Is alcoholism treatment effective?

Is Alcoholism Treatment Effective?

THE costs of treatment for alcoholism and alcohol-related disorders are approaching 15% of the national health bill--most of it spent on patients who are not diagnosed as problem drinkers (Science, 6 March, p. 1132). But as the pervasiveness of drinking disorders has become increasingly recognized, so has the need for research on which of the multitude of treatments available are the most effective, and for whom.

From the standpoint of cost-effectiveness, the chief candidate for critical examination is the lengthy (usually 28 days) inpatient stay that has become the cornerstone of alcoholism treatment in the United States. This is the main feature of the growing number of insurance plans that cover alcoholism, despite the fact that studies have indicated that inpatient programs do not result in any better outcome for the alcoholic population as a whole than does treatment on an outpatient basis.

Alcoholism treatment has evolved into a major industry, particularly within the past few years. But the scientific basis for treatment remains elusive. Early theory and practice developed largely outside the mainstream of medicine, with self-help groups and peer counseling based on the principles of Alcoholics Anonymous (AA). Since 1957, when the American Medical Association officially recognized alcoholism as a chronic and progressive "disease,' lay and professional treatment approaches have become increasingly intermingled. This has resulted in a "haphazard mixture of largely unvalidated approaches' in the words of Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

The picture is beginning to change, though. Most attempts at scientific treatment have been based on a unitary concept of alcoholism as a disease, and, says one NIAAA official, the goal has been to find a "magic bullet' that will work with all (or most) alcoholics. As the heterogeneous nature of alcoholism and alcohol abuse is increasingly recognized, the focus has turned to identifying characteristics that will predict whether a patient will benefit from treatment, and to "matching' particular patients to particular treatments.

Alcoholism is now seen by most experts as a "final common pathway' arrived at through a multitude of factors including genetic vulnerability, environmental stresses, social pressures, psychiatric problems, and personality characteristics. Although advanced chronic alcoholics look very much alike, the course of the disorder is by no means uniform or predictable. Physical deterioration, physical and psychological dependency, behavior changes, and general dysfunctionality progress at different rates for different people. Drinking patterns vary widely. Some, for example, may drink alcoholically for a period and then revert to normal drinking. Some are compulsive drinkers from the beginning; others take decades to become dependent on the drug. As Thomas McLellan of the Philadelphia Veterans Administration Hospital says, "absolutely anything you want to say about alcoholics is true about some of them and not true about all of them.'

That also applies to the treatment of alcoholics, a subject teeming with conflicting opinions. Whether or not alcoholism should be called a disease is still debated. Some see the "medical model' at war with the...