinking patterns were identified. Patients who engaged in persistent heavy drinking throughout treatment and those who returned to persistent heavy drinking during treatment had the worst long-term outcomes. Patients who engaged in some heavy drinking during treatment had better long-term outcomes than persistent heavy drinkers. Patients who reported low-risk drinking or abstinence had the best long-term outcomes. There were no differences in outcomes between low-risk drinkers and abstainers.

CONCLUSIONS

Abstinence, low-risk drinking, or even some heavy drinking during treatment are associated with the best long-term outcomes. Patients who are engaging in persistent heavy drinking are likely to have the worst outcomes and may require a higher level of care.

Predictors of pretreatment commitment to abstinence: results from the COMBINE study

OBJECTIVE

Patients entering treatment for alcohol problems do not have uniform treatment goals, and a pretreatment drinking goal has a significant impact on treatment outcome. The objective of this study was to understand better how an array of individual characteristics, including factors that affect treatment, are related to treatment goals before beginning alcohol treatment in the COMBINE (Combining Medications and Behavioral Interventions) Study.

METHOD

Participants were alcohol-dependent individuals (N = 1,156; 357 women) recruited at 11 outpatient academic alcoholism-treatment clinics across the United States to participate in a randomized, double-blind, placebo-controlled trial that combined behavioral intervention with acamprosate and/or naltrexone. Treatment goal was coded as controlled drinking, conditional abstinence, or total abstinence. Multinomial logistic regressions assessed whether there were significant relationships between predictor variables and pretreatment goal selection.

RESULTS

Lower levels of alcohol-related consequences, lower readiness to change, higher family income, more daily drinkers in social network, and lack of prior treatment or Alcoholics Anonymous engagement predicted choice of a controlled drinking goal over a total abstinence goal. Fewer alcohol-related consequences, lower readiness to change, and more daily drinkers in-network predicted choice of a conditional abstinence goal over a total abstinence goal.

CONCLUSIONS

Higher levels of functioning, lower levels of consequences, no prior involvement in treatment and Alcoholics Anonymous, and a more drinking-saturated social environment are associated with the choice of a non-abstinence goal.

Therapeutic emails

Background

In this paper, we show how counselors and psychologists can use emails for online management of substance abusers, including the anatomy and content of emails that clinicians should send substance abusers. Some investigators have attempted to determine if providing mental health services online is an efficacious delivery of treatment. The question of efficacy is an empirical issue that cannot be settled unless we are explicitly clear about the content and nature of online treatment. We believe that it is not the communications via internet that matters, but the content of these communications. The purpose of this paper is to provide the content of our online counseling services so others can duplicate the work and investigate its efficacy.

Results

We have managed nearly 300 clients online for recovery from substance abuse. Treatment included individual counseling (motivational interviewing, cognitive-behavior therapy, relapse prevention assignments), participation in an electronic support group and the development of a recovery team. Our findings of success with these interventions are reported elsewhere. Our experience has led to development of a protocol of care that is described more fully in this paper. This protocol is based on stages of change and relapse prevention theories and follows a Motivational Interviewing method of counseling.

Conclusion

The use of electronic media in providing mental health treatment remains controversial due to concerns about confidentiality, security and legal considerations. More research is needed to validate and generalize the use of online treatment for mental health problems. If researchers have to build on each others work, it is paramount that we share our protocols of care, as we have done in this paper.

Are preoperative patterns of alcohol consumption predictive of relapse after liver transplantation for alcoholic liver disease?

Predictive factors for alcoholic relapse after liver transplantation (LT) performed for alcoholic liver disease (ALD) have been assessed in numerous studies, often with contradictory results. The aim of the study was to assess pretransplantation alcohol consumption characteristics on alcoholic relapse after LT. Patients transplanted for ALD for at least 6 months were included. An anonymous questionnaire assessed socio-demographic characteristics, medical history, and alcohol consumption before and after LT. Relapse was defined as any alcohol use after LT. Severe relapse was defined by heavy drinking: more than 21 units/week for males and 14 units/week for females. A total of 61 patients were studied. The mean follow up after LT was 49 +/- 34 months. Alcoholic relapse occurred in 32 of 61 patients (52%) and severe relapse in eight of 61 patients (13%). Risk factors for severe relapse were: length of abstinence before LT (P = 0.0001), more than one alcohol withdrawal before LT (P = 0.001), alcohol dependence (P = 0.05), alcohol abuse in first relatives (P = 0.05), and younger age (P = 0.05). Information on previous alcohol consumption (dependence, number of withdrawals, family history) helps to predict severe relapse after LT in patients with ALD, allowing early awareness and specific postoperative care.

Mediators of outcome of psychosocial treatments for cocaine dependence

This study examined endorsement of 12-step philosophy and engagement in recommended 12-step activities as a mediator of the outcomes of individual plus group counseling for cocaine dependence. Assessments of drug use outcomes and the mediator were made at baseline and monthly for 6 months. Engagement in recommended 12-step activities was found to be a partial statistical mediator of drug use outcomes of individual (plus group) drug counseling, but no evidence for change in the mediator preceding change in drug use was found. In addition, a measure of beliefs about addiction developed to test mediation of outcome of cognitive therapy was found to correlate moderately with drug use outcomes in both cognitive therapy and individual drug counseling.

The effects of sponsorship in 12-step treatment of injection drug users

What contributes to sustained abstinence from injection drug use by those who participate in community-based Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) is not well understood. We know that sponsorship is a central element in these programs. To investigate the relationship between sponsorship and abstinence, we evaluated NA/AA sponsorship over a 1-year period in a longitudinal study of 500 former and current injection drug users in inner-city Baltimore recruited from the community-at-large, independent of treatment center affiliation. The findings indicated that having a sponsor in NA/AA for this population was not associated with any improvement in 1-year sustained abstinence rates than a non-sponsored group. However, being a sponsor over the same time period was strongly associated with substantial improvements in sustained abstinence rates for the sponsors, controlling for involvement with community organizations, NA/AA meeting attendance, marital status, employment, participation in drug and alcohol treatment centers and HIV status. Involvement in community organizations was also strongly associated with successful abstinence, controlling for the same variables. Of those participants involved with community organizations, more than half reported involvement in church activities. Our investigation suggests that, for NA/AA sponsors in this study population, providing direction and support to other addicts is associated with improved success in sustained abstinence for the sponsors but does little to improve the short-term success of the persons being sponsored.

The relative impact of waiting time and treatment entry on drug and alcohol use

One hundred and twenty-three treatment-seeking substance misusers were recruited to a study assessing the early impact of treatment. Participants were interviewed at treatment entry and 3 and 6 months later, regardless of their treatment status (i.e. including those who had dropped out of treatment), while additional data were obtained from the two assessment interviews carried out prior to the initiation of treatment. Three consistent observations can be applied to both the opiate misuser (n = 61) and problem drinker samples (n = 62): (1) the period of pre-treatment wait (mean of 8 weeks) was characterized by stable patterns of substance misuse with no significant 'spontaneous' improvement in indices of severity of drug or alcohol problems; (2) the period immediately following initiation of treatment was associated with substantial reductions in the quantity and frequency of substance use, an effect not influenced by the length of time for treatment initiation; (3) these benefits are maintained to 6 months after treatment initiation. The waiting period for treatment initiation does not seem to be characterized by significant changes in drug or alcohol use patterns, at least among those who made it into treatment, with clear and sustained improvements irrespective of the length of treatment wait.

Long-term outcome in 306 males with alcoholism

The subjects of this study were 306 male alcoholics who lived in Osaka, Japan, and who were initially diagnosed with alcoholism at a psychiatric institution between 1972 and 1983. Follow-up studies were done on three occasions: 1 March 1985 (Time 1), 1 November 1988 (Time 2) and 1 March 1992 (Time 3). We followed up 232 (75.8%) of the 306 male alcoholics. By the end of the study period 110 (35.9%) of the subjects were deceased. Regarding cross-sectional sobriety status, from Time 1 to Time 3 the complete abstinence rate changed from 16.0 to 18.6%, excessive drinking rate was from 13.1 to 9.8%, and controlled drinking rate was from 6.9 to 9.8%. The longitudinal sobriety status of 122 living patients during the 5 years before the close of this study were: rate of stable abstinence, 28.7%; unstable abstinence, 21.3%; controlled drinking, 12.3%; and relapse 37.7%. Such variables as being without public assistance at the time of the initial diagnosis of alcoholism and attending a self-help group soon after the initial treatment were associated with stable abstinence. Age (20-39 years) and receiving outpatient treatment at the time of the initial treatment also emerged as predictors of survival. However, those variables, except attending a self-help group soon after the initial treatment, might merely indicate severity of alcoholism. For improving treatment results, it may be most important to provide a treatment environment within the residential area so that alcoholics may receive treatment at an early stage of alcoholism and attend a self-help group.

General and alcohol-specific social support following treatment

Both general and alcohol-specific support have been shown, albeit inconsistently, to affect drinking behavior. The discrepant findings may be clarified by examining how they work together. In exploratory analysis of clients following private outpatient alcoholism treatment, we found that the two variables add uniquely to the explanation of the variance in proportion of days abstinent (PDA). Both contribute significantly in the short term (3 months posttreatment), but only alcohol-specific support helps to explain variance over the longer term (15 months posttreatment), and alcohol-specific support explains more of the variance in PDA than general support at both time periods. More complex relationships are operating when short-term treatment effects have diminished. Alcohol-specific support mediates the relationship between general support and PDA, and both general social support and alcohol-specific support are moderators of one another in their relationships to PDA. Knowing how different types of social support affect drinking behavior at different intervals following treatment may help treatment providers to better prepare their clients for the posttreatment social environment.

Investigation of Cigarette Smokers Who Quit without Treatment

This study investigates the phenomenon of spontaneous recovery through qualitative methodology. The Development Research Model, as introduced by James Spradley (1979) was employed with a sample of people who quit smoking without the aid of formal treatment. This technique examines the language used by informants to describe the experience of quitting. The results report that many of the informants used multiple techniques. Also of importance is the finding that the majority of the informants had relapsed and used the experience as motivation to continue trying to quite smoking. It was also found that many individuals experienced vivid dreams about smoking while undergoing the cessation process. Several important factors about the decision to quit are discussed as well as the treatment implications.

Symptoms and characteristics of individuals with different types of recovery from DSM-IV alcohol dependence

Symptoms and criteria for DSM-IV alcohol dependence and demographic and drinking characteristics are compared for three groups. Group I (N = 1,044) consists of persons who formerly met the criteria for dependence but were abstinent in the past year, Group II (N = 2,325) consists of persons who were formerly dependent but did not meet the criteria for abuse or dependence in the past year despite drinking, and Group III (N = 22,204) consists of persons who never met the criteria for dependence. Members of Group II lay between members of Groups I and III in terms of the numbers of prior dependence symptoms and criteria, past level of intake, degree of familial alcoholism and history of alcohol treatment. Both groups of former alcoholics were equally likely to have experienced withdrawal, drinking more/longer than intended and tolerance. The criteria that most strongly distinguished the groups were continued use despite physical or psychological consequences, time spent drinking and activities given up, all of which were far more common in Group I than in Group II. Members of Group II had earlier onsets of heavy drinking and dependence than members of Group I, supporting the existence of a developmentally limited subtype of alcoholism that is subject to spontaneous remission in early adulthood without treatment. The paper compares three options for tightening the criteria for dependence, all of which remove more members from Group II (28% to 41% depending on option) than from Group I (12% to 19%).

Coping methods and reasons for not drinking

Methods for coping with stress and reasons for not drinking were examined among abstinent alcoholics to determine whether change occurred with length of sobriety. Results showed that 1) alcoholics with briefer abstinence relied more heavily on coping methods, 2) alcoholics relied less on negative than positive coping methods regardless of length of sobriety, and 3) the number and types of reasons for not drinking did not vary with length of sobriety, rather, several positive reasons for not drinking continued as motivators. Concerning coping methods, the authors speculate that as alcoholics remain sober longer, coping methods become less important or automatic and less conscious.

Alcoholics Anonymous affiliation during early recovery

This study analyzed the Alcoholics Anonymous (AA) participation of 55 patients during the 3 months after their discharge from structured treatment, when dropout is high. Three levels of meeting attendance were discerned: low, mid-level, and "90 meetings in 90 days." Of greatest interest, the mid-level group showed mixed interest in AA practices despite substantial meeting attendance, that is, they admitted powerlessness, but had less enthusiasm for the higher power concept, and relapsed significantly; they were likely to have a sponsor, but were less involved with other AA members; and they reported working the 12 Steps, but were less interested in the AA literature. Findings suggest that individuals who are attending AA but having difficulty embracing key aspects of the program need professional assistance that focuses more on AA practices and tenets and less on meeting attendance. Barriers to affiliation can also serve as opportunities for furthering both counseling goals and affiliation.

DOUBLE TROUBLE IN RECOVERY: SELF-HELP FOR PEOPLE WITH DUAL DIAGNOSES

Self-help is gaining increased acceptance among treatment professionals as the advent of managed care warrants the use of cost-effective modalities. Traditional "one disease-one recovery" self-help groups cannot serve adequately the needs of the dually diagnosed. This article discusses Double Trouble in Recovery (DTR), a 12-step self-help group designed to meet the special needs of those diagnosed with both a psychiatric disability and a chemical addiction, DTR differs from traditional self-help groups by offering people a safe forum to discuss their psychiatric disabilities, medication, and substance abuse. Preliminary data collected at four DTR sites in NYC indicate that DTR members have a long history of psychiatric disabilities and of substance abuse, and extensive experience with treatment programs in both areas. They are actively working on their recovery, as evidenced by their fairly intensive attendance at DTR. Recent substance use is limited, suggesting that participation in DTR (in conjunction with format treatment when needed) is having a positive effect. Most members require medication to control their psychiatric disabilities, and that alone may make attendance at "conventional" 12-step groups uncomfortable. Ratings of statements comparing DTR to other 12-step meetings suggest that DTR is a setting where members can feel comfortable and safe discussing their dual recovery needs.

Self-help activities in cocaine dependent patients entering treatment: results from NIDA collaborative cocaine treatment study

Although little is known about self-help attendance among cocaine dependent patients, clinicians frequently recommend this treatment. Cocaine dependent patients (519) entering a psychotherapy study were therefore surveyed regarding their recent self-help group attendance and participation. During the previous week, 34% had attended a self-help group. Of self-help attenders who actively participated 55% initiated abstinence within the next month, compared with 40% of non-attenders and 38% of non-participating attenders (P < 0.01). These findings support the potential short-term positive prognostic significance of self-help attendance and participation in cocaine dependent patients.

Composite outcome measures in alcoholism treatment research: problems and potentialities

Alcoholism treatment researchers have increasingly incorporated multiple measures representing multiple dimensions in assessing treatment outcomes. However, no satisfactory model exists for examining the dynamic interrelationships of multiple measures in determining clinically meaningful and interpretable outcomes. One approach to analyzing multiple outcomes is to combine them into a composite measure. In their most elementary form, composite measures combine alcohol consumption and consumption-related problems dimensions into treatment outcome classifications. This paper discusses conceptual and methodological issues in studies reporting composite outcomes and provides a model and recommendations for using composite measures in alcohol treatment research.

A 48-week natural history follow-up of alcoholics who do and do not engage in limited drinking after treatment

The research on the controversial Alcoholics Anonymous tenet that limited drinking rapidly leads alcoholics to inebriety is inconclusive. We conducted 48-week follow-ups on 51 posttreatment alcohol dependents who had reportedly engaged in limited drinking and 51 paired controls who apparently had not. According to the informants, the limited drinkers consumed 16 times as much alcohol and were 4 times as likely to regress to unacceptable drinking as controls. They were also more often rehospitalized and attended fewer Alcoholics Anonymous meetings than the controls. They were, however, usually (62%) categorized as abstinent or moderate drinkers when assessed during the follow-up period. The groups did not differ in risk of jailing, detoxification, or job loss, nor did limited drinkers ordinarily regress quickly to inebriety. The outcomes of our limited drinkers were inferior to those of controls but much less negative than those Wilson's Alcoholics Anonymous maintains.

Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992

Past-year status was investigated in a sample of 4,585 adults with prior DSM-IV alcohol dependence. Those who had and had not received treatment for alcohol problems were compared in terms of past-year status and its correlates, to see if the experience of treatment samples would be reflective of the course of alcoholism in the general population. In the past year, 27.8% of the total sample met the criteria for alcohol abuse or dependence, 22.3% were abstinent, and 49.9% were drinkers who did not satisfy the criteria for either abuse or dependence. Persons who had been treated for alcohol problems were about twice as likely to be abstainers as those who had not been treated (38.8% vs. 16.4%), but only about half as likely to fall into the past-year category of drinking without abuse or dependence (28.0% vs. 57.8%). These differentials were of constant magnitude, regardless of the interval since the onset of dependence. For the sample as a whole, persons who had received treatment were slightly more likely than their untreated counterparts to have had alcohol abuse or dependence in the past year (33.2% vs. 25.8%), and this differential increased with the interval since the onset of dependence. The odds of both past-year abstinence and drinking without abuse or dependence were decreased by male gender, Black race, rapidity of the onset of dependence and ethanol intake per drinking day, and were increased by ever having been married and by later ages at onset of dependence. The odds of drinking without abuse or dependence relative to abstinence were increased by college attendance and reduced by the number of dependence symptoms, and having been a daily drinker was associated with increased odds of past-year abstinence. Treatment history modified the associations between past-year status and race, marital and educational status, number of past alcohol problems, and rapidity of onset of dependence and age at onset. These results suggest that treatment studies may not be generalizable to alcoholics who do not seek treatment.

Older adult controlled drinkers and abstainers

Little is known about the lifetime course of alcohol problems, especially during late adulthood. Many individuals with a history of alcohol problems achieve remission of their symptoms through abstinence or controlled drinking. This study examined 135 older adults with a prior history of alcohol diagnoses who were symptom free for at least the past year. Two groups were identified based on their alcohol consumption within the past year: abstinent individuals (n = 92) and controlled drinkers (n = 43). The groups did not differ in age, racial composition, education, income, or years since their last alcohol-related symptom, but they did differ in gender composition, indices of alcoholism severity, history of formal and informal treatment, as well as lifetime alcohol consumption patterns. Abstinent individuals had more severe alcohol problems, consumed higher amounts of alcohol on drinking days, had more years of heavy alcohol consumption, and were more likely to have attended alcohol treatment and Alcoholics Anonymous (AA). The controlled drinkers had a longer history of moderate social drinking, and their current consumption habits appeared to be similar to symptom-free older adult drinkers. The results suggest that gender, alcoholism severity, history of formal and informal treatment, and past consumption patterns are associated with whether older adults with histories of alcoholism attain successful outcomes through abstinence or controlled drinking.

A review of factors affecting treatment outcomes: Expected Treatment Outcome Scale

The Expected Treatment Outcome Scales was developed to gather information on clients who abuse drugs or alcohol, to assess their severity of illness, and to evaluate the effectiveness of drug treatment in nonrandomized clinical studies. The scale is based upon a multiattribute value model reflecting the opinions of an expert panel. The experts identified 25 variables, or predictors of relapse, from which 48 questions were constructed. Answers to the questions are individually scored. These scores are summed to produce an overall Expected Treatment Outcome score. This paper focuses on the development and preliminary validation of the Expected Treatment Outcome Scale. Results of our analysis show a correlation of .89 between the experts' average ratings of hypothetical clients and scores based on our scale. This finding suggests that the Expected Treatment Outcome Scale has face validity and accurately simulates the experts' judgments regarding treatment outcome. Further research is necessary to assess the reliability as well as the concurrent and predictive validity of our instrument.

A 6-year follow-up of alcoholics after long-term outpatient treatment

The predictors of the long-term outcome in alcoholics (n = 50) who had been treated in a 2-year outpatient treatment program were investigated. Previously, the sample had been followed up personally 2 years after the termination of treatment. This study is a repeated, independent follow-up of the same sample over a 4-year period, 3-6 years after termination of treatment. Outcome could be categorized in 38 subjects. Patients with a favorable outcome during at least 2 years of the 4-year follow-up period (n = 21), who were categorized as a positive outcome group, were compared with the other patients (n = 17). There was no significant correlation between initial patient characteristics and outcome 3-6 years after treatment. Drinking outcome during the 1st half-year of treatment had no correlation to positive drinking outcome in years 3-6, whereas there was a positive correlation for later phases of treatment and outcome reaching a significant level during the 2nd and 4th half-year of treatment. A favorable drinking outcome during years 1-2 after treatment had a positive significant correlation to outcome in years 3-6 after treatment [i.e., 80% of the patients with a favorable outcome during the 1st follow-up period also had a positive outcome during the 2nd follow-up period, and 72% of those who had an unfavorable outcome during the 1st follow-up period had an unfavorable outcome also during the 2nd follow-up period (chi 2 test = 10.4, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of abstinent substance abusers who first sought treatment in adolescence

A survey was given to 141 male and female substance abusers who had eleven or more months of continuous abstinence and first sought treatment in adolescence in an attempt to add to the limited knowledge of known variables associated with successful adolescent response to clinical and community-based treatment. Results were used to create a composite of successfully abstinent adolescents. Generally, parental alcoholism and most drug use patterns were not related to the number of relapses or length of sobriety. Most of the respondents entered twelve-step programs via treatment. The only two variables that were significantly correlated with the dependent measures of more relapses and less overall sobriety were getting high for the first time at a younger age and polydrug abuse. There were about five times more adoptees represented in this sample than would be statistically expected. Implications for adolescent substance abuse diagnosis and prognosis are discussed.

Why alcoholism is a disease

Arguments of proponents and critics of a disease concept of alcoholism are reviewed. It is concluded that the disease concept of alcoholism is in accord with modern usage of the concept of disease in the philosophy of science and the practice of biomedical science. Ascription of the term "disease" involves a value judgment by experts that observed lawfully recurring signs and symptoms are a significant deviation from a norm or standard of health. Value judgments of this and other kinds are inherent in biobehavioral science and its application. Criticisms of the traditional conception of the disease concept fail to distinguish empirical questions of etiology, treatment, and the characteristic features of alcoholism from the conventional and evaluative nature of the classification "disease." A critical review of the empirical research purporting to question the signs and symptoms of loss of control in alcoholics is also provided.

Treatment outcome of 600 chemically dependent patients treated in a multimodal inpatient program including aversion therapy and pentothal interviews

A sample of 600 patients treated in a multimodal treatment program using aversion therapy and narcotherapy at three Schick freestanding addiction treatment hospitals and one Schick unit in a general hospital were followed-up. Contact was made a minimum of 12 months and as many as 20 months after completion of treatment (mean 14.7 mos.). Telephone contact was made by an independent research organization with 427 of the patients (71.2%). Of these, 65.1% were totally abstinent for 1 year after treatment and 60.2% were abstinent until follow-up a mean of 14.7 months later. Fifty-two percent of the alcoholics were using or dependent on other drugs at admission. Seventy-five of these treated for cocaine dependence and 47 treated for marijuana dependence. The cocaine 12 month and "total" abstinence (mean 14.7 mos.) rates for the 49 contacted patients were 83.7% and 81.6%, respectively. The marijuana 12 month and "total" abstinence (mean 14.7 mos.) rates for the 30 contacted patients was 70.0% for both groups. Abstinence rates for alcohol and/or other drugs were also calculated including noncontacted patients who had chart documented evidence of relapse. The most powerful predictor of success was whether or not all urges to drink or use had been eliminated (presumably by aversion therapy). Of additional importance was the use of support groups and reinforcement treatments after completion of the initial hospitalization. The two most prominent factors initiating a relapse were "intrapersonal determinants" such as stress from work or marriage/family relationships and "interpersonal determinants" such as being around others who were drinking/using or being at a celebration or special event. The two factors were of equal importance in the alcoholics. However, interpersonal determinants were far more important in the cocaine and marijuana treated patients. Increased utilization of reinforcement treatments was associated with decreased urges to drink/use and increased abstinence rates. In contrast, increased frequency of support group utilization was associated with increased urges to drink/use and lower abstinence rates. This suggests the need to take seriously patient reports of "urges" in the first year after treatment and to carefully assess the cause and initiate or update an individualized plan of treatment. Such treatment may include increased reinforcement treatments, treatment of depression, and additional assistance in coping with intrapersonal and interpersonal determinants of relapse.

Private substance abuse treatments: are some programs more effective than others?

There have been few studies of treatments for substance dependence among private programs. The present study compared the patient populations, treatment services provided and six-month outcomes of employed, insured patients referred by an employee assistance program to four private treatment programs (two inpatient and two outpatient). Subjects were alcohol and/or cocaine dependent males referred from a single employer. Ninety-four percent were successfully contacted at six-month follow-up, with confirmatory urinalysis and breathalyzer samples taken. Three results were obtained. First, there were significant and pervasive improvements shown in the total sample at follow-up. Fifty-nine percent were completely abstinent, 82% were working and only 8% required re-treatment. Second, there were significant differences among the programs in levels of improvement and six-month outcomes. Finally, the differences in efficacy were related to the differences in the nature and amount of treatment services provided.

Requests for medications during chemical dependency rehabilitation as a predictor of relapse

This study tested an aspect of the low-frustration-tolerance hypothesis by investigating the relationship between nonprescription medication requests by chemical-dependency patients, while in treatment, and their relapse rate. Subjects were 200 adult, chemically dependent patients admitted to a 28-day inpatient treatment program. The number of requests for nonprescription medications for subjective and objective symptoms were recorded for all patients during the course of their treatment, and these patients were followed for 1 year after treatment to determine if they had remained abstinent. Results were consistent with the predictions of the low-frustration-tolerance hypothesis. Patients who requested more medications for subjective symptoms during treatment were less likely to remain abstinent for 1 year after treatment.

Homogeneous versus heterogeneous age group treatment of adolescent substance abusers

The treatment outcome from homogeneous age group substance abuse treatment centers, whose clientele consisted primarily of adolescent substance abusers, was compared to heterogeneous age group substance abuse treatment centers, where adolescent and adult patients were treated together. Subjects were 100 substance abusers, from 20 states, who recovered in adolescence and had at least 11 months of continuous abstinence. A 24-item self-report questionnaire was used to ascertain the type of recovery treatment experienced, number of relapses, and duration of sobriety. Results indicated a disproportionate number of substance abusers who recovered in adolescence were treated in a heterogeneous age group clinical setting. There was no significant difference in the length of sobriety and number of relapses between the homogeneous and heterogeneous treatment groups. These data suggest adolescent substance abusers can be treated at a lower cost and with a higher recovery rate by placing them in adult treatment settings.

Abstinence, reasons for not drinking, and life satisfaction

This study examines the reasons given for not drinking by abstinent alcoholics with varying lengths of sobriety. A Reasons for Not Drinking Scale is tested, as well as the Purpose in Life Questionnaire and Life Satisfaction Scale. Subjects are 60 males from a VA population. Results show that subjects with less education and those treated in a detoxification setting are more likely to endorse negative reasons for not drinking. Individuals with short and long abstinence have a higher level of life "dissatisfaction" than those with moderate periods of abstinence. The study suggests that purpose in life, life satisfaction, and reasons for not drinking are important measures of progress in treatment and movement through phases of recovery.

Controlled drinking, treatment effectiveness, and the disease model of addiction: a commentary on the ideological wishes of Stanton Peele

Despite a long history of extravagant claims followed by sobering discomfirmations, advocates of controlled drinking continue to promote nonabstinent treatment goals and procedures for alcoholics. Recent claims by Stanton Peele in favor of controlled drinking are examined critically in the context of a continuing debate concerning empirical studies of nonabstinent treatment goals, treatment effectiveness, and inpatient versus out-patient treatment of alcoholism. Peele's views concerning "conventional disease-based alcoholism treatment," controlled drinking, and "the disease model" are shown to be based largely on inadequate scholarship, misrepresentations of the literature, inappropriate comparisons, unwarranted generalizations, and straw-man arguments.

Critical aspects of the psychodynamics of substance abuse and the evaluation of their application to a psychotherapeutic approach

A model of psychotherapy is proposed which integrates psychodynamic theory, AA and other 12-step groups, family therapy, and dual-diagnosis issues into a phase-specific method. This therapy is done in three stages: (1) dryness (assessment and detoxification); (2) sobriety (achieving stable abstinence); and (3) wellness (using sobriety as a basis for personal growth and intimacy. The utility of an evolving concept of countertransference and new studies demonstrating the efficacy of psychotherapy are also discussed. Several challenging research questions are presented which, if answered, would assess the efficacy of this model.

Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program

A sample of 200 patients who had been treated for alcoholism in a multimodal inpatient program that used aversion therapy as a treatment component was selected for outcome evaluation. One hundred sixty (80%) were located. A minimum of 13 months had elapsed since treatment (mean 20.5 months) collateral reports were used to verify self-reports in 36% of the cases. Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment (range 13 to 25 months, mean 20.5 months), and "current abstinence" (last 6 months). The abstinence rate for the first 12 months was 71.3%; for the total period since treatment, the rate was 65% (mean 20.5 months); the current abstinence rate was 78.1%. The data was also viewed from other perspectives. The findings of this study suggest that a multimodal alcoholism treatment program utilizing aversion conditioning is at least as acceptable to patients as counseling centered programs and can be expected to yield favorable abstinence rates.

Can Stanton Peele's opinions be taken seriously? A reply to Peele

In an article in the October-December 1988 issue of the Journal of Psychoactive Drugs, Stanton Peele expressed a number of opinions against alcoholism treatment and in favor of controlled drinking as a treatment goal for alcoholics. These opinions are examined critically and found to be contradicted by recent studies, empirical observations, and reinterpretations of earlier studies. It is concluded that marginal scholarship, partial and/or inaccurate representations of research, and inappropriate generalizations do not constitute the basis for drawing reliable and valid conclusions about alcoholism treatment or about controlled drinking as a feasible treatment goal for alcoholics.

The natural history of alcoholism versus treatment effectiveness: methodological problems

A majority study of alcoholism treatment concluded that results of treatment were no better than the natural history of untreated alcoholism. This conclusion cannot be considered valid because of methodological problems which render the treated and untreated samples incomparable. The latter methodological problems include age cohort differences between the untreated and treated samples, and differences in socioeconomic status. Other issues confounding the original conclusion are inadequacy of the minimal treatment provided. Major reviews of alcoholism treatment and recent outcome studies indicate that treatment optimism is warranted in contrast to the view that treatment renders no advantage over "natural" outcome.

Alcoholics Anonymous: membership characteristics and effectiveness as treatment

Reports published since 1976 were reviewed with respect to the characteristics of alcohol-dependent individuals who affiliate with Alcoholics Anonymous (AA). No "AA personality" was identified inasmuch as systematic differences have not been observed between affiliates and nonaffiliates. Evaluation studies were reviewed with regard to data on AA's effectiveness as treatment, leading to several observations. When "alcoholics" participate in AA in addition to professional treatment, their outcome on drinking and other indices is no worse, and may be better, than that of patients who do not involve themselves in AA. AA involvement tends to be associated with relatively high abstinence rates but with only fairly typical total improvement rates. The effectiveness of AA as compared to other treatments for "alcoholism" has yet to be demonstrated. Reliable guidelines have not been established for predicting who among AA members will be successful. An alcohol-involved person's chances of participating in AA are related to the type of drinking outcome achieved. Caution was raised against rigidly referring every alcohol-troubled person to AA.

Six-month treatment outcomes in socially stable alcoholics: abstinence rates

A randomly selected sample of 181 socially stable patients were followed for a period of six months after leaving alcoholism treatment. Collateral verification of drinking status was used to validate patient self-reports. A follow-up rate of 94% was achieved. For all patients, a continuous abstention rate (no drinking at all for the entire six-month period) of 61% was achieved, while 72% of the located patients were currently abstinent at the time of followup. For alcoholics with no other drug problems, a 66% continuous abstention rate was achieved, and 77% were currently abstinent at followup. These results suggest that alcoholism treatment can be effective for samples of socially stable alcoholics treated with multimodal treatments in a specialized, freestanding, alcoholism treatment facility.

An application of an MMPI classification system for predicting outcome in a small clinical sample of alcoholics

The purpose of this study was to apply Conley and Prioleau's MMPI classification system to predict drinking and adjustment outcome for a sample of 113 inpatient alcoholics. Although a dual grouping (termed "reactive" and "essential") of the original six MMPI subtypes was found to be more useful for this sample size, the findings, nevertheless, supported the predictive value of this MMPI classification system. The "essential" group, derived from a triad of Psychopathic and Schizoform MMPI types was rated as drinking significantly more often during 4 years after treatment than the "reactive" group, derived from a triad of Neurotic and Classic MMPI types (Fisher's p = .02). Females classified as the "essential" MMPI group were rated as having significantly poorer adjustment (Fisher's p = .007) than females classified as the "reactive" MMPI group.

Alcoholics anonymous affiliation and treatment outcome among a clinical sample of problem drinkers

Pretreatment and posttreatment Alcoholics Anonymous (AA) affiliation was investigated in respect to treatment outcome, demographic variables, and psychometric variables for 173 consecutive admissions to a residential behaviorally oriented, multimodal treatment program. Few variables were found to distinguish clients who chose to affiliate with AA following treatment from those who did not. However, AA attenders tended to report a higher incidence of and more severe alcohol-related problems prior to treatment. Pretreatment AA affiliation was not found to influence prognosis significantly. However, an infrequent or irregular pattern of posttreatment AA attendance was associated with a much poorer prognosis than either regular attendance or nonattendance. Success:failure ratios were statistically equivalent for the latter two groups. It is suggested that the poor outcome evident among the infrequent attenders may be the result of "misaffiliation" or incomplete affiliation with the fellowship and/or the presence of a problem which supersedes the alcohol abuse.

Recidivism in "controlled drinker" alcoholics: a longitudinal study

This study tested the conflicting positions which maintain that moderate drinking invariably and rapidly leads alcoholics to uncontrolled inebriacy and that alcoholics are capable of sustaining controlled drinking over long periods without special training. We obtained 3-, 6-, 9-, and 12-month control-over-drinking follow-up ratings on 42 treated alcoholics who had been identified as completely controlled drinkers. Between a fourth and a half were rated as abstinent or controlled drinkers at each follow-up, while 21% to 37% were categorized either as uncontrolled or institutionalized. No subject was completely controlled for more than two consecutive trimesters. However, only 19% reportedly regressed to completely uncontrolled consumption within 3 months of their first evaluations, which casts doubt on the contention that even limited drinking ordinarily is followed by rapid regression. At their final follow-ups, 47% were rated as abstinent or controlled drinkers and only 36% as uncontrolled or institutionalized. The findings did not support well either the abstinence or the controlled drinking position.

Female alcoholics: III. Patterns of consumption 3-10 years after treatment

In a follow-up study of 55 female alcoholics, 44 women (80%) were interviewed on an average of 6.5 years after treatment. According to the reported quantity and frequency of drinking the year prior to follow-up, eight women (18%) were classified as abstainers, nine (20%) as light drinkers, ten (22%) as moderate drinkers, and 17 (39%) as heavy drinkers. In a longitudinal perspective, four main patterns of outcome could be discriminated: long-term abstinence, short-term abstinence intermingled with drinking, asymptomatic drinking and continuous heavy drinking. Most of the asymptomatic drinkers reported a consumption of very small amounts of alcohol, avoiding becoming intoxicated. Those women who reported consumption of more than 2/3 of a bottle of spirits on any single drinking day or consumed more than 7 liters of pure alcohol annually, usually satisfied the DSM-III criteria for alcohol abuse or alcohol dependence.

[Attitude to the disease model and self-help groups as predictors of participation in after care and of therapeutic outcome in alcoholic patients]

The study was conducted to determine the predictive value of attitudes towards the goals derived from the disease model of alcoholism (life-long acceptance of alcoholic status and endorsement of abstinence) as well as towards self-help groups. The criteria to be predicted were the intention to participate and actual participation in self-help groups as well as four indicators of therapeutic success. Only in cross-sectional analysis were significant correlations found. Longitudinally, there were no relevant relationships between the attitudes expressed by the patients at the end of inpatient treatment (t1) and subsequent participation in self-help groups or indicators of therapeutic success (t2: follow-up, 9 month after discharge). The discrepancy between cross-sectional and longitudinal analysis can be attributed to the fact that attitudes become increasingly less stable with time. This indicates that it is only possible to a limited extent to predict from the attitudes expressed during inpatient treatment how patients will actually behave in daily life outside the clinic. The consequences of these findings for therapy are discussed.

Alcohol and drug abuse treatment in three different populations: is there improvement and is it predictable?

Prior research had shown that alcohol and drug abuse treatments were effective and that the results of treatments could be predicted from pretreatment information regarding the patient's employment, family, and especially psychiatric problems. However, this research had been conducted entirely with adult male service veterans, largely from lower socioeconomic strata. Three treatment centers were included in the present study to examine these conclusions with other populations containing adolescents, females, and patients from higher socioeconomic strata. Data from the Addiction Severity Index was collected at treatment admission and again at independent follow-up, 6 months later. Results confirmed prior observations. Both alcohol and drug abuse treatments showed substantial improvements in the chemical use problems of their patients and in the important areas of employment, criminal behavior, family relations, and psychological health. As in earlier reports, a global measure of the nature and extent of pretreatment psychiatric problems was the single best predictor of treatment response for both alcoholics and drug-dependent samples.