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Treatment Settings

Various alcoholism treatments differ not only in the methods they use but also in the setting in which they are delivered. Thus, alcoholism treatment can be performed either in residential and hospital (i.e., inpatient) settings or in outpatient settings. Inpatient rehabilitation programs traditionally last 28 days and provide highly structured treatment services, including group therapy, individual therapy, and alcoholism education. Furthermore, professional staff members are available around the clock to help manage the patient's acute medical and psychological problems during the initial treatment period (i.e., detoxification). Alternatively, the patient may receive only short-term inpatient detoxification services before being transferred to an outpatient setting for further rehabilitation.

Currently, the vast majority of alcoholic patients are treated in outpatient facilities. Those programs offer alcoholism services of various intensity and duration. Day hospital programs (i.e., intensive outpatient programs) involve the patient for several hours per day, several days per week and were developed as alternatives to inpatient programs. Day hospital programs allow the patients to maintain their family roles while simultaneously receiving treatment. Less intensive outpatient services generally offer counseling sessions (i.e., group sessions, individual sessions, and – if necessary – family or couples therapy) once or twice per week. For many patients, those services are intended as maintenance therapy after the patients have received initial inpatient or intensive outpatient treatment.

Because of escalating health care costs, the focus in recent years has shifted away from inpatient treatment and toward outpatient treatment for all stages of recovery. This shift has resulted in an emphasis on outpatient detoxification and intensive outpatient services for initial treatment, approaches that are less expensive than inpatient treatment. In addition, the typical length of stay in inpatient programs has decreased substantially. The effectiveness of inpatient treatment versus outpatient treatment is controversial. Finney and colleagues (1996) concluded from their analysis of the findings of several studies that outpatient treatment is appropriate for most people with sufficient social resources and without co-occurring serious medical and/or psychiatric impairment. Conversely, inpatient treatment should be retained for clients with serious co-occurring medical and/or psychiatric conditions as well as for clients with few social resources and/or environments not supportive of recovery.

Detoxification

Sudden cessation of alcohol consumption in people who have consumed alcohol regularly can lead to a variety of clinical symptoms that collectively are called alcohol withdrawal syndrome. The manifestations of alcohol withdrawal can range from mild irritability, insomnia, and tremors to potentially life-threatening medical complications, such as seizures, hallucinations, and delirium tremens. Consequently, before beginning long-term alcoholism treatment, many patients require a detoxification period during which they become alcohol free under controlled conditions. Depending on the severity of the withdrawal symptoms, those services can be delivered in either an inpatient or outpatient setting.

Medically supervised detoxification frequently involves treatment with medications (i.e., pharmacotherapy), particularly for patients with moderate to severe withdrawal symptoms. For most patients, benzodiazepines – a class of sedative medications that affect some of the same molecules in the brain as does alcohol – are the treatment of choice. An early randomized clinical trial demonstrated that benzodiazepines effectively prevented the development of delirium tremens (Kaim et al. 1969). Since that study was conducted, benzodiazepine use has revolutionized the treatment of alcohol withdrawal syndrome. Initially, benzodiazepines were administered on a predetermined dosing schedule for several days, often in gradually tapering doses. Recent studies have shown, however, that lower overall benzodiazepine doses can be used if the dosage is continually adjusted to the severity of the symptoms (Saitz 1998). Because benzodiazepines have an abuse potential of their own, therapists should not prescribe them after the acute withdrawal period.

Current state-of-the-art alcohol detoxification begins with an assessment of the severity of the patient's withdrawal symptoms using such assessment tools as the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA–Ar) (Sullivan et al. 1989; Foy et al. 1988). This questionnaire evaluates the presence and severity of various withdrawal symptoms, such as nausea and vomiting; tremors; sweating; anxiety; agitation; tactile, auditory, and visual disturbances; headaches; and disorientation. The higher the patient's score is on the CIWA–Ar, the greater is his or her risk for experiencing serious withdrawal symptoms, such as seizures and confusion.

Patients who experience only mild withdrawal symptoms according to the CIWA–Ar (i.e., score below 8 points) do not require pharmacotherapy; however, they should be monitored by their physician for potential complications. Conversely, patients who experience withdrawal symptoms that are either moderate (i.e., score from 8 to 15 points) or severe (i.e., score more than 15 points) should be treated with medications, such as benzodiazepines. Hayashida and colleagues (1989) demonstrated that patients with moderate withdrawal symptoms can be treated safely on an outpatient basis.

Hayashida (1998) has indicated that outpatient detoxification offers several advantages. For example, the patient may be able to use the same facility for both detoxification and subsequent longterm outpatient treatment. In addition, the patient may be able to more easily maintain family and social relationships and thus experience greater social support. Finally, the costs are lower for outpatient than for inpatient detoxification.

Outpatient detoxification is not appropriate, however, for patients who are at risk for life-threatening withdrawal symptoms, have other serious medical conditions, are suicidal or homicidal, live in disruptive family or job situations, or cannot travel daily to the treatment facility. Furthermore, outpatient detoxification is associated with significantly lower completion rates compared with inpatient detoxification (Hayashida et al. 1989). Finally, patients undergoing outpatient detoxification are at an increased risk of relapse during or shortly after detoxification because they have easier access to alcoholic beverages. However, long-term outcomes (i.e., more than 6 months) do not appear to differ between patients who receive inpatient or outpatient detoxification (Hayashida 1998).

Source: National Institute on Alcohol Abuse and Alcoholism