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2 VVhat Is Being Treated? George, aged 19, is a college freshman from a comfortable middle-class home in which his parents drink on occasion. He was forbidden to do so, and has continued to drink very little while in college. However, he recently pledged the local chapter of his fa- ther's fraternity, where heavy weekend drinking is common. Wanting to "fit ink he has learned to enjoy beer, although ordinarily he does not consume large amounts. But last weekend he became intoxicated and, while pursuing a dare, crashed his car and fractured his pelvis. Sally has had a speech impediment from childhood. Despite considerable attention from speech therapists, her ability to speak clearly has been only intermittent. In her adolescence she developed the notion that she was able to speak much more clearly while under the influence of alcohol; she did not like its taste, however, and so used it only sparingly. Recently she accepted a position as an assistant receptionist. When her coworker is absent, she is called upon to be the interface between the office and the outside world, something she has found difficult because of her impediment. Accordingly, she has turned increasingly to the use of alcohol, taking vodka in the mornings before work and at lunchtime. As yet her drinking has gone undetected in the workplace, but she has recognized that what was initially self-medication has become a practice that she is beginning to find gratifying in itself. Patrick, a foundry worker, is one of a pair of fraternal twins. His father was a foundry worker as well, and had a small local reputation as "a man who could hold his liquor. Peter, his twin, has reacted strongly to his father's drinking (which was not as well controlled within the home as outside it) and has become an abstainer. Patrick, however, enjoys the conviviality of before-dinner drinks at the local bar with his workmates. A small group of them has taken to attending the races on weekends and skipping work on Monday if they make money on the horses, in part to recover from "being under the weather. On two occasions in the past half-year, Patrick's foreman has spoken sharply to him regarding his absenteeism. David is the star salesman for a small company that specializes in corporate liability insurance. Because of the pressures of his clients' work, and because of his own view that an important factor in his success is his personal relationship with them, much of his business is transacted at luncheons or dinners. In part because they are underwritten as legitimate business expenses, these occasions tend to be lavish both in terms of food and drink. On weekends, feeling "let down" from "the excitement of the working week," David has taken to having two to four drinks per day, preferring to remain at home. Increasing tension has developed with his wife and children for this as well as other reasons. Both his wife and his private physician have cautioned him about the level of his alcohol consumption, his weight, and his gradually rising blood pressure. In dismissing their objections, he points out that they have never seen him in an intoxicated state. Ordinarily, William is a sober and well-mannered man. A loner, he lives in a rented room and rarely goes out except to work. However, from time to time, and increasingly in recent years, he will suddenly start drinking enormous quantities of alcohol in the form of cheap fortified wine. Except to purchase his gallon jugs he does not leave his room at these times, but he can be heard at all hours, pacing up and down and talking loudly to himself. After a week or two (or three, in recent months) his room becomes quiet, and some time later, looking much the worse for wear, William emerges to seek a new temporary job. When asked by his sympathetic landlady what causes him to behave in this way, he says, simply, "I don't know." 23

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24 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Elizabeth and her family have lived in the California wine country ever since their ancestor migrated to North America several generations ago. For as long as anyone can remember, both in the Old World and the New, most family members have been involved in the production of wine. Plentiful and inexpensive, it is always in evidence, and not only at mealtimes. For most of her adult life Elizabeth has accounted for between one and three bottles daily, depending in part on whether there was something to celebrate. Aside from a tendency toward stoutness, she has been in good general health and of a pleasant disposition. Last week, however, she suddenly began to vomit bright red blood and then passed out. Although she is now out of immediate danger, the doctors have told the family that her "condition" is Serious." Gregory does not drink. Yesterday, however, he took two drinks of whiskey; they proved to be two too many. He and his close circle of friends had been celebrating, and (primarily to deflect their insistent teasing) he participated in their good cheer. After doing so, he developed what his friends recall as a "glazed" appearance and briefly left the group. He returned with a shotgun that he promptly discharged at point blank range into the chest of his closest friend, killing him instantly. Returning home, he immediately fell into a deep sleep, from which he awakened with a professed amnesia for what had happened. Informed of the death of his friend, he reacted with an outpouring of grief. As he waits in his detention cell to be evaluated by a forensic psychiatrist, he maintains that he could not possibly have killed his friend deliberately but must have been temporarily insane at the time. Jimmy did not drink a great deal until he entered the military, where a combination of boredom, the ready availability of alcohol, and boon companions led to excesses that occasionally resulted in disciplinary action. Nevertheless, he compiled an impressive service record and was considered a war hero in his neighborhood at the time of discharge. Initially successful as a junior executive, he soon found that coping with the adjustment to civilian life, a sharply competitive business environment, a joyless marriage, advancing age, and the sudden death of his father from cirrhosis of the liver was a burden that was bearable only with the daily consumption of alcohol and frequent extramarital affairs. He has had a long series of admissions to inpatient medical care for gastritis and pancreatitis; during the course of one of these hospitalizations he developed delirium tremens. On three separate occasions in the last five years he attended well-known 28-day residential treatment programs and briefly affiliated afterwards with Alcoholics Anonymous; subsequently he did reasonably well for several weeks to several months. On this occasion he is accompanied to the emergency room of the local hospital by a police officer; he was found wandering about the streets intoxicated and bleeding profusely from both wrists, which he had slashed with his army sheath knife after an especially bitter encounter with his estranged wife. * * * The foregoing vignettes are based upon actual individuals encountered by clinicians in the course of providing services to persons seeking assistance for alcohol problems. In light of the limited number of instances that are portrayed, the vignettes cannot be con- sidered fully representative of the great variety of individuals who develop alcohol problems, or of the problems themselves. Yet those who have worked in treatment settings will recognize all or most of these people and their problems-and many more besides. They are the focus of the treatment enterprise. In the sense that they possess a number of common characteristics, these individuals form an identifiable group. For example, all are experiencing problems around their consumption of beverage alcohol. All may need to be dealt with effectively in some manner by someone with special knowledge of alcohol problems (ntreated,n in the older

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WHAT IS BEING TREATED? 25 sense of the term, which survives when one speaks of a literary or other artistic treatment of a person or subject). Yet within even this small group there are marked differences. Some of the problems experienced by these individuals are relatively mild (e.g., George, Sally), others are quite severe (e.g., Gregory, Jimmy), and the remainder occupy intermediate positions. Some problems are relatively acute or intermittent (e.g., Patrick, William, Gregory) while others are relatively chronic (e.g., Sally, David, Elizabeth). Some problems have occurred in the context of heavy consumption and some in the context of comparatively light consumption. Some problems are clearly secondary to specific, preexisting conditions; others are not. Some individuals have developed various signs and symptoms or have experienced specific consequences associated with the use of alcohol; others have not. The individuals described here differ widely in terms of age, sex, cultural background, occupation, education, and other factors. That both important commonalities and important diversities exist in such a group of persons presents a major challenge to those who deal with them. To what degree should each be emphasized, and for what purposes? Some frameworks which are currently employed in dealing with these phenomena, such as those for which the key terms are alcoholism and the alcohol dependence syndrome, tend to emphasize the diversity of the group as a whole, and at the same time the commonalities between individual members of the group, especially at the more serious end of the spectrum. An alternative approach is to emphasize the commonalities of the group as a whole and at the same time the diversities between individual members of the group, even at the more serious end of the spectrum. This approach has been taken in the present study, as will be discussed in the balance of this chapter. These two approaches are alternative perspectives upon the same phenomena. Both represent attempts to cope with the combination of commonalities and diversities that are intertwined in this complex and perplexing human problem. The Alcohol Problems Perspective Alcohol problems are defined for the purposes of this report as those problems that may arise in individuals around their use of beverage alcohol and that may require an appropriate treatment response for their optimum management. Alcohol problems can be conveniently described in terms of their duration (acute, intermittent, chronic) and severity (mild, moderate, substantial, severe). Yet such abbreviated descriptions should not be permitted to conceal the fact that alcohol problems are extremely diverse; they vary continuously along many dimensions. For example, the manifestations of these problems will sometimes be primarily physical, sometimes social, sometimes psychological; most often they will be variable combinations of all of these. Alcohol problems also vary greatly in terms of the kinds of treatment responses that may be appropriate, responses ranging from simple advice to elaborate combinations and/or sequences of biological, social, and psychological interventions. Access to a comprehensive and coherent system of care that is capable of identifying and implementing the appropriate responses is desirable for all persons with alcohol problems. The term alcoholproblems was first used as an organizing concept in a 1967 report of the Cooperative Commission on the Study of Alcoholism (Plaut, 1967~. In that context it referred Moth to any controversy or disagreement about beverage alcohol use or nonuse, and to any drinking behavior that is defined or experienced as a problem" (p. 4~. The first part of this definition has been seen as problematic (cf. Levine, 1984~. As used herein the term is consistent with, as well as an extension of, only the second part of the 1967 definition.

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26 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS If the vignettes of the opening section of this chapter are examined in the light of the foregoing definition, each individual can be viewed as manifesting an alcohol problem. As already noted these problems can be usefully described (though not, to be sure, fully characterized) by duration and severity; for example, George exhibits an acute mild alcohol problem and Jimmy a chronic severe alcohol problem. A measured therapeutic response may be advisable in all instances. The need for treatment is more apparent at Jimmy's end of the spectrum. But George might benefit considerably from some well-chosen words of advice from the physicians attending to his injury, as well as assistance to help him modify at least aspects of his conformity to his present social environment. From the committee's perspective, the principal advantage of the alcohol problems approach is that it identifies the population of individuals toward which the treatment activities it sees as necessary can be directed. It provides a succinct answer to the question posed in the title of this chapter: what is being treated are alcohol problems. People with alcohol problems are the group that should be dealt with in a variety of ways relevant to the charge to the committee. Treatment should be provided for this group in all its diverse manifestations, which means that policy should be formulated around this group and-as a crucial enabling development financing mechanisms should be developed to cover the entire spectrum of possible therapeutic responses. At the same time that the alcohol problems perspective provides a broad, overall approach useful in terms of policy and planning, it also emphasizes the diversity of the problems which are presented and of the individual who present them. The committee feels that this perspective of diversity in individual instances, of what in this report will often be referred to as heterogeneity, is essential to the development of an informed therapeutic response. Such a response involves the systematic identification of salient individual differences and the tailoring of treatment in the light of those differences. It is related to, though not identical with, the classic medical paradigm of differential diagnosis followed by specific treatment A final possible advantage is that, in employing a relatively limited and deliberately neutral set of terms, the alcohol problems perspective is not freighted with a large body of theory. Accordingly, it does not constrain thinking about many issues that continue to be actively debated. The use of some alternative terminologies (see below) implies the acceptance of particular positions on certain issues. As will be seen, the alcohol problems perspective does not contradict the validity of these alternative perspectives but sees them as appropriately addressed to parts of the overall picture, rather than to the overall picture itself. Other Perspectives Alcoholism The term alcoholism was first used by the Swedish physician and temperance advocate Magnus Huss in 1849 to refer "only to those disease manifestations which, without any direct connection with organic changes of the nervous system, take on a chronic form in persons who, over long periods, have partaken of large quantities of brandy (Jellinek, 1943:86~. It enjoys widespread use, though there been no consensus as to its meaning (Babor and Kadden, 1985; IOM, 1987~. A recent definition, derived through a Delphi pro- cess that surveyed persons felt to possess appropriate expertise nominated by 23 professional organizations, is "a chronic, progressive, and potentially fatal biogenetic and psychosocial disease characterized by tolerance and physical dependence manifested by a loss

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WHAT IS BEING TREATED? of control, as well as diverse personality changes and social consequences" (Rinaldi et al., 1988:556). 27 Most persons with clinical experience will immediately recognize this description as applicable to individuals they have seen in practice. This applicability is attested to by the high levels of interrater agreement achieved for the similarly defined diagnosis "alcohol use disorder" in the field trials (Spitzer et al., 1979) of the third edition of the Du~gnostic arid Statistical Manual of the American Psychiatric Associati~or' (DSM-III) (American Psychiatric Association, 1980~. Indeed, persons without clinical experience will nevertheless recognize that the definition applies to some people they have encountered during the course of their everyday lives, as well as to current popular notions of the nature and course of heavy drinking (Mulford and Miller, 1964; Rodin, 1981; Caetano, 1987~. The question, however, is not whether the formulation or formulations embodied

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28 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS his book, The Disease Concept of Alcoholism (Jellinek, 1960), is considered a classic. The National Council on Alcoholism (NCA), the principal citizen's group involved in the field, was an outgrowth of both AA and the Yale (later Rutgers) Center of Alcohol Studies. Yet the key individuals involved in these significant developments did not see alcoholism as a useful synonym for the totality of problems. Bill W., for example, spoke in "The Big Book" of "moderate drinkers" and of "a certain type of hard drinker" who could experience serious consequences but who were not "real alcoholics" (Alcoholics Anonymous World Services, Inc., 1955:20-21). In like manner Marty Mann, the first woman to come through Alcoholics Anonymous and the founder of the National Council on Alcoholism, identified Two groups . . . whose drinking is not so easy to distinguish from alcoholic drinking," which she labeled "heavy drinkersn and "occasional drunks." She placed many of her New York friends, with whom she lost contact during her sojourn abroad and her own successful struggle with alcohol problems, in the former category. When she eventually returned to New York, I met once again many of my own acquaintances of the Twenties. Some of them were still drinking exactly as they had when I had first known them, with no visible harmful effects. The maioritv. however. today drink ~ ,, , ~ comparatively little-at most, social drinking in the strictest sense of the term. None that I have met again has stopped drinking entirely-and none has become an alcoholic. (Mann, 1981:82) In Me Disease Concept of Akoholism, E. M. Jellinek (1960) identified what he called different "species" of alcoholism. He was particularly concerned with five such species, to which he assigned as identifiers the first five letters of the Greek alphabet-alpha, beta, gamma, delta, and epsilon. Jellinek felt that only the gamma and delta species could be viewed as diseases. me ~^~^~ Am Or Hit qr.cs ~.~ri.c~ elf ~r~h<~li~ m which cannot be regarded as illnesses (p. 35), and added that "all the remaining 19 letters of the Greek and if necessary other alphabets are available for labelling them" (p. 39~. Jellinek also mentioned "other species of alcoholism" such as "explosive drinking" and "fiesta drinking," with the admonition that "the student of the problems of alcohol cannot afford to overlook these behaviors, whether or not he is inclined to designate them as species of alcoholism" (p. 39~. Finally, he observed that "By adhering strictly to our American ideas about alcoholism (created by Alcoholics Anonymous in their own image) and restricting the term to these ideas, we have been continuing to overlook many other problems of alcohol which need urgent attention" (Jellinek, 1960:35~. Jellinek's view of alcoholism as a diverse phenomenon, and of the need to look beyond it in a broad perspective, is consistent with the view of the committee. [1C; llU tW ally L ~ U V 1V UO1 y ally ~1 ~ ~eVAA~A1& ~Add_-~ Alcohol Dependence Syndrome In 1976 Edwards and Gross first described the alcohol dependence syndrome. Their stated aim was "to help further to delineate the clinical picture," and even the brief "provisional" description contained in the original article includes memorable descriptions of clinical phenomena. The authors proposed that the "essential elements" of the syndrome might include Ha narrowing in the repertoire of drinking behavior; salience of drink-seeking behavior; increased tolerance to alcohol; repeated withdrawal symptoms; repeated relief or avoidance of withdrawal symptoms by further drinking; subjective awareness of a compulsion to drink; reinstatement of the syndrome after abstinence" (Edwards and Gross, 1976:1058).

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WHAT IS BEING TREATED? 29 Edwards and Gross further stated that "all these elements exist in degree, thus giving the syndrome a range of severity." They also proposed a category of Drink-related disabilities" (subsequently "alcohol-related disabilitiesn). It consisted of various problems (in the original paper the examples given were the development of cirrhosis, the loss of a job, the breakup of a marriage, and the crashing of a car) that could occur as a result of drinking but Without suffering from the dependence syndrome." Although the authors suggested that the syndrome Should therefore not monopolize medical and social concern, they emphasized that such disabilities would "often accumulate for the person who is dependent and are more likely to occur the greater his dependence. In the more than a dozen years since its enunciation, the concept of the alcohol dependence syndrome has undergone much examination and testing, as well as amplification and some modification. (For summaries see Edwards [1977, 1986~; the most detailed explication of the alcohol dependence syndrome is in Edwards and coworkers [1977~. The concept has received its share of criticism (e.g. Shaw, 1979; Caetano, 1985; Skinner, 1988~. Overall, however, it has gained currency, having been adopted by both of the major diagnostic classification systems that are now in use for mental disorders. With respect to the International Classif~cafion of Diseases, it replaced the term alcoholism as a designation in the 9th edition (ICD-9), implemented in 1979 (World Health Organization, 1979), and operationalized criteria are now being tested for inclusion in the forthcoming tenth edition. With respect to the D`agnostm and Statistical Manual of the American Psychiatric Assocu~t~on, the alcohol dependence syndrome has become the conceptual basis for the diagnosis of "psychoactive substance use disorders" in the revised version of the 3rd edition of the manual, or DSM-III-R, implemented in 1987 (American Psychiatric Association, 1987~. In the United States, DSM-III-R is more widely used than ICD-9; the DSM-III-R version of the alcohol dependence framework thus requires some additional comment. In keeping with the high degree of specificity introduced into the prior edition (DSM-III), this version of the alcohol dependence framework is quite detailed. It enumerates nine specific "criteria" (similar to but not identical with the symptoms enumerated in the original paper by Edwards and Gross) and specifies that three or more of these must be met to make a diagnosis. An important consequence is that neither physical dependence nor tolerance need be present to diagnose the dependence syndrome. DSM-III-R also specifies an "abuse" category that is similar to but not identical with Edwards and Gross's category of Alcohol-related disabilities. Finally, in DSM-III-R the criteria and the diagnostic category itself are to be applied not only to alcohol but to all drugs; hence the category is labeled Psychoactive substance use disorders. A more extensive detailing of the criteria for this version of the alcohol dependence framework, its rationale, and the results of field trials carried out in the United States is available in the literature (Rounsaville et al., 1986, 1987~. Efforts are under way currently to attempt to resolve some of the differences between the DSM-III-R and the forthcoming ICD-10 versions of this framework. There can be little doubt that the concept of the alcohol dependence syndrome has presented a significant and highly sophisticated challenge to researchers and clinicians, requiring them to rethink many fundamental concepts and definitions. The ensuing dialogue has enriched the field. Nevertheless, for the purposes of this report, the same question must be posed regarding the alcohol dependence framework as was articulated for the alcoholism framework: does it encompass all of the individuals the committee feels must be included within the scope of planning, policy formulation, and treatment? Once again, the committee feels that the answer is in the negative. Many such persons are included within the concept of "alcohol-related disabilities. In terms of the vignettes presented at the outset of this chapter, George's fractured pelvis, Patrick's absenteeism, and even Gregory's homicide would be classified in this category rather than as instances of the alcohol dependence syndrome. Nor would George, Sally, or Gregory

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30 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS meet DSM-III-R criteria for either alcohol abuse or alcohol dependence. From planning, policy, and treatment perspectives, the potential hazard is that individuals failing to be classified as alcohol dependent might readily come to be assigned a lower priority, while those manifesting the genuine syndrome might be accorded a higher priority. A Terminological ~Map" The committee feels that the alcohol problems perspective, as defined above, most readily encompasses the target population of the present report. Nevertheless, it does not feel that this perspective is contradictory to, or even precludes the use of, other perspectives such as that of alcoholism or the alcohol dependence syndrome. In many ways the perspectives are compatible, at least over portions of the range of problems. For the sake of simplicity and uniformity, the committee has used the alcohol problems perspective and its associated terminology throughout the balance of this report. As an aid to understanding, however, Figure 2-1 shows in an organized manner the interrelationships between these various perspectives. me - - - O CO S rare ~1 slate ~ Hi?- ? -- 5~05 ~p606~5 FIGURE 2-1 A terminological map. The triangle represents the population of the United States. The alcohol consumption of the population ranges from none to heavy (along the upper side of the triangle) and the problems experienced in association with alcohol consumption range from none to severe (along the lower side of the triangle). The two-way arrows and the dotted lines indicate that, both from an individual and a population perspective, consumption levels and the degree of problems vary from time to time. The scope of terms that are often used to refer to individuals and groups according to their consumption levels and the degree of their problems are illustrated; question marks indicate that the lower boundary for many of the terms is uncertain. The triangle in the figure represents the population of the United States, partitioned into drinking categories according to level of alcohol consumption, which is indicated along the upper arm of the triangle. In the United States there is a substantial population that does not consume alcoholic beverages, and most individuals' consumption would be classified as light or moderate; such categories account for approximately three-quarters of the population. Approximately one-fifth consumes substantial amounts

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WHAT IS BEING TREATED? 31 of alcohol, and approximately 5 per cent drink heavily. Too much should not be made of these figures,-however, as they tend to change over time and are extremely variable depending on location, degree of urbanization, and other factors. As suggested in the figure, there is a generally positive and direct relationship between the level of alcohol consumption in a population and the nature and severity of the problems experienced by that population (Hilton, 1987; Babor et al., 1988~. This relationship is less consistent at the individual level, where discrepancies between consumption levels and problems are often observed. These discrepancies are the basis for the committee's recommendation of a routine assessment of both consumption levels and problems in evaluating individuals for treatment (see Chapter 10~. In aggregate data, however, these individual differences tend to balance out, and a relatively direct relationship between consumption and alcohol problems emerges. By drawing dotted rather than solid lines, and by placing two-way arrows in the figure, the committee intends to indicate that both alcohol consumption and alcohol problems lie along a continuum and that categories, such as moderate or severe, are conveniences for communication rather than fixed entities. In addition, the relative size of the categories, as well as the positioning of a single individual within the confines of the diagram, are not static but vary substantially over time. The principal purpose of the diagram is not to apportion drinkers in the United States into categories but to indicate graphically the committee's view of the scope of the alcohol problems framework and alternative conceptual frameworks. Thus, the committee sees alcohol dependence and alcoholism as occupying primarily the apex of the triangle, together with heavy alcohol consumption. Their analogue in the alcohol problems framework would be severe, chronic alcohol problems (the figure does not show a temporal dimension). Alcohol-related disabilities, alcohol abuse, and problem drinking occupy portions of the less severe area of the diagram. (Problem drinking was not discussed as an alternative framework because, as the concept is currently used, it would exclude the apex of the triangle; for a different viewpoint, however, see Cahalan [1970~.) The question marks indicate that the placement of various terms within this context is hardly precise, particularly at the lower end. What emerges principally from the diagram is that the alcohol problems perspective encompasses within a single category a larger portion of the relevant spectrum than other perspectives but at the same time is not incompatible with them. This property makes it particularly useful for the committee's purposes and influenced its choice as the frame of reference for the present report. Those who are more comfortable with or more accustomed to an alternative frame of reference can use the figure to place what is said in a more familiar perspective. The Heterogeneity of Alcohol Problems Having selected a broad, overarching framework within which all problems requiring treatment in a broad sense are viewed as similar in important ways for policy, planning, and treatment purposes, the committee proposes to explore the marked diversity within this unitary framework, principally for treatment purposes. On its surface, this seems contradictory. Yet the seeming paradox is readily resolved. The committee wishes to assure the availability of treatment for the broad spectrum of individuals with alcohol problems but at the same time recognizes that different individuals will manifest different problems and will require different treatment or treatments. Toward the end of the 18th century Dr. Thomas Trotter, an English physician, anticipated a major conclusion of the present report when he wrote with regard to alcohol -problems that "in treating these various descriptions of persons and characters, it will

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32 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS readily appear, to a discerning physician, that very different remedies will be required" (Jellinek, 1941~. The differential treatment of alcohol problems is not a new idea. To an important degree, however, it seems to have been disregarded until comparatively recently, and the committee believes it requires re-emphasis. Perhaps the reasons for its relative neglect are historical. Following the long hiatus in treatment efforts occasioned by Prohibition in the United States and elsewhere (see Chapter 1) a new beginning was required. Under such circumstances it is the more chronic and more severe cases that come immediately to attention, and it is perhaps not surprising that they should have become the major focus of clinical efforts. Only in the last two decades, through large-scale epidemiological studies of general populations, has the existence of a large population of persons with less than maximally severe alcohol problems become apparent, and only subsequent to that discovery have treatment approaches been developed that may be particularly suitable for such problems. An emerging perspective on the diversity or heterogeneity of alcohol problems can be traced in the contemporary literature. By law, the secretary of Health and Human Services is required to report to Congress periodically on the health consequences of alcohol consumption and on research findings regarding alcoholism and alcohol abuse. lithe Secretary's Fifth Special Report to Congress on Alcohol and Health states: The traditional concept of alcoholism as a unitary disease has been challenged. Over the past decade, researchers and clinicians have come to realize that multiple patterns of alcohol use may result in multiple forms of disability. Accordingly, a new emerging model of treatment stresses the heterogeneous nature of the client population, the need for more specific and efficient treatments, and the importance of maintaining gains after treatment. This model differentiates among alcoholics . . . and attempts to match each type with the most appropriate combination and configuration of treatments. (USDHHS, 1983:116) By the time the next special report appeared in January 1987, what had been a "new emerging model of treatment" only three years before was now itself described as "traditional" (USDHHS, 1987:121~. Four months later the Institute of Medicine (1987) published Causes awl Consequences of Alcohol Problems. It stressed that one of the two Developments of particular note" during 1980-1985 was that Increasing numbers of examples have been found to support the concept of heterogeneity among individuals in the impact of heredity and environment on both the social and biological aspects of drinking (p.l). The other development noted was the contribution made by genetic studies in humans and animals, which stressed the heterogeneity of the contribution of genetics to alcohol problems (c Cloninger, 1987~. The disease concept of alcoholism has sometimes been viewed (see above) as retarding an acceptance of the heterogeneity of alcohol problems. Yet Jellinek's concept of alcoholism, as discussed earlier, included at least two types that he considered diseases and that differed from each other, as well as other types that he did not consider diseases. This report will not deal extensively with the disease concept debate, which is well detailed elsewhere (cf. Keller, 1976; Fingarette, 1977; Kissin, 1983; Room, 1983; Fingarette, 1988~. However, many diseases are heterogeneous for example diabetes, hypertension, asthma, cancer, schizophrenia, end-stage renal disease, syphilis, and tuberculosis. Dealing with severe and institutionalized cases of post-encephalitic Parkinson's disease, a gifted observer noted:

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WHAT IS BEING TREATED? What excited me . . . was the spectacle of a disease that was never the same in Ho patients, a disease that could take any possible form . . . Post-encephalitic illness could by no means be considered a simple disease, but needed to be seen as an individual creation of the greatest complexity, determined not simply by a primary disease-process, but by a vast host of personal traits and social circumstances . . . a coming-to-terms of the sensitized individual with his total environment. (Sacks, 1987:21) 22 Some time ago, Griffith Edwards observed that "the decision as to alcoholism being a disease will still rest very much on the definition of alcoholism on the one hand and of disease on the other" (Edwards, 1970:161~. Within the perspective of alcohol problems it would not be surprising if particular individuals were most effectively and realistically viewed as suffering from a disease, whereas others should not be so viewed. It is part of this perspective that all individuals with alcohol problems should have broad access to appropriate and elective treatment; it follows that access should not be contingent on whether a disease is present. As diseases themselves can be heterogeneous, differential treatment is required even if a disease Is present. There may be reasons for continuing the debate over the disease concept, but progress in treatment need not await its resolution. Heterogeneity of Presentation There are a number of ways in which alcohol problems are heterogeneous. One is the manner in which they initially present. They are protean; they can imitate the presentation of any other disorder, but even if they present as alcohol problems they are extraordinarily diverse (as demonstrated in the vignettes at the outset of this chapter). Based on longitudinal research on several different populations, George Vaillant has eloquently stated the case: Alcoholism is a syndrome defined by the redundancy and variety of individual symptoms. Efforts to fit all alcohol users who are problems to themselves or others into a single, rigid definition will prove procrustean. It is the variety of alcohol-related problems, not a unique criterion, that captures what clinicians really mean when they label a person alcoholic (Vaillant et al., 1982:229~. This summary statement is concretely embodied in the lengthy lists of medical history items and clinical signs that may alert a physician to the presence of an alcohol problem (cf. Tables 1 and 2 in Skinner et al., 1986~. In an earlier era Sir William Osler remarked that "to know syphilis is to know medicine." Some medical educators feel that this is now true of alcohol problems precisely because of their seemingly infinite variety of clinical presentations. At Johns Hopkins Medical School, alcohol problems have become the central focus of teaching: "the purpose of the program is to get every medical student and every clinician at the institution acquainted with the early signs of alcoholism and competent to detect and recommend appropriate treatment for the disorder" (Holder, 1985~. As part of this approach research- ers carried out a study of all new admissions to adult inpatient services at Johns Hopkins Hospital. They confirmed that approximately 20% of all admissions had significant alcohol problems and that these problems frequently went unrecognized by the hospital staff (Moore et al., 1989~.

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34 Heterogeneity of Course BROADENING IlIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS As noted earlier, a progressive course in which a problem becomes increasingly severe as time passes is a part of at least some definitions of alcoholism. Although it is understandable that individuals pursuing such a course should make a strong impression on clinicians who are trying to help them, further experience has documented that a progressive course is by no means the only direction pursued by individuals manifesting alcohol problems. The observations of Marty Mann (see above) are an example that has been confirmed by more systematic research many times over. Vaillant's longitudinal studies, for example, delineated a group of "atypical alcoholics," individuals "who spend a lifetime abusing alcohol but never progress." He commented that "the atypical alcohol abusers by no means were individuals who were not really alcoholics and illustrated this point by a statistical comparison with his clinic sample (Vaillant, 1983:144-45). He labeled as an "illusion" the notion that "alcoholism is a progressive disease that ends in abstinence or death" (p.160) and indicated that the assumption of universal progression may be an artifact produced by a focus upon skewed clinic samples: ". . . if one looks at those individuals whose alcoholism has been progressive (that is, relapsing alcohol-dependent individuals seen in alcohol clinics and emergency rooms) then alcoholism certainly appears to be progressive" (p.309). There is ample evidence that, even in clinic samples of individuals with severe problems, the progression of these problems is by no means a universal course. This statement is even true for some groups of patients who continue to consume alcohol not an ideal treatment goal for persons with severe problems but certainly a critical test of the universal progression notion. For example, in a recent study that followed a large sample for three years after treatment, in excess of 18 per cent of the sample had continued to drink at different levels without experiencing any further problems (Helzer et al., 1985; see also Miller, 1985). Similar findings indicating a lack of progression for some persons even in the face of continuing alcohol consumption have been reported in the post-treatment period by others (Armor et al., 1978; Gottheil et al., 1979; Paredes et al., 1979.) Studies in nontreatment populations find a similarly variable mixture of progression and other patterns (Cahalan, 1970; Clark and Cahalan, 1976; Fillmore and Midanik, 1984; Temple and Fillmore, 1985; Fillmore, 1987). In the largest study yet mounted of nontreatment populations, the so-called Epidemiologic Catchment Area (ECA) study, fully 84 per cent of those who met DSM-III lifetime criteria for alcoholism and had reported especially heavy consumption at some time (7 or more drinks daily for two or more weeks) reported no periods of such drinking during the past year. Rates of remission (defined as the proportion of lifetime cases that had no alcohol problems in the past year) were found to be high, ranging from 45 to 55 per cent across the different sites of the study and averaging 51 per cent for the study overall. Most remitted cases dated their first and last symptoms at less than 5 years apart; more than three-quarters of the entire sample provided an estimated duration of less than 11 years (Helzer and Burnham, in press). Thus, some persons with alcohol problems run a progressive course, and some do not. Systematic examination of the courses actually traversed in any reasonably sized population, whether of persons who have been treated or persons who have not, regularly finds a multiplicity of courses. A number of factors that may affect the course of alcohol problems have been identified, but no determinative factors, either biological or otherwise, that invariably result in a particular course have come to light (Babor and Kadden, 1985; IOM, 1987).

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WHAT IS BEING TREATED? Heterogeneity of Etiology 35 What is the cause of alcohol problems? Although this question has been repeatedly and insistently asked over the years, no ready answer, in terms of the identification of a single cause, has emerged, and the committee believes none is likely. As noted in the 1987 IOM report, "these are complex phenomena, occurring at the junction of biologic, behavioral, and social forces (IOM, 1987~. In light of this conclusion, the committee's response to the commonly-asked question about the cause of alcohol problems is fourfold: 3. 4. There is no likelihood that a single cause will be identified for all instances of alcohol problems. There is every likelihood that the range of causes that interact to produce alcoholproblems in the population can be identif ed. Alcohol problems will prove to be the result of different interactions of different etiological factors in diaperer individuab. W7zibe elective treatment will be served by a more precise knowledge of etiology, elective treatment is possible in the absence of such knowledge. This viewpoint on etiology is similar to that of the biopsychosocial model of etiology in medicine (Engel, 1977; Engel, 1980; Engel, 1988) and to the multifactorial model of etiology in human behavior (cf. Babor and Kadden, 1985~. A representative statement of this perspective for alcohol problems is the following: This way of thinking views every drinker as being at some stage of a dynamic, lifelong process influenced by a multitude of weak, interacting social, psychological, and physical forces with no single factor, except alcohol, being necessary, and none at all being sufficient to cause advance- ment in the process to the point of being labelled Alcoholic or Problem drinker. From this viewpoint, the alcohologist's task of identifying the forces influencing the alcoholic process and untangling their complex interrelationships is much like that of the meteorologist's attempts to understand the process called "the weather. (Mulford, 1982:451) This type of multidimensional approach has been taken by investigators in the area of genetics. That genetic factors play a role in the etiology of alcohol problems, as in most aspects of human behavior, has been thought likely for some time. Recently, however, it has been felt that the available data are more understandable if that role is viewed as diverse rather than identical in all instances, and an attempt has been made to delineate those instances in which genetic influences are likely to be of greater or of lesser importance (Murray and Gurling, 1982; Murray et al., 1983; Cloninger, 1987~. An important general principle in genetic epidemiology," writes a group of involved investigators, His that disorders as prevalent as alcoholism have complex patterns of development involving the interaction of many genetic and environmental influences. Accordingly, such common disorders are expected to be heterogeneous both clinically and etiologically (Cloninger et al., 1988:500~.

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36 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS It has long been recognized that treatment can be effective in the absence of detailed knowledge of etiology. Mortality from many of the common infectious diseases declined steadily long before the bacteriologic identification of the offending organisms and the development of specific antibiotics as a result of general measures of public hygiene and the provision of adequate nutrition (McKeown, 1976~. The etiology of essential hypertension is unknown, but its effective treatment is commonplace. Schizophrenia is a devastating problem of unknown etiology, but the appropriate deployment of pharmacotherapy, psychotherapy, and social restructuring can be effective in dealing with it. Many other examples are available. It is also the case, regrettably, that precise knowledge of etiology does not in all instances lead to effective treatment (cf. Luzzatto and Goodfellow, 1989~. This is not to deny that the elucidation of etiological factors for alcohol problems is a pressing need; it is, and it should be attended to. But the development of an effective treatment response need not and, indeed, cannot be viewed as contingent upon such an elucidation. Much can be done-must be done-even as that knowledge unfolds. Knowledge of etiology will unfold slowly, and its applicability will be limited by the diversity and complexity of the problems and of the human condition. Nevertheless, effective assistance is now available, and further delays in deploying it would be both unnecessary and unfortunate. Implications of Heterogeneity for Treatment In closing, it seems desirable to address again and to refine the implications of the foregoing discussion for treatment, the principal subject of this report. If persons with alcohol problems are viewed as heterogeneous in significant ways, there are potentially important implications for treatment. One is that no one form of treatment is likely to be effective for all persons with alcohol problems. A related implication is that each treatment may be eJ/,ective for some persons with alcohol problems (see Chapter 5~. It follows that a princi- pal task in providing treatment is to identify the kind of trea~mem tam is most likely to prove elective for a given person with a given problem (see Chapter 11~. Some of those who have acknowledged the wide differences among alcohol problems and among the individuals who manifest them have nevertheless questioned the significance of these differences. Keller's law holds that "the investigation of any trait in alcoholics will show that they have either more or less of it." Keller's overall conclusion, however, is that "alcoholics are different in so many ways that it makes no difference" (Keller, 1972:1147~. A similar conclusion has sometimes been applied to treatment: Practically, differences that do not make any difference are not differences. It does not seem warranted at our present level of therapeutic knowledge to develop separate programs for different categories of alcoholics .... Within a single treatment approach it is possible to acknowledge and deal with individual differences thereby treating both the common problem of alcoholism-chemical dependency and the problems unique to individual patients. (Laundergan, 1982:36) The committee favors a combined approach. Not all differences between problems or between individuals manifesting them will necessarily require different treatments all of the time. For example, experience suggests that it is not always necessary to provide differ- ent treatments for men and women with alcohol problems. However, some differences among problems or individuals will require different treatments some of the time. Thus experience, as well as a substantial body of experimental evidence (Annie, 1988), also

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WHAT IS BEING TREATED? 37 suggests that at times it may be necessary to provide different treatments for men and women with alcohol problems to achieve the best possible outcomes for each (see Chapters 15 and 18~. Much of the remainder of this report is devoted to spelling out the implications of this view for treatment. To summarize briefly, however, the committee believes that, for persons with problems that do not appear to require specialized treatment or for those who are unwilling to undertake such treatment, it is reasonable, as well as practical at present, for nonspecialists to offer a generalized brief intervention (see Chapter 9~. In addition, although the committee considers as potentially important differences those characteristics which distinguish what have been called special populations, it believes that, at present, such differences should be dealt with in the context of standard treatment programs (see Section IV). On the other hand, the committee feels that some differences will at some times require differential treatment. Hence, in each instance of an individual seeking specialized treatment, individual differences must be carefully assessed (see Chapter 10) and, where indicated, taken into account by selecting the most appropriate treatment (see Chapter 11~. Fortunately, there is a considerable variety of treatment programs that have already been developed (see Chapter 3), although the availability of different programs may still be a problem (see Chapter 7~. Treatment so conceived is not a simple matter. There is no standard formula; instead, the constant exercise of judgment is required in deciding when individual differences are likely to be crucial to the choice of treatment. It is a heavy responsibility. The committee recommends that steps be taken to inform that judgment to a much greater extent than is now usually the case-for example, through the development of knowledge regarding outcome (see Chapter 12) and the development of treatment systems (see Chapter 13~. Even if these recommendations are implemented, however, the committee recognizes that the treatment of people with alcohol problems will remain a complex, arduous task for both the treaters and the treated. Summary and Conclusions To focus concretely on its response to the question, "What is being treated?", the committee has presented a series of vignettes of individuals in whom problems have arisen around their use of beverage alcohol and who may require an appropriate treatment response for their optimum management. The committee's preference is to refer to these problems simply and directly as "alcohol problems," and it has used this terminology consistently throughout the report. It recognizes, however, that other frames of reference (e.g. "alcoholism," "alcohol dependence syndrome") may be more familiar or preferred by some and, viewing these as compatible if ultimately less satisfactory frameworks, provides a terminological "map" to facilitate understanding. Although it is convenient to use a single term to designate the focus of treatment efforts, the committee places strong emphasis on the heterogeneity of the target population. In many crucial respects alcohol problems, as well as the individuals who manifest them, are quite different from one another. Present knowledge suggests that the causes of alcohol problems are multiple and diverse, and long experience indicates that alcohol problems present for treatment in many different forms and guises and follow a variety of courses. The implications of this impressive diversity for treatment are discussed in the next sections of the report. The differences among alcohol problems and among individuals are viewed as potentially relevant to treatment. Hence, they must be comprehensively assessed on an individual basis prior to treatment and taken into account in selecting that treatment

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38 BROADENING 1:HE BASE OF TREATMENT FOR ALCOHOL PROBLEMS or treatments that are most likely to be associated with a favorable outcome. Treatment so conceived is a more complex matter than is sometimes recognized. Nevertheless, considering the complexes of the problems themselves and of the individuals who manifest them, the committee believes that effective approaches to treatment for alcohol problems must be able to cope with these complexities. REFERENCES Alcoholics Anonymous World Services, Inc. 1955. Alcoholics Anonymous. Second edition, revised. New York: Alcoholics Anonymous World Services, Inc. American Psychiatric Association (APA). 1980. DSM III: Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Washington, D.C.: APA. American Psychiatric Association (APA). 1987. DSM III-R: Diagnostic and Statistical Manual of Mental Disorders 3rd edition revised. Washington, D.C.: APA. Annis, H. M. 1988. Patient-treatment matching in the management of alcoholism. Presented to the 50th Annual Scientific Meeting of the Committee on Problems of Drug Dependence, Incorporated, North Falmouth, Mass., June 28. Armor, D. J., J. M. Polich, and H. B. Stambuhl. 1978. Alcoholism and Treatment. New York: John Wiley and Sons. Babor, T. F., and R. Kadden. 1985. Screening for alcohol problems: conceptual issues and practical considerations. Pp. 1-30 in Early Identification of Alcohol Abuse, N.C. Chang and H. M. Chao, eds. Washington, D.C.: U.S. Government Printing Office. Babor, T. F., Z. Dolinsky, B. Rounsaville, and J. Jaffe. 1988. Unitary versus multi- dimensional models of alcoholism treatment outcome: An empirical study. Journal of Studies on Alcohol 49:167-77. Caetano, R. 1985. Alcohol dependence and the need to drink: A compulsion? Psychological Medicine 15:463~9. Caetano, R. 1987. Public opinions about alcoholism and its treatment. Journal of Studies on Alcohol 48:153~0. Cahalan, D. 1970. Problem Drinkers: A National Survey. San Francisco: Jossey-Bass. Clark, W. B., and D. Cahalan. 1976. Changes in problem drinking over a four-year span. Addictive Behavior 1:251-59. Cloninger, C. R., S. Sigvardsson, A.-L. van Knorring. 1988. The Swedish studies of the adopted children of alcoholics: A reply to Littrell. Journal of Studies on Alcohol 49:500-509. Cloninger, C. R. 1987. Neurogenetic adaptive mechanisms in alcoholism. Science 236:410-16. Edwards, G. 1970. The status of alcoholism as a disease. Pp. 140~3 in Modern Trends in Drug Dependence and Alcoholism, R. V. Phillipson ed. New York: AppletonCentury-Crofts. Edwards, G. 1977. The alcohol dependence syndrome: Usefulness of an idea. Pp. 136-56 in Alcoholism: New Knowledge and New Responses, G. Edwards and M. Grant, eds. Baltimore: University Park Press. Edwards, G. 1986. The alcohol dependence syndrome: A concept as stimulus to enquiry. British Journal of Addiction 81:171-83. Edwards, G., and M. M. Gross. 1976. Alcohol dependence: provisional description of a clinical syndrome. British Medical Journal 1:1058~1. Edwards, G., M. M. Gross, and M. Keller. 1977. Alcohol Related Disabilities. Geneva: World Health Organization. Engel, G. L. 1977. The need for a new medical model: a challenge for biomedicine. Science 196:129-36.

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WHAT IS BEING TREATED? 41 Temple, M. T., and K M. Fillmore. 1985. The variability of drinking patterns and problems among young men, ages 16-31: a longitudinal study. International Journal of the Addictions 20:1595-1620. U.S. Department of Health and Human Services (USDHHS). 1983. Fifth Special Report to the U.S. Congress on Aleohol and Health. Roekville, Md.: National Institute on Aleohol Abuse and Aleoholism. United States Department of Health and Human Services (USDHHS). 1987. Sixth Special Report to the U.S. Congress on Aleohol and Health. Roekville, Md.: National Institute on Aleohol Abuse and Aleoholism. Vaillant, G. E. 1983. The Natural History of Aleoholism: Causes, Patterns, and Paths to Recover. Cambridge: Harvard University Press. Vaillant, G. E., L. Gale, and E. S. Milofsly. 1982. Natural history of male alcoholism. II. The relationship between different diagnostic dimensions. Journal of Studies on Aleohol 43:216-32. World Health Organization (WHO). 1979. International Classification of Diseases, 9th ed. Geneva: WHO.