Substance Abuse in Brief Fact Sheet
Winter 2004, Volume 3, Issue 1
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Treating Alcohol Problems
Most people who drink do so without adverse consequences. However, some may develop alcohol problems that require some type of intervention or treatment. In 2000, nearly two-thirds of the 3.5 million persons who received treatment for a substance use disorder in the past year received treatment for alcohol problems—an estimated 2.4 million persons (Substance Abuse and Mental Health Services Administration [SAMHSA] 2003). Problem alcohol use can lead to various physical, psychological, and social consequences. Early detection and treatment of alcohol problems can minimize or prevent these consequences and related costs. This issue of Substance Abuse in Brief discusses several aspects of treatment, including identifying problem alcohol use, applying brief interventions, introducing behavioral treatment approaches, and providing supportive services and appropriate treatments.
Identifying Alcohol Problems
Brief Interventions
Treatment Approaches
Supportive Services
Treatments Using Medications
Treatment Effectiveness
Locating Screening and Assessment Tools
Inpatient or Outpatient Treatment?
Know Your Treatment Community
What You Can Do To Increase Awareness
Substance Abuse in Brief
References
Identifying risky drinking behavior, alcohol abuse, or alcohol dependence can be difficult. Related health, social, and personal problems often develop slowly and may not be detected without a precipitating event such as a workplace crisis, an incident involving the police, or an alcohol-related automobile crash. In addition, people are often reluctant to acknowledge or discuss alcohol-related problems, even with their doctors. One study found that approximately half of those with alcohol use disorders never mentioned the problem to their doctors and, of those who did, only half were diagnosed as a result (Commander et al. 1999). Studies such as this point to the importance of routine screening and assessment by primary care providers to detect and identify problems with alcohol consumption (Center for Substance Abuse Treatment [CSAT] 1997).
Health care providers have a unique opportunity to identify individuals in their care with substance use disorders at an early stage. Health care providers should screen all patients routinely for problems with alcohol by asking questions to learn how much alcohol they drink and how often. They also should ask whether patients’ use of alcohol creates problems in their daily lives and relationships, such as frequent absences from work or arguments with family members about alcohol use.
Various screening tests for alcohol use are available for use by the trained health care clinician, including Alcohol Use Disorders Identification Test , and questionnaires such as (AUDIT) questionnaires and the CAGE instrument. Regardless of length or type, screening instruments have the same goal—to identify individuals who are or may become problem drinkers (CSAT 1997).
When health care providers ask specific questions about alcohol use, patients have an opportunity to share their concerns and are reportedly two to three times more likely to speak again about their alcohol use with a health care professional. In addition, when such discussions include other health topics such as exercise, diet, weight control, and medications, both providers and patients may feel more comfortable discussing problems with substance use (CSAT 1997).
Once an alcohol problem is identified, finding appropriate treatment for the individual is the next step. The level of treatment required depends on the type and severity of alcohol use and any associated problems the person may have. For example, a person with mild alcohol problems usually can benefit from a brief intervention; someone with more severe alcohol problems may require specialized treatment services (Fleming and Manwell 1999). To guide treatment planning further, a substance abuse treatment specialist or a physician trained in addiction medicine also can assess the person’s emotional, psychiatric, and behavioral status.
Individuals identified with mild-to-moderate drinking problems may benefit most from a brief intervention, a time-limited, client-centered counseling strategy focused on changing behavior and improving compliance with therapy. Brief interventions typically include five components:
Brief interventions usually can be conducted in less than half an hour, making them especially useful in settings in which health care providers have limited time, such as hospitals, primary care clinics, and urgent care facilities. For information on conducting brief interventions in primary care settings, see Treatment Improvement Protocol (TIP) 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997).
Brief interventions often succeed in reducing clients’ alcohol consumption and related problems as well as their use of health care services for alcohol-related medical conditions and trauma (Fleming et al. 2002; Fuller and Hiller-Sturmhofel 1999). An estimated 15 to 20 million heavy drinkers potentially could be helped by brief interventions that might prevent adverse alcohol-related consequences, such as accidents and emergency room visits (CSAT 1997).
Brief interventions have been found to be more effective than no intervention and often are as effective as a more extensive treatment. Brief interventions also can be cost effective. A recent study found that every $10,000 a physician invested in brief alcohol intervention reduced potential health care costs by an estimated $43,000 (Fleming et al. 2002).
People with mild-to-moderate alcohol use problems often respond well to brief interventions. However, those diagnosed with alcohol use disorders or dependence require more intensive behavioral treatment approaches, such as cognitive behavioral therapy and motivational enhancement therapy.
Cognitive behavioral approaches to alcohol treatment help clients identify high-risk relapse situations; learn and rehearse strategies for coping with these situations; and recognize and cope with their cravings for alcohol and its effects (Kadden 2001). Clients participate in role-playing activities and are assigned homework to help develop behavioral and cognitive skills that enable them to cope better with situations that might tempt them to resume former alcohol habits.
Motivational enhancement therapy encourages clients to use their own resources to change their behavior. Based on the therapist’s assessment of the type and severity of clients’ drinking-associated problems, clients receive structured feedback to stimulate their motivation to change (Fuller and Hiller-Sturmhofel 1999). Research has shown cognitive behavioral and motivational therapies to have comparable long-term success rates. According to one study, 24 percent of clients in cognitive behavioral therapy and 27 percent in motivational enhancement therapy were abstinent three years after treatment (Project MATCH Research Group 1998).
Another approach, known as 12-Step facilitation, adapts traditional 12-Step methods to behavioral therapy.
Programs that provide services for people dependent on or addicted to alcohol can be much more effective when they also address clients’ social, family, and practical needs. Supportive services can be crucial in keeping clients in treatment and preventing relapse. Self-help approaches, such as the 12-Step Alcoholics Anonymous program, provide support through the recovery process. Clients attend regular meetings and often maintain a close relationship with a sponsor who is an experienced member of the group (Fuller and Hiller-Sturmhofel 1999). Self-help programs commonly are used in conjunction with formal alcohol treatment programs. There is a strong correlation between attending self-help meetings during and after treatment and successful recovery from alcohol use disorders (NIAAA 2000).
Clients also experience better outcomes when they receive additional services that help them stay in treatment, such as childcare assistance, family counseling, and training in interpersonal and parenting skills. Services that address clients’ needs for practical help with education, job training, and legal, housing, and transportation issues also have a positive effect on treatment outcomes (CSAT 2000). For example, one SAMHSA study found that clients in residential treatment programs were six times more likely to stay in treatment for 90 days or longer if they also were enrolled in vocational training (Simpson et al. 1997). Another SAMHSA study found that clients who received vocational training services were nearly three times more likely to complete treatment (CSAT 1999a).
People in treatment for alcohol dependence also can benefit from appropriate medications. Today, two prescription drugs approved by the Food and Drug Administration are used to treat alcohol dependence.
Disulfiram, an aversive medication, provides a powerful incentive to avoid alcohol by causing severe physical symptoms (e.g., nausea, vomiting, cardiovascular changes) when a client drinks. However, this medication does not eliminate the craving for alcohol. Patients—particularly those with low motivation to abstain—may stop taking the medication and relapse (West et al. 1999).
Naltrexone, which suppresses alcohol craving, was approved for use in 1995. It works by diminishing alcohol’s pleasurable stimulant effects, while magnifying negative effects such as grogginess and lack of energy (NIAAA 2000). Naltrexone’s adverse side effects may include liver toxicity, so this drug should not be given to patients with acute hepatitis or liver failure. Before treatment with naltrexone, patients should be tested for liver function, with periodic tests during treatment. Naltrexone may cause or aggravate withdrawal in people who are physiologically dependent on opioids (CSAT 1998).
Numerous studies have demonstrated that people can be treated effectively for alcohol dependence. A nationally representative study of treatment outcomes found that the number of days per month that alcohol was consumed by clients in treatment decreased from 17 days before treatment to 10 days after treatment (SAMHSA 1998). SAMHSA’s National Treatment Improvement Evaluation Study found that the percentage of clients in treatment who reported getting drunk decreased from 33 percent in the month before the study to 24 percent following treatment (CSAT 1999a).
Treatment not only reduces alcohol use, but also has been shown to reduce other alcohol-related problems (Figure 1). For example, in one study, posttreatment clients committed fewer crimes (down from 24 to 11 percent) and experienced an increase in employment (up from 29 to 54 percent) (CSAT 1999b). Another study found that clients used fewer health services after alcohol treatment, particularly more expensive ones such as inhospital stays and emergency room services (Armstrong et al. 2001).
Posttreatment improvements like these benefit the health care system and society at large, as well as the individuals who are helped, their families, and their communities. Preliminary findings of the Persistent Effects of Treatment Studies indicate that 2 years after treatment, each dollar spent on alcohol and drug treatment resulted in a saving of $6.40 per patient to society due to lower costs for health care and criminal justice services and increased earnings (Harwood et al. 2001).
Locating Screening and Assessment Tools
Numerous screening and assessment tools, including several for specific populations such as youth, can be obtained from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at or by calling toll free 1-800-729-6686, Hablamos Español 1-877-767-8432, or TDD (hearing impaired) 1-800-487-4889.
Outpatient or Inpatient Treatment?
Depending on circumstances, clients may receive inpatient treatment, outpatient treatment, or a combination of both. Long-term treatment outcomes of inpatient and outpatient clients appear similar (Fuller and Hiller-Sturmhofel 1999; National Institute on Alcohol Abuse and Alcoholism [NIAAA] 2000), yet individual client characteristics and the nature of the alcohol problem may make one type of treatment more appropriate than the other.
Outpatient programs
Inpatient programs
Professionals working in health care, social service, criminal justice, and mental health fields should be familiar with available resources for patients with alcohol use disorders. Each State has a drug and alcohol authority that can provide information about licensed treatment programs (for additional information, visit ). CSAT’s Substance Abuse Treatment Facility Locator also can help identify treatment centers and support groups in local communities (visit www.findtreatment.samhsa.gov or call 1-800-662-HELP.
Health Care Providers: Routinely ask patients about alcohol use, screen for alcohol-related problems, and conduct brief interventions when appropriate. For practical information on the role of health care providers in the treatment process, consult CSAT’s TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997).
Faith-Based and Community Organizations: Work together to provide integrated education and support to those with alcohol problems. For additional information on faith-based and community partnerships, visit HHS-SAMHSA’s Faith-Based and Community Initiative’s Web site at www.ncadi.samhsa.gov/initiatives/faithbased.
Substance Abuse in Brief
Substance Abuse in Brief is produced under contract number 270-99-7072 by Johnson, Bassin & Shaw, Inc., and The CDM Group, Inc., for the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment. Edwin M. Craft, Dr.P.H., LCPC, is the SAMHSA editor for this publication.
An electronic version of Substance Abuse in Brief is available on line at www.csat.samhsa.gov under publications. If you wish to reference or reproduce this issue, citation of the publication is appreciated.
Recommended Citation: Center for Substance Abuse Treatment. Treating Alcohol Problems. Substance Abuse in Brief, Winter 2004. Volume 3, Issue 1.
DHHS Pub. No. (SMA) 04-3902
NACDI No. MS940
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Commander, M.; Odell, S.; Williams, K.; Sashidharan, S.; and Surtees, P. Pathways to care for alcohol use disorders. Journal of Public Health Medicine 21(1):65–69, 1999.
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