After completing alcoholic rehabilitation, 60% or more of alcoholics maintain abstinence for at least a year, and many achieve lifetime abstinence. Considering the lack of evidence for the superiority of any specific treatment type, it is best to keep interventions simple.
Maneuvers in rehabilitation fall into several general categories, which are applied to all patients regardless of age or ethnic group. However, the manner in which the treatments are used should be sensitive to the practices and needs of specific populations. First are attempts to help the alcoholic achieve and maintain a high level of motivation toward abstinence. These include education about alcoholism and instructing family and/or friends to stop protecting the person from the problems caused by alcohol. The second step is to help the patient to readjust to life without alcohol and to reestablish a functional life-style through counseling, vocational rehabilitation, and self-help groups such as Alcoholics Anonymous. The third component, called relapse prevention, helps the person to identify situations in which a return to drinking is likely, formulate ways of managing these risks, and develop coping strategies that increase the chances of a return to abstinence if a slip occurs.
There is no convincing evidence that inpatient rehabilitation is always more effective than outpatient care. However, more intense interventions work better than less intensive measures, and some alcoholics do not respond to outpatient approaches.
The decision to hospitalize or place into residential care can be made if (1) the patient has medical problems that are difficult to treat outside a hospital; (2) depression, confusion, or psychosis interferes with outpatient care; (3) there is a severe life crisis that makes it difficult to work in an outpatient setting; (4) outpatient treatment has failed; or (5) the patient lives far from the treatment center. The best predictors of continued abstinence include evidence of higher levels of life stability (e.g., supportive family and friends) and higher levels of functioning (e.g., job skills, higher levels of education, and absence of crimes unrelated to alcohol).
Whether the treatment begins in an inpatient or an outpatient setting, subsequent outpatient contact should be maintained for a minimum of 6 months and preferably a full year after abstinence is achieved. Counseling with an individual physician or through groups focuses on day-to-day living - emphasizing areas of improved functioning in the absence of alcohol (i.e., why it is a good idea to continue to abstain) and helping the patient to manage free time without alcohol, develop a nondrinking peer group, and handle stresses on the job.
The physician serves an important role in identifying the alcoholic, treating associated medical or psychiatric syndromes, overseeing detoxification, referring the patient to rehabilitation programs, and providing counseling. The physician is also responsible for selecting which (if any) medication might be appropriate during alcoholism rehabilitation. Patients often complain of continuing sleep problems or anxiety when acute withdrawal treatment is over, problems that may be a component of protracted withdrawal. Unfortunately, there is no place for hypnotics or antianxiety drugs in the treatment of most alcoholics after acute withdrawal has been completed. Patients should be reassured that the trouble sleeping is normal after alcohol withdrawal and will improve over the subsequent weeks and months. Patients should follow a rigid bedtime and awakening schedule and avoid any naps or the use of caffeine in the evenings. The sleep pattern will improve rapidly. Anxiety can be addressed by helping the person to gain insight into the temporary nature of the symptoms and to develop strategies to achieve relaxation as well as by using forms of cognitive therapy.
While the mainstay of alcoholic rehabilitation involves counseling, education, and cognitive approaches, several medications might be useful. The first is the opioid-antagonist drug naltrexone, 50 to 150 mg/d, which has been reported in several small-scale, short-term studies to decrease the probability of a return to drinking and to shorten periods of relapse. However, at least one longer-term large-scale trial questioned the superiority of naltrexone to placebo, and more studies are required before the cost-effectiveness of this approach can be established. A second medication, acamprosate (Campral), 2 g/d, has been tested in >5000 patients in Europe, with results that appear similar to those reported for naltrexone. Several long-term trials of naltrexone and acamprosate, used individually and in combination, are in progress, and early results are promising. A third medication, which has historically been used in the treatment of alcoholism, is the ALDH inhibitor disulfiram. In doses of 250 mg/d this drug produces an unpleasant (and potentially dangerous) reaction in the presence of alcohol, a phenomenon related to rapidly rising blood levels of the first metabolite of alcohol, acetaldehyde. However, few adequate controlled trials have demonstrated the superiority of disulfiram over placebo. Disulfiram has many side effects, and the reaction with alcohol can be dangerous, especially for patients with heart disease, stroke, diabetes mellitus, and hypertension. Thus, most clinicians reserve this medication for patients who have a clear history of longer-term abstinence associated with prior use of disulfiram and for those who might take the drug under the supervision of another individual (such as a spouse), especially during discrete periods that they have identified as representing high-risk drinking situations for them (such as the Christmas holiday).
Additional support for alcoholics and their relatives and friends is available through self-help groups such as Alcoholics Anonymous (AA). These groups, which typically consist of recovering alcoholics, offer an effective model of abstinence, provide a sober peer group, and make crisis intervention available when the urge to drink escalates. This can help patients optimize their chances for recovery, especially when incorporated into a more structured treatment milieu.
Alcohol and Alcoholism
Revision date: July 8, 2011
Last revised: by Sebastian Scheller, MD, ScD