Alcohol dependence is a chronic, relapsing bio-behavioral disease mediated by various parts of the brain, including reward systems, memory circuits, and the prefrontal cortex.

It is characterized by loss of the ability to drink alcohol in moderation and continued drinking despite negative consequences.

The alcohol withdrawal syndrome is a common but not universal diagnostic feature of alcohol dependence.

Benzodiazepine assisted detoxification of the alcohol withdrawal syndrome prevents the development of withdrawal seizures and delirium tremens, and makes patients more comfortable, which promotes engagement in treatment.

Symptom-triggered dosing, based on a withdrawal rating scale such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, is optimal for minimizing the total benzodiazepine dosage.

Use of a long-acting benzodiazepine (eg, chlordiazepoxide) is preferred in uncomplicated patients.

Thiamine should be administered routinely before the administration of intravenous fluids to prevent the development of Wernicke’s encephalopathy and Wernicke-Korsakoff syndrome.

In combination with psychosocial treatment naltrexone, and acamprosate can reduce the frequency of relapse.

Naltrexone may be more effective for reduction of loss of control with the first drink and cue-related craving.

Acamprosate may be more effective for stabilizing the physiology of post-acute withdrawal.

Psychiatric co-morbidity, especially depression, is common and is best addressed concurrently, although definitive diagnosis may have to await a period of prolonged sobriety.

Prescription of addictive substances, including benzodiazepines beyond the period of acute detoxification, should be avoided, and if necessary should be closely monitored (eg, by frequent visits with small prescriptions or clinic administed, and/or urine or breath alcohol screenings).

Abstinence from alcohol is recommended for persons with alcohol dependence.

Psychosocial treatment and participation in Alcoholics Anonymous can help patients achieve and maintain abstinence.

Research report; The psychiatric management of patients with alcohol dependence. Curr Treat Options Neurol. 2007 Sep;9(5):381-92. Ritvo JI, Park C.

Brief-TSF training is designed to complement this model.

Alcoholics Anonymous and long term matching effects.

AIMS: (1) To examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networks highly supportive of drinking 3 years following treatment; (2) to test a causal chain providing the rationale for this effect. DESIGN: Outpatients were re-interviewed 3 years following treatment. ANCOVAs tested the matching hypothesis. SETTING: Outpatients from five clinical research units distributed across the United States. Participants: Eight hundred and six alcohol-dependent clients. INTERVENTION: Clients were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET or Cognitive Behavioral Coping Skills Therapy (CBT). MEASUREMENTS: Network support for drinking prior to treatment, Alcoholics Anonymous (AA) involvement during and following treatment, percentage of days abstinent and drinks per drinking day during months 37-39.

FINDINGS:

• The a priori matching hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3 year follow-up;
• AA involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA;
• AA involvement was associated with better 3-year drinking outcomes for such clients.

CONCLUSIONS:

• in the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking;
• involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.

Research; Longabaugh R, Wirtz PW, Zweben A, Stout RL. Network support for drinking, Alcoholics Anonymous and long-term matching effects.Addiction. 1998 Sep;93(9):1313-33.

Compatibility With Other Treatments

Brief-TSF may be utilised in combination with supportive pharmacotherapy; for example, craving reduction medications.

While recognising the existence of multiple problems of adjustment in most problem drinkers (e.g., marital conflict, family dysfunction), Brief-TSF advocates pursuing the goal of early recovery as primary, delaying most other therapies if necessary, until the client has achieved approximately 6 months of sobriety.

The primary exceptions to this recommendation would be emergency or incapacitating medical treatment, debilitating depression or other major affective disorder, or a psychotic disorder, which would take precedence over Brief-TSF.

Brief-TSF is not compatible with treatments based on notions of controlled use.

Brief-TSF updates by RSS feed – subscribe.

Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.

The purpose of the study was to examine the rates and inter-relationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care.

While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (using the TWEAK and quantity and frequency of alcohol use in past year), and depression (using the Center for Epidemiological Studies Depression Scale – CESD and prior history of depression).

Over 30% of women reported either violence receipt, alcohol use problems or depression risk.

Significant inter-relationships among all measured risk variables were found.

Violence receipt was significantly related to

• alcohol misuse,
• cigarette use,
• less education, and
• scoring above the cutoff on the CESD (? 16).

Practitioners can be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.

Research; H. A. Flynn, M. A. Walton, S. T. Chermack, R. M. Cunningham and S. M. Marcus. Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings. Archives of Women’s Mental Health, 1434-1816 (Print) 1435-1102 (Online), Volume 10, Number 4 / August, 2007

Brief-TSF provides guidelines and strategies for using the TWEAK.

Alcoholics Anonymous and Nursing; Lessons in Holism and Spiritual Care.

Alcoholic Anonymous (AA) is a worldwide, 2 million-member organization that has assisted countless alcoholics to achieve sobriety through a spiritual program of recovery from alcoholism.

Based on spiritual principles known as the “Twelve Steps” and “Twelve Traditions,” AA has provided a model for other recovery programs such as

• Narcotics Anonymous (NA),
• Gamblers Anonymous (GA), and
• Sex and Love Addicts Anonymous (SLAA).
• Al-anon
• Adult Children of Alcoholics

Recovery in AA appears to involve a process of self-transcendence.

In recent years, nursing scholars have increasingly explored the concepts of self-transcendence and spirituality as they apply to nursing theory and practice.

This article explores the roots and spiritual dimensions of 12-step recovery programs. It further explores the ways in which theoretical and clinical knowledge about the delivery of spiritual care interventions may be gained from an understanding of AA’s spiritual approach to recovery.

Alcoholics Anonymous and Nursing; Lessons in Holism and Spiritual Care. Eileen M. McGee, J Holist Nurs 2000; 18; 11.

Brief-TSF can assist patients cease alcohol consumption.

TSF for Dual Diagnosis

The role of 12-step programs and 12-step-oriented treatments for dually diagnosed individuals (DDI) remains unclear. Here are presented the results of a pilot study in a target population of 10 seriously mentally ill patients received an adjunctive modified 12-step facilitation (TSF) therapy emphasizing engagement of DDI in a specialized 12-step program for DDI.

Participants significantly increased their 12-step attendance and decreased their substance use during the 12 weeks of treatment.

Larger and longer-term studies are needed to assess the efficacy of modified TSF for DDI relative to other treatments, and to determine what forms of TSF are most effective in this population.

Research; Bogenschutz MP. Tucker NE Specialized 12-step programs and 12-step facilitation for the dually diagnosed. Community Ment Health J. 2005 Feb;41(1):7-20.

Brief-TSF can be adapted to serve these people.

A comparative evaluation of substance abuse treatment

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups.

The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment.

Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up.

Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up.

These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes.

Moos RH, Finney JW, Ouimette PC, Suchinsky RT. A comparative evaluation of substance abuse treatment. Alcohol Clin Exp Res. 1999 Mar;23(3):529-36.

Screening for Alcohol Problems in Primary Care;

A Systematic Review

Background; Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.

Objective; To evaluate the accuracy of screening methods for alcohol problems in primary care.

Methods; We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results.

Results; Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated.

The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%).

The CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%).

These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions.

The studies inconsistently adhered to methodological standards for diagnostic test research: 3 provided a full description of patient spectrum (demographics and comorbidity), 30 avoided workup bias, 12 avoided review bias, and 21 performed an analysis in pertinent clinical subgroups.

Conclusions; Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care.

Research; David A. Fiellin, M. Carrington Reid, Patrick G. O’Connor. Screening for Alcohol Problems in Primary Care; A Systematic Review. Arch Intern Med. 2000;160:1977-1989.

Brief-TSF includes both the AUDIT and CAGE questionnaires.

• Early detection, including screening and brief interventions (for nondependent problem drinkers)
• Comprehensive assessment and individualized treatment plan
• Care management
• Individually delivered, proven professional interventions
• Contracting with patients
• Social skills training
• Medications
• Specialized services for medical, psychiatric, employment or family problems
• Continuing care
• Strong bond with therapist or counselor
• Longer duration (for alcohol dependent persons)
• Participation in support groups
• Strong patient motivation

Research Sources: McLellan, T.A. 2002; Miller,W.R. 2002; National Institute on Drug Abuse. 1999; Project MATCH Research Group. 1997.

Active participation in a support group can contribute to long-term recovery.

Project MATCH and other studies in the 1990s definitively proved that AA can be an active ingredient of treatment both during a professional intervention and afterward, depending on the patient’s type of therapy.

Patients who joined the AA fellowship or who had an AA sponsor after receiving twelve step facilitation therapy had better abstinence records than those who received an intervention but did not continue their AA participation upon completion.

Other research indicates AA participation may be less effective for patients who receive cognitive behavior therapy because the programs have different goals that may confuse patients.

What researchers still don’t understand, however, are the precise mechanisms of AA participation.

While AA affiliation is associated with self-efficacy, motivation and coping efforts, all significant predictors of good outcome following a professional intervention, some studies have shown that patients who adopt more of the fellowship’s basic tenets – such as acknowledging that alcoholism is a disease, admission of their powerlessness over alcohol and working the twelve steps of the program – relapse at the same rates as patients who adopt very few.

This suggests that the active ingredient may be less about AA per se than continuing participation in support groups that promote a lifestyle inconsistent with the problematic use of alcohol and other drugs.

From; www.ensuringsolutions.org

Brief-TSF is designed to support active participation in Alcoholics Anonymous.

A new report shows that people in recovery can help hospitalized alcoholics by encouraging them to quit drinking and enter counseling, Reuters reported June 11.

“A recovering alcoholic can help alcoholics who are still suffering from the disease, because the patients relate to them,” said Dr. Richard D. Blondell, an addiction-medicine specialist at the University of Louisville School of Medicine in Kentucky. “The patients credit the visitor as the main thing that motivated them.”

The study included 140 patients who were hospitalized for alcohol-related incidents. One group received standard medical care, a second group received medical care plus a 15-minute intervention by a trained addiction specialist, and the third group received medical care, intervention, and an in-depth talk with a recovering alcoholic.

Researchers found that 59 percent of those who met with recovering alcoholics abstained from drinking for six months after the incident, compared to 44 percent of those who received addiction counseling alone, and one-third of those who only received medical care.

In addition, half the patients who met with recovering alcoholics had entered some form of treatment, compared with only 15 percent of those who received medical treatment and counseling by an addiction specialist.

The study is published in the May issue of the Journal of Family Practice.

From; Jointogether

Brief-TSF is based on these principles.