UNIVERSITY OF NEW YORK IN PRAGUE
Department of Psychology
Alcohol Use Disorder and Key Factors in Successful Treatment
Master’s Thesis
Supervisor: Submitted by: PhDr. Michal Miovsky Mgr. Karin Kempf
Prague 2021 Alcohol Use Disorder and Key Factors in Successful Treatment 2
Declaration
I hereby declare that I wrote this thesis individually based on literature and resources stated in the references section.
In Prague: 5.5.2021 Signature: Karin Kempf Alcohol Use Disorder and Key Factors in Successful Treatment 3
Acknowledgments
I would like to thank my advisor, PhDr. Michal Miovský for his advice, support, patience and good will. He has helped to acquaint me with the field of AUD, and was open and responsive to all of my questions and ponderings. I am grateful to have had someone well-versed and passionate about this field as a mentor. I would also like to thank my family for their patience, support and cheerleading as I embark on this new phase of my life. It has been a good reminder of what an important role support plays for us as social beings, and I hope to not only return the favor to my family, but to also pay it forward in other areas of my personal and professional life.
Alcohol Use Disorder and Key Factors in Successful Treatment 4
TABLE OF CONTENTS
Abstract...... 7
Prologue……………………………………………………………………….... 8
Introduction……………………………………………………………………... 9
1. Purpose of the Study……………………………………………………… 10
1.1 Description of the Work…………………………………………....12
2. Alcohol Use Disorder – What is it?...... 12
2.1 The Biopsychosocial Model of AUD…………...... 14
2.2 AUD in the DSM IV vs. DSM V……………………………...... 15
2.3 AUD in the ICD 11…………………………………………...... 18
2.4 The Biomedical Model of AUD……………………………….... 19
2.1.2 Epigenetics…………………………………………………… 21
3. Development of AUD……………………………………………….…….. 22
3.1 Biological Factors in AUD Development...... ………………….. 23
3.2 Psychological Factors in AUD Development………………...... 25
3.3 Social Factors in AUD Development…………………………… 28
4. The Adverse Childhood Experiences (ACE) Study………………………. 30
4.1 ACE Study Findings……………………………………………. 32
4.2 ACEs and AUD…………………………………………………. 33
4.3 Screening for ACEs and Trauma………………………………. 34
5. Stress, Trauma and AUD……………………………………………...... 36
6. Phases of AUD Development……………………………………………. 37
Alcohol Use Disorder and Key Factors in Successful Treatment 5
6.1 Jellinek’s Phases of Alcohol Addiction...... 38
6.2 The Jellinek Curve...... 41
7. Diagnosing AUD – Diagnostic Tools...... 42
8. Complicating Factors in AUD Diagnosis and Treatment...... 45
8.1 Underdiagnosis of AUD...... 46
8.2 AUD Research...... 46
9. The Alcohol Burden...... 48
9.1 Drinking Statistics in the Czech Republic...... 48
9.2 Consequences of Alcohol Consumption...... 50
9.3 AUD Epidemic?...... 52
10. Personal Reflection...... 53
11. AUD - Is it a Disease?...... 58
11.1 The Brain Disease Model of Addiction...... 59
11.2 Brain Disease Model of Addiction vs. Biopsychosocial Model.61
11.3 Personal Reflection...... 62
11.4 The Benefits of Viewing AUD as a Disease...... 65
11.5 The Drawbacks of Viewing AUD as a Disease...... 67
12. AUD Treatment and Recovery...... 70
12.1 AUD Treatment in the Czech Republic...... 71
12.2 A History of AUD Treatment in the Czech Lands - Velké Kunčice...... 72
12.3 Treatment at the Tuchlov Facility...... 74
12.4 Inpatient Treatment in the Czech Republic Today...... 76
Alcohol Use Disorder and Key Factors in Successful Treatment 6
12.5 Therapeutic Communities...... 77
12.6 Personal Reflection...... 79
12.7 Outpatient Day Treatment...... 80
12.8 Ambulatory/Outpatient Care...... 81
12.9 Self-Help Groups...... 81
13. Alcoholics Anonymous...... 83
13.1 The Twelve Steps...... 84
13.2 Honza – AA...... 86
13.3 AA Sponsorship...... 89
13.4 AA in the Czech Republic...... 89
14. Effectiveness of AUD Treatment...... 90
15. The Cochrane Review...... 93
15.1 Possible Explanations for TSF/AA Success...... 95
16. Importance Factors to AUD Recovery...... 97
17. Methods...... 98
18. Results...... 100
18. Discussion...... 102
18. Limitations of the Study...... 104
19. Conclusion...... 106
20. References...... 108
Alcohol Use Disorder and Key Factors in Successful Treatment 7
Abstract
The purpose of this study is to examine alcohol use disorder (AUD), including its etiology and contributing factors to its development, its impact on the individual as well as on society, and the related economic implications. The study looks at the history and development of AUD treatment with a focus on the Czech Republic. Finally, this study seeks to determine the key facets of successful AUD treatment. The methods used in undertaking this research are primarily literature review, with a small-scale survey regarding key factors in AUD recovery.
The responses to the questionnaires used in the survey were compared with the findings of this study, and the answers were found to reflect the information gathered during the literature review. Key factors in successful AUD treatment/maintenance of sobriety are: the support and care of a group and/or individual, personal resolution and persistence in maintaining a treatment regime, whether formal (i.e. professional therapy) or informal, for example, Alcoholics
Anonymous (AA). The results strongly suggest that these factors are of greater importance than the actual mode of therapy. This is significant because this information can be used by people working with AUD clients to better support them, and secondly, because it means that AA, which is free, easily accessible in many cities, and does not require appointments may be a viable and effective mode of AUD recovery, or recovery support, both for maintaining recovery after formal treatment, or as a form of treatment itself.
Keywords: AUD, alcohol, biopsychosocial, trauma, treatment, support, recovery Alcohol Use Disorder and Key Factors in Successful Treatment 8
Prologue
“Not every story has a happy ending, ... but the discoveries of science, the teachings of the heart, and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question.”
(Maté, 2018, p. 3)
“Having spent years working closely with addiction researchers and clinicians, I had guessed that the primary driver of numbing would be our struggles with worthiness and shame: We numb the pain that comes from feeling inadequate and “less than.” But that was only part of the puzzle. Anxiety and disconnection also emerged as drivers of numbing in addition to shame. As
I’ll explain, the most powerful need for numbing seems to come from combinations of all three – shame, anxiety and disconnection.”
(Brown, 2012, p. 138)
Alcohol Use Disorder and Key Factors in Successful Treatment 9
Introduction
About a year ago, I came across a New York Times article titled “Alcoholics Anonymous vs. Other Approaches: The Evidence Is Now In” (Frakt & Carrol, 2020), with a subtitle that read: “An updated review shows it performs better than some other common treatments and is less expensive.” This piqued my interest because I have long thought about what the workings of alcohol abuse and addiction are, how treatment works or why it does not work (as the rates of relapse are high), and how to achieve the best results in the AUD treatment.
Though my immediate family members are not big drinkers, I have been surrounded with people whose parents, partners, or family members have struggled with alcohol abuse or addiction for most of my life, and I myself have had partners or friends who regularly drank to excess and/or struggled with addiction. I have also watched these same people avoid treatment because of shame, denial, fear, or perhaps a lack of information, and have seen them try to manage their problems with alcohol themselves, often not successfully. The few that did find their way to rehab often did not have clear-cut, straight paths to sobriety – trying for moderation and failing, eventually relapsing to their original state and lack of control over their drinking until they decided to seek help. Seeing these people struggle with their alcohol use made me wonder, what makes it so difficult for some people to drink in moderation, until the point of addiction? What is not working when, after months of intensive treatment, they relapse into old patterns? Is there something about AUD treatment that is lacking, which is not addressing the crux of addiction? And if so, what? And conversely, when treatment is successful, what are the factors that allowed it to be successful? Alcohol Use Disorder and Key Factors in Successful Treatment 10
These questions are in large part why I decided to undertake a study of AUD. It is my intention to become a psychotherapist, and I believe that it is likely that I will encounter clients who struggle with AUD or are in a relationship with someone who does. Perhaps issues relating to AUD, or AUD itself, will be a focus of our sessions. To this end, I wanted to be better equipped to understand what AUD is, its etiology, treatment, and the factors, which contribute to its development, as well as to successful recovery.
The following work is my endeavor to cultivate this understanding of AUD. I hope that it will constitute a solid foundation for future work, and that what I have learned will stand me in good stead when dealing with those in my life who struggle with AUD, whether personally or professionally.
Chapter 1
Purpose of the Study
The aim of this thesis is to examine AUD and its etiology, and to discern some of the most important factors in the successful treatment of AUD. This study will also examine how these findings relate to what the Cochrane review (Kelley et al., 2020) found, namely that
Alcoholics Anonymous (AA) is comparable in its effectiveness to other therapeutic approaches, including complex, in-patient therapy.
It should be noted that though the term “AUD” will be predominantly used throughout this thesis, the term “alcoholism” will also appear, namely when referring to AUD in a historic context. AUD is a relatively recent term and concept which was introduced in 2013 in the
Diagnostic and Statistics Manual V (DSM V; American Psychiatric Association, 2013). The term Alcohol Use Disorder and Key Factors in Successful Treatment 11
“alcoholism” had been frequently used in clinical and academic contexts before then, and can still be seen or heard, though usually in colloquial contexts.
Studying AUD is somewhat of a challenging endeavor because there is such broad heterogeneity in the factors around AUD’s etiology and treatment, as well as between the individuals struggling with AUD and their respective circumstances (Berkel & Pandey, 2017;
Litten et al., 2015). This makes research in this field difficult (and not particularly plentiful), as it is difficult to control for the multitude of heterogeneous, yet potentially influential, factors, and studies are often deemed as inconclusive (Kelly et al., 2020; Morgenstern et al., 1997; Owen et al., 2003).
Nonetheless, AUD is a pervasive problem which has far-reaching effects on health – both emotional and physical, as well as on relationships and finances (Dobiášová & Hnilicová, 2020;
Mravčík et al., 2019; WHO, 2018). The ripples extend not only to the individual and their immediate surroundings, but frequently to the family and friends around them, as well as to society at large. Having a better understanding of the mechanisms around AUD, particularly around treatment, as well as more public education and information about alcohol and the repercussions of its use could be of great value to the systems which it effects.
The goals of this study are relatively modest. It is not a demonstration of research methodology prowess, but rather a sincere endeavor through which to gain a deeper, broader, and meaningful understanding of a subject which I believe deserves more attention. It is the understanding of a subject that can help to lead to change; it is my hope that the research and thinking that this work will entail will help me to become a provider of some of this education Alcohol Use Disorder and Key Factors in Successful Treatment 12 and information in both my personal and professional life, and to be better able to support those who I work with.
1.1 Description of Work
This body of work will be divided into several sections which will examine alcohol use and the factors contributing to its abuse, as well AUD treatment, both past and current. There will be an emphasis on discerning which factors seem to be necessary to achieve successful treatment. I have included some personal reflections about the material at hand, as well as about related issues which were inspired by my research. The study will include an analysis of responses to a questionnaire I distributed, asking those in my extended community who have dealt with AUD about which factors they have perceived as being of greatest importance in AUD treatment/recovery. The questionnaire was distributed among both professionals working with patients who are being treated for AUD, as well as to people who have themselves struggled with
AUD in the past. The study and research used will focus mostly on the Czech Republic and other western countries, namely Europe and North America, because of a relative similarity in culture around alcohol use and AUD treatment. In addition to this, the majority of research that has been done on AUD has originated in North America.
Chapter 2.
Alcohol Use Disorder – What is it?
There has long been a lack of clarity around what alcohol abuse and dependency is, and how this relates to “alcoholism,” which is now often used as a colloquial term (NIAAA, 2020).
This lack of clarity can even be found in the academic community; both “AUD” and Alcohol Use Disorder and Key Factors in Successful Treatment 13
“alcoholism” can be found in many scientific research papers for example, “The Role of
Neuroimmune Signaling in Alcoholism” (Crews et al., 2017), or “Pharmacotherapy of
Alcoholism – An Update on Approved and Off-label Medications” (Soyka and Müller, 2017) though the official DSM 5 (2013) description makes no use of the term “alcoholism.” Dawson
(2011) writes about the lack of consensus over what constitutes high risk or low risk drinking, stating that there are numerous questions which have not been definitively answered, for example how to define or measure drinking risk, questions pertaining to drink size and amounts of alcohol, or how to measure alcohol related damage and in what areas, among many others.
The term “alcohol use disorder” or AUD has come into more frequent use with the publication of the DSM V in 2013, which has combined the previous 2 diagnoses used in the
DSM IV – “alcohol abuse” and “alcohol dependency,” into one diagnosis, “alcohol use disorder,” or AUD. AUD has sub-classifications of mild, moderate, and severe. Nonetheless, as illustrated, the word “alcoholic” is still occasionally used to describe someone who has problems with controlling their alcohol intake, or to describe a person with a severe form of AUD that has a component of physical dependency (NIAAA, 2020).
For most of the twentieth century, AUD was viewed in one of two ways: It was either a moral failing and weakness of will on the part of the individual, or it was viewed as a disease with biological roots which the individual had no choice or control over. As neurobiological research technology and understanding became more advanced, the scientific community favored the disease model of alcoholism (Pickard et al., 2015), though moral overtones of how
AUD is viewed still persist today (Hammarlund et al., 2018).
Alcohol Use Disorder and Key Factors in Successful Treatment 14
2.1 The Biopsychosocial Model of AUD
In 1977, George Engel proposed the biopsychosocial model of approaching health and illness (Engel, 1977). This was a departure from the traditional biomedical model, which focused almost exclusively on pathology of a biological nature, or in Engel’s (1977) words, “Assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables” (p. 130). However, Engel felt that the psychological and social spheres in which the individual lives should have as much consideration as the biological. He was aware of the impact of the closely related interplay of these three spheres on health and wellbeing, and felt that neither diagnosis nor treatment could be accurately determined without taking these into account
(Engel, 1977). Engel’s proposed model was met with three main criticisms. According to Smith et al. (2013), the biopsychosocial model was 1. not testable, 2. too general and 3. had no method.
Additionally, as Smith went on to note, another problem that the new model presented was that the biopsychosocial model itself did not address the complex process needed to arrive at a relevant biopsychosocial understanding of the patient (Smith, 2002). A process which took the psychological, social as well as biological aspects into account in equal measure was something which most medical professionals were simply not trained for, and the prospect of approaching each patient by these measures was daunting, if not threatening, to say the least. As Dr. Vincent
Felitti wrote in 2002 when talking about medical care which takes into account the psycho-social aspects through the lens of adverse childhood experiences:
“If the treatment implications of what we found in the ACE Study are far-reaching, the
prevention aspects are positively daunting. The very nature of the material is such as to
make one uncomfortable. Why would one want to leave the relative comfort of traditional Alcohol Use Disorder and Key Factors in Successful Treatment 15
organic disease and enter this area of threatening uncertainty that none of us has been
trained to deal with?” (Felitti, 2002)
These issues will be discussed further later in the paper. For now, let us turn our attention to AUD as defined by the DSM, published by the American Psychological Association (APA).
2.2 AUD in the DSM IV vs. DSM V
The DSM IV based diagnosis pertaining to alcohol abuse by determining how many out of 11 listed criteria the individual fulfilled. If the individual fulfilled any one factor of the first 4, they were eligible to be diagnosed with alcohol abuse; if they met any 3 of the remaining 7 criteria, they were eligible to be diagnosed as being alcohol dependent. The DSM V includes most of the same 11 factors for diagnosis, but introduced 4 main differences:
1. In the DSM IV, there were 2 separate disorders described: alcohol abuse, and alcohol
dependence. The DSM V combined these 2 disorders into one - Alcohol Use Disorder
(AUD), and determines gradients of the disorder depending on how many symptoms of
11 are fulfilled – 2-3 symptoms of 11 qualifies for a mild version, 4 to 5 are moderate,
and the presence of 6 or more of the symptoms is considered to be a severe version AUD.
2. In the DSM IV, there was a distinction between criteria, which are divided into 2
different diagnoses. Therefore, if a person was diagnosed with items 1 through 4 within a
12-month period, they would receive a diagnosis of “alcohol abuse.” If, within the same
12-month period, they fulfilled 3 or more of the other 7 symptoms, they could receive a
separate diagnosis of “alcohol dependent.” This somewhat clumsy system was
streamlined into 11 overarching factors, and depending on the number of factors met Alcohol Use Disorder and Key Factors in Successful Treatment 16
within a 12-month period, a respective mild, moderate or severe version of AUD can be
diagnosed.
3. The DSM IV includes legal problems as a result of alcohol use as one of the symptoms;
the DSM V does not include this criteria.
4. “Craving” was added as a symptom in the DSM V; it was not present in the DSM IV.
Alcohol Use Disorder and Key Factors in Successful Treatment 17
(NIAAA, 2016)
The current 11 points of diagnostic criteria for AUD as stated by the DSM V are any 2 of the following points within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or
recover from its effects
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced be
cause of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or
desired effect. Alcohol Use Disorder and Key Factors in Successful Treatment 18
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of
the criteria set for alcohol withdrawal, pp. 499-500).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to
relieve or avoid withdrawal symptoms.
(DSM V, 2013)
If 2-3 of these symptoms are present, the individual may be diagnosed with mild AUD, 4-
5 symptoms indicate moderate AUD, and 6 or more symptoms indicate severe AUD.
There is controversy, however, about whether the DSM V changes are an improvement over the DSM IV version (Dawson et al., 2013). Some professionals fear that the DSM V criteria will lead to unnecessary increases in diagnosis as well as inaccurately diagnosed AUD, because even mild cases of AUD are still under the same label as those that are severe – that is to say, are equally categorized under a perception of being “addicts,” unlike the previous DSM version, where alcohol abuse and alcohol dependency were differentiated as two separate diagnosis. The concern is that extra stigma or unnecessary diagnosis could be conferred on those who meet the
DSM V criteria for AUD, for example college students who may binge drink on occasion and occasionally miss classes as a result, but who are independently able to return to healthier drinking patterns after graduation (T.B., 2019).
2.3 AUD in the ICD 11 Alcohol Use Disorder and Key Factors in Successful Treatment 19
The latest version of the International Classification of Disease (ICD), the ICD 11, was published by the World Health Organization (WHO) in 2019. It uses the term “alcohol dependence” rather than “alcohol use disorder” and describes alcohol dependence as follows:
“Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or
continuous use of alcohol. The characteristic feature is a strong internal drive to use
alcohol, which is manifested by impaired ability to control use, increasing priority given
to use over other activities and persistence of use despite harm or negative consequences.
These experiences are often accompanied by a subjective sensation of urge or craving to
use alcohol. Physiological features of dependence may also be present, including
tolerance to the effects of alcohol, withdrawal symptoms following cessation or reduction
in use of alcohol, or repeated use of alcohol or pharmacologically similar substances to
prevent or alleviate withdrawal symptoms. The features of dependence are usually
evident over a period of at least 12 months but the diagnosis may be made if alcohol use
is continuous (daily or almost daily) for at least 1 month.”
(ICD-11, 2019)
One can see that though the format varies from that of the DSM V, many of the same criteria, for example, an impaired ability to control alcohol use, prioritizing use over other activities despite negative repercussions, or craving, are present. Criteria to describe AUD in the
DSM V as well as the ICD 11 both reflect the biopsychosocial model of disease, taking into account all 3 domains of the disorder.
2.4 The Biomedical Model of AUD Alcohol Use Disorder and Key Factors in Successful Treatment 20
The biomedical model has traditionally been the dominant model for addictions. It looks at addictions as diseases which are driven chiefly by biochemical and neurophysiological processes that are measurable (Skewes & Gonzales, 2013). This model makes addictions much easier to research because there are far fewer variables, and the biochemical and neurophysiological processes are more easily quantifiable and measurable. However, it is now generally agreed that the biomedical model is a far from accurate view of addictions (Skewes &
Gonzales, 2013), as there are many other variables (for example, those pertaining to psychological and environmental factors) which are subjective and difficult to quantify involved.
As Berkel and Pandey wrote in their 2017 study of the relationships between epigenetics and
AUD, “Alcoholics present with extremely varied levels of dependence, exposure, tolerance, and withdrawal symptoms. Perhaps this complexity contributes to the rare correspondence of results among studies and the ever-increasing list of genes of interest” (Berkel & Pandey, 2017). They continue by writing in reference to the limitations of their own study of epigenetics in relations to
AUD, which can be generalized to other aspects of AUD research as well - “A third limitation resides in the sheer complexity of AUD, which is characterized by widely varied severity in multiple phases, each affected by environmental and genetic influences” (Berkel & Pandey,
2017).
The most accepted model of AUD development today is the biopsychosocial model
(Skewes & Gonzales, 2013), which posits that AUD occurs as a combination of biological factors, for example genetic and neurobiological, psychological factors - this can include childhood events or self-medication because of the presence of other psychological disorders like depression or anxiety among others, and social factors, for example culture – both on macro (for example, culture in the sense of drinking norms in a given country) and micro (for example, the Alcohol Use Disorder and Key Factors in Successful Treatment 21 norms of drinking among family or friends) scales. The biopsychosocial model strives to look at the individual holistically, taking into account the interplay of factors from all aspects of the person’s life, and can also use this information to inform treatment. Some variations of the biopsychosocial model include a spiritual aspect (bio-psycho-social-spiritual), which draws attention to the person’s feelings of fulfillment, purpose, meaning, etc. as well as to religion in some cases (Ghaferi et al. 2016), or lack thereof, or bio-psycho-social-environmental, which draws attention to the significance of the environment itself, though some may believe this belongs under the title of “social” (Galbicsek, 2021).
This multifaceted approach to understanding and studying the development and treatment of AUD is also part of the reason for the confounding aspects of AUD research. The wide variability and non-homogeneity of factors influencing the etiology of the disorder (Berkel &
Pandey, 2017; Tawa et al., 2016) can in turn help to inform the appropriate treatment, meaning that variations in treatment can cover a broad spectrum. At the same time, this can make finding the best treatment for a particular individual more challenging (Litten et al. 2015). Additionally, the factors involved in AUD etiology may vary in significance among individuals according to their particular childhoods, environments (including family and cultural systems), support systems, individual biological factors, life events particular to their experience, and how these were perceived and processed by the individual, among many other variations. Each domain may have overlap and influence on other domains of the individual’s life, for example, one’s family environment can impact AUD development in a biological sense, for example through epigenetics (Berkel & Pandey, 2017; Yehuda & Learner, 2018).
2.1.2 Epigenetics. Alcohol Use Disorder and Key Factors in Successful Treatment 22
Epigenetics is a relatively recent field of study which takes into account how both biological as well as environmental factors interact to influence gene expression (Meaney, 2010).
Epigenetic studies examine how environmental factors can act as catalysts in activating certain genetic traits and function, facilitating the development of, for example, anxiety, post-traumatic stress disorder (PTSD), or AUD (Berkel & Pandey, 2017; Pucci et al. 2018; Yehuda & Learner,
2018). These may predispose individuals to developing addictions, but there are also studies looking at how stress itself can influence genetic function, supporting the development addictions (Berkel & Pandey, 2017; Juergens, 2020).
One can begin to see the endless number of permutations that may lead to the development of AUD in a given individual, and consequentially, the similarly large range of factors that could indicate which type of treatment may be the most effective for that particular individual. As stated earlier, though treatments can be similar in their general framework, the emphasis given to certain areas and contributing factors will often vary widely. Best practice treatment is not a one-size-fits-all prescription, which is a reflection of the broad variety of factors contributing to the development of AUD (Litten et al., 2015).
Chapter 3
Development of AUD
It is clear that there are a number of factors involved leading to both psychological and physiological dependency on alcohol. But why are some people able to drink heavily during certain periods of their lives, yet not become addicted? Why are some people drawn to alcohol as their ‘self-medication’ of choice, while others feel little or no affinity for using alcohol, whether Alcohol Use Disorder and Key Factors in Successful Treatment 23 as a coping mechanism or even recreationally, though they may have tendencies to engage in other types of compulsive or dysfunctional, self-soothing behavior?
As previously discussed, the current, most commonly used framework for looking at
AUD development is one that looks at the biological, psychological and social factors. However, there are is evidence that attending professionals often do not spend an equal amount of time and attention to examining each of these areas (Felitti, 2002). In the case of primary care physicians, there is often not enough time during routine appointments, and the physicians are often not sufficiently trained in screening for or working with AUD, despite its prevalence (Csemy &
Sovinová, 2015; Hallgren et al., 2020; Kranzler and Soyka, 2018; Mitchell et al., 2012).
3.1 Biological Factors in AUD Development – Genetics and Epigenetics
Studies have shown that in some cases, there may be up to a 50% genetic heritability for
AUD development (Deak et al., 2018; Verhulst et al., 2015). These studies include twin and adoption studies (Tawa et al., 2016; Verhulst et al., 2015). However, though the estimates of heritability have been repeatedly indicated through additional research (Kranzler et al., 2019;
Sanchez-Roige et al., 2019), these studies also state that there are limitations because of the difficulty in controlling for environmental factors. This is another example where one can see the complications that the biopsychosocial model can pose for clinicians. Environmental factors, both internal and external, have a significant impact on genetic expression that cannot be ignored
(Boyce et al., 2020; Maté, 2018; Meaney, 2010; Rutter, 2012), and recent research around neuroplasticity and epigenetics support the fact that environmental interaction cannot be separated from cellular and genetic function. Boyce, Sokolowski and Robinson (2020) write, “A Alcohol Use Disorder and Key Factors in Successful Treatment 24 now substantial body of science implicates a dynamic interplay between genetic and environmental variation in the development of individual differences in behavior and health.”
What happens on the outside has an effect on the inside - external events as related to internal processing on any number of levels. Furthermore, Boyce, Sokolowski and Robinson
(2020) point out that genetic expression also happens on a number environmentally dependent levels in relation to time. They go on to write:
“Trajectories of development increasingly appear best accounted for by a complex,
dynamic interchange among the highly linked elements of genes, contexts, and time at
multiple scales, including neurobiological (minutes to milliseconds), genomic (hours to
minutes), developmental (years and months), and evolutionary (centuries and millennia)
time.” (Boyce et al., 2020)
Genes change over time according to both internal (for example, prenatal conditions as dictated by the nutrition or stress levels of the mother) and external (for example, events or social interaction) environmental stimuli which then elicit genetic expression that we recognize as, for example, disease, how we age, or our propensity for developing AUD. However, simply stating that genetic expression via heritability is in part responsible for AUD is not completely accurate, because as stated in the citation above, genetic change is not only environmentally dependent, but also time dependent, as the time will help to determine the type of genetic change occurring.
If we are discussing change on an evolutionary level, we are not referring to change which can be inherited from one generation to the next. However, if we are discussing genetic changes and heritability at neurobiological, genomic, or developmental levels, these can occur between generations (that is to say, can be passed on from grandmother to father to daughter), but they are Alcohol Use Disorder and Key Factors in Successful Treatment 25 largely dependent on environmental stimuli. These changes are not actually due to a change in the genetic DNA – the essential coding of a gene, but rather to heritable changes in gene expression that seem to be in large part motivated by triggers in the environment. As explained in an article titled “Can Your Environment Change Your DNA” from Duke University (2012), one can think of genes as “computer hardware,” which does not undergo essential changes except on evolutionary scales (over centuries or millennia), but there are several types of
“software” programs that influence how the hardware functions. This brings us into the field of epigenetics, which is the study of how this “software” works, and the changes brought about in gene function. In this way, genetic expression is quite malleable as well as heritable, though these changes may or may not manifest from generation to generation. Things like nutrition, stress, human interaction, toxins, among a plethora of other environmental factors can result in changes in genetic activity (Tiffon, 2018), as well as major changes through switching genes
“on” or “off” (Duke Magazine, 2012; Morris, 2009). Thus, the relationship between our genetic predispositions, our environments and what we encounter there are of critical importance when looking at biological (genetic) factors, and it is equally as important to bear in mind that different individuals will respond to and process these experiences differently (Boyce et al., 2020; Rutter,
2012). There is little reason to believe that the same is not true in the case of AUD development.
One could then say, that though there appears to be a relatively strong (~50%) possibility of the genetic heritability of AUD (Verhulst et al., 2015), and though certain individuals may be more predisposed to develop AUD than others, this should not be considered without taking environmental context into account, as it is this interplay which seems to be responsible for the activation of these genetic tendencies.
3.2 Psychological Factors in AUD Development Alcohol Use Disorder and Key Factors in Successful Treatment 26
There are a number of angles from which one can approach the psychological aspects of
AUD. Firstly, when looking at predisposing factors, one can look for previous mental health issues, for example, depression, anxiety, social anxiety, panic disorder or stress among others
(Fink et al., 2016; Kuria et al., 2012; Obeid et al., 2020), or Cluster B personality disorders
(Tragesser et al., 2007) which are both found to have a high comorbidity with AUD (Swift &
Aston, 2015). Kuria et al. (2012) found there to be a 68% co-occurrence of depression among the 188 participants of their study, as compared to a 63.8% occurrence of depression in alcohol dependent individuals. This indicates that not only is there often a link between depression and subsequent development of AUD, but that AUD itself also often precipitates the onset of depression; dual diagnoses in both psychiatric and substance abusing, or dependent patients are not uncommon. After undergoing treatment for AUD, there was a significant decrease in depression among the study participants, and only 3 were sent for subsequent treatment for depression (Kuria et al., 2012).
As far as other psychological conditions, Heather, Raistrick and Godfrey (2006) write that psychiatric co-morbidity is often found among problem drinkers – occurring in up to 10% of severe mental illnesses, up to 50% in personality disorders, and up to 80% of individuals with neurotic disorders. They comment that this comorbidity is likely to make treatment more challenging and of longer duration. Other studies have also found that over one third of people on the AUD spectrum have a coexisting mental disorder, which increases to ~50% in treatment populations (Kalina & Vácha, 2013; Regier et al., 1990). Boden and Fergusson (2011) as well as
Conner, Pinquart and Gamble (2009) found that in addition to frequent co-occurrence of problematic drinking and depression, the presence of either disorder on its own doubles the risk of a second disorder. Alcohol Use Disorder and Key Factors in Successful Treatment 27
These findings illuminate the strong probability that if the pre-AUD morbidity and psychological state is not taken into account and treated concurrently with the AUD, it may set up the individual’s AUD treatment for added difficulty, manifesting also in the forms of temporary or long-term relapse, not to say failure of treatment (Heather et al., 2006).
As will be discussed in more detail a bit later in the paper, adverse childhood experiences
(ACEs), that is to say, external stressors, events and relationships which happen in the individual’s life up to the age of 18, have been shown to have a significant impact on the individual’s mental health in adult years (Bellis et al., 2013; Briggs et al., 2021; Chapman et al.,
2004). Among other issues, ACEs have been shown to lead to an increased risk of depression, anxiety, and AUD, further demonstrating the overlap between environmental/social factors and the psychology of the individual.
One can also look at the psychological factors in AUD from the point of view of the individual’s perception of themselves in terms of self-esteem, feelings of self-efficacy, or self- image in the light of their alcohol use. As Dr. K. Temple (2020) wrote in an article about AUD stigma and treatment, there is a stigma in being seen (or seeing yourself) as someone who “can’t hold their drink” or who has lost control over their drinking, and, as an official admission of this, seeking formal treatment. Additionally, because the rate of relapse in AUD is high, and AUD is considered to be a chronic health issue, openly admitting this not only to yourself but to those around you means also facing a high possibility of failure, dealing with that reality and the further implications to your self-perception, awareness of how those around you may perceive you, and eventually acknowledging that this is not a condition for which there is an easy or conclusive treatment. Dr. M. Jarvis, a contributor to Temple’s article (2020) writes that there is a perceived hierarchy among substance abuse; alcohol is legal, popular and widely used, thus Alcohol Use Disorder and Key Factors in Successful Treatment 28 overuse may not be seen as problematic or stigmatized as, for example, the use of illegal street drugs. This can add to a reluctance to admit that one has lost control over the use of alcohol, a societally acceptable, even lauded and ritualized, substance. Apart from psychological pressure and dependence, if the AUD is severe, the individual may also be dealing with a physical dependence. Once again, the crossover between the bio-psycho-social spheres of AUD is evident.
3.3 Social Aspects of AUD Development
The social aspects of AUD refer to the relational and cultural systems on both micro and macro scales surrounding the individual. In 1979, Urie Bronfenbrenner proposed a theory called the Ecology of Human Development, a socio-ecological model similar to the one illustrated below, that posited that individuals are influenced by the circles of social environments by which they are surrounded. The circle that typically has the strongest influence is the individual’s immediate family and surroundings, including school or work environments. However, the meso and outer circles of community- society, cultural and policy norms, will also play roles that can also be very significant to the individual’s behavior and development (Bronfenbrenner, 1979;
Kilanowski, 2017; Paquette & Ryan, 2011).
Alcohol Use Disorder and Key Factors in Successful Treatment 29
(Sudhinarase et al., 2016)
It follows that the individual’s social circumstances will interact with his/her biological as well as psychological states, for example the impact of nutrition or toxins in the environment on the individual’s physical state of health, or the result of family or other relational dynamics on the individual’s mental health and well being.
Alcohol Use Disorder and Key Factors in Successful Treatment 30
Chapter 4
The Adverse Childhood Experiences (ACE) Study
“Our usual approach to many common adult chronic diseases reminds one of the relation between smoke and fire. A person unfamiliar with fires would initially be tempted to treat the smoke—i.e., the most visible aspect of the problem. What we have learned in the ACE Study represents the underlying fire. Fortunately, fire departments learned to distinguish cause from effect long ago; if they had not, they would use fans instead of water hoses.”
-Dr. Vincent Felitti, 2002
In 1998, a landmark study on adverse childhood experiences, or ACEs, now familiarly known as the ACE Study (Felitti et al., 1998) was published. The study was led by Dr. Vincent
Felitti who was chief of the Department of Preventative Medicine at Kaiser Permanente, a medical consortium of not-for-profit and for-profit entities in San Diego, California. Kaiser
Permanente was, and still is, one of the biggest non-profit healthcare plan providers in the United
States. The study was conceived after Felitti, who was at the time also in charge of an obesity clinic associated with the organization, presented data which showed that the majority of morbidly obese patients had been sexually abused as children (Felitti, 2002). Though this study was the target of much skepticism because of a perceived lack of relationship between obesity and abuse by most healthcare professionals, it nonetheless led Felitti to undertake a much larger study, what came to be known as the ACE Study, about the impact of particular adverse childhood experiences on physical and mental health in later life. The study ended up having a sample size of 17,421 participants who were Kaiser Permanente patients, all of whom had Alcohol Use Disorder and Key Factors in Successful Treatment 31 detailed medical histories, and continued to be medically monitored throughout the study. It is also interesting to note that the majority of these subjects were white, middle-class, educated, and financially secure. The study used a questionnaire to ask participants about 10 main categories of negative experiences, which can be divided into 3 sub-categories as follows:
Abuse: Physical, Emotional, Sexual
Neglect: Physical, Emotional
Household Dysfunction: Mental Illness, Incarcerated Relative, Mother Treated
Violently, Substance Abuse, Divorce
(Riley, 2020) Alcohol Use Disorder and Key Factors in Successful Treatment 32
(Riley, 2020)
4.1 ACE Study Findings
The ACE Study revealed a number of significant findings. Firstly, it indicated that the number of incidences of childhood adversity are grossly underreported, and the researchers found that traumatic childhood experiences are far more common than expected (van der Kolk,
2014). Roughly only one-third of the respondents had reported no ACEs, while the remaining two-thirds reported at least one ACE. Of those, 87% of respondents had had two or more ACEs, and one in six had experienced 4 or more ACEs. The fact that most people who reported having numerous ACE experiences makes sense; as Bessel van der Kolk (2014) points out in his book,
The Body Keeps the Score, if a child grows up with a parent who has a substance use disorder, or struggles with mental illness (especially untreated), it stands to reason that other types of Alcohol Use Disorder and Key Factors in Successful Treatment 33 adversity will be implicated; there will likely be other ACEs occurring in relation to each other.
For each additional ACE, it was found that the correlated impact in later life rose exponentially.
Why are these findings important? They are important because the study found that there was an overwhelming correlation between the number of ACEs and health issues, both mental and physical, later in life. For example, the overall rate of chronic depression for people with an
ACE score of 0 was found to be 12%. However, for those who had ACE scores of 4 or more (for example, divorce, emotional neglect, depressed/anxious parent, substance abuse), the percentages rose to 66% in women, and 35% in men. Vares et al. (2016) also found a high correlation between childhood trauma and depression in later life. It is worth noting that it is likely that depression in men is prone to be underreported because men seek help for depression less often than women. Depression may also present differently in men, who have a greater tendency to self-medicate their depression or anxiety with drugs or alcohol, mask depression with anger, violence or compulsive behavior such as ‘workaholism,’ thus leading to a greater number of misdiagnosed, or under diagnosed cases (APA, 2005; Martin et al., 2013; NIMH,
2017; Real, 2003).
4.2 ACEs and AUD
As far as findings in the ACE Study pertaining to AUD, it was found that people with
ACE scores of 4 or higher were 7 more times likely to develop AUD as adults than those with scores of 0. A study done by Pilowski, Keyes and Hasin in 2009 found that only experiencing 2 adverse childhood events already put individuals at a significantly increased risk for lifetime alcohol dependence, even after controlling for sociodemographic variables and other potentially confounding factors. These studies indicate that the risk of developing AUD rises exponentially Alcohol Use Disorder and Key Factors in Successful Treatment 34 with increased stress and trauma in childhood. The ACE Study found that for each adverse experience, the likelihood of early substance abuse rose 2 to 4 times. For individuals who had 5 or more ACEs, the risk of substance abuse increased by 7 to 10 times as compared to those who scored 0 on ACEs. Dr. Felitti, the leading researcher in the ACE Study, found that a male child with an ACE score of 6 has a 4600% increase in the likelihood of later using intravenous drugs
(Felitti, 2002). The study concluded that nearly two-thirds of injection drug users had sustained abusive and/or traumatic childhood events. Bear in mind that the population studied was a relatively healthy and stable one, as far as socioeconomic resources are concerned, and that the use of alcohol as a coping mechanism (“self-medication”) is far more prevalent than intravenous drug use. Consequent studies, like those undertaken by S. R. Dube et al. (2003), Hughes et al.
(2017) or A. Knopf’s (2018) article, “ACE-AUD Link, and Challenges of Medication
Development,” which writes about the AUD-ACE link with respect to developing treatment for both, all provide strong evidence that stress and trauma are precursors if not directly related to the causation of AUD or other substance use disorders.
4.3 Screening for ACEs and Trauma
I was hard-pressed to find information regarding whether the screening of AUD patients for ACEs or trauma is common practice, though I did find one study (Kalmakis et al. 2018) which reported that screening for ACEs in primary care patients is infrequent, despite the strong association between ACEs and chronic health conditions. I was able to find a doctoral thesis which stated the same (Emerson, 2019), and one study which examined the “efficacy and feasibility of a trauma-informed screening for ACEs among individuals in a substance use disorder recovery program” (Chandler et al., 2018). This study, conducted at a substance use Alcohol Use Disorder and Key Factors in Successful Treatment 35 disorder clinic found that, out of the 29 clients who had completed the questionnaire, 100% reported having at least one ACE, and 82.8% reported having 6 or more ACEs. The study also noted the clients’ “lack of awareness” of the connection between ACEs and substance abuse in later life, and that receiving knowledge regarding this connection seemed to bring the clients relief and a sense of normalization. The study concluded that screening for ACEs was necessary in order to provide effective interventions, with the goal of improving client outcomes (Chandler et al., 2018).
These findings make it seem that it would be shortsighted to dismiss or overlook childhood trauma and stress, as well trauma experienced in adulthood, as factors that would strongly influence, not to say inform, treatment of AUD. And yet, as Dr. Bruce Carruth wrote in
2006, it was only in the last decade before his article that more attention had begun to be paid to treating trauma and addictions concurrently, though people have long been aware of the connection between the two. Dr. Felitti likened the usual approach of treating chronic disease of all types to smoke and fire; if people are not aware or trained in the origins of the smoke, they will continue to address the problem of smoke, rather than to investigate and deal with the cause of the smoke, which is to say, the fire. However, Felitti also writes that few are trained to put out the “fire”; it is much more comfortable to remain within the domains of organic disease, than to explore the daunting and “threatening uncertainty” of dealing with the implications of the ACE
Study. (Felitti, 2002)
Alcohol Use Disorder and Key Factors in Successful Treatment 36
Chapter 5
Stress, Trauma and AUD
There are other studies like those undertaken by Perry and Pollard (1998) which look at the effect of trauma and stress in childhood from a neurodevelopmental angle. They have found that childhood events can alter neurodevelopment in such a way that the individual is predisposed to suffer from neuropsychiatric disorders such as depression, anxiety, dissociation, hypervigilance, and sleep disorders, among others, later in life, and further, that these childhood experiences prime the adult for greater consequences if trauma is again encountered later in life
(Perry & Pollard, 1998). Perry and Pollard go on to state that these children are more vulnerable to substance abuse and dependence as self-soothing coping mechanisms later in life.
One could further extrapolate that stress and trauma do not cease to have this effect once a child crosses the threshold into adulthood, and that the same stress mechanisms in childhood which increase the likelihood of AUD development during adult years, may have the same, or similar effect even once the individual reaches adulthood. There are limitations to this proposition, for example that adults may have greater agency over their situation than children, and thus be able to more effectively mitigate stressful factors or situations, or that stressors may have different effects on the child or adolescent psyche than they do on the adult psyche. In my research, most of the studies that I was able to find about the relationship between stress, trauma and AUD focused on post-traumatic stress disorder (PTSD); I am not sure why there are not more studies on the relationship between other types of adult stressors and AUD. Perhaps it goes Alcohol Use Disorder and Key Factors in Successful Treatment 37 back to what I wrote about at the beginning of this work- the vast heterogeneity of AUD makes
(Litten et al., 2015; Sullivan et al., 2010) clean, scientifically rigorous studies very difficult and daunting for any potential researchers. Nonetheless, that does not change the possibility, and I would dare to say probability, that trauma and stress of all types in adulthood may also play a significant role in the development of AUD, as the ACE Study clearly indicates. As such, one may consider that, if it is not already a part of a particular course of treatment, screening for and treating childhood and adult trauma as a part of AUD treatment could be effective towards the individual’s recovery. Addictions specialist Dr. Gabor Maté has said, “The question should not be why the addiction, but why the pain?” (Maté, 2018) This shines a light on the view that addiction, and in the case of this paper, AUD, is actually a secondary, or perhaps even tertiary manifestation of trauma, and that in successfully treating addiction, one must first focus on the root cause of the self-medication. Maté also notes that though not every person who has experienced trauma becomes an addict, it is uncommon to find an addict who has not experienced some type of trauma, a statement which the findings of the ACE Study support.
Chapter 6
Phases of AUD Development
Though AUD is today largely characterized and diagnosed by the presence of 2 or more of the 11 criteria as stated by the DSM IV, where the number of criteria present determines the severity of the disorder, several popular alcohol addiction information or treatment center websites still describe alcohol as a progressive phenomenon, often referred to as a disease, which has stages. Many websites, such as the American Addiction Centers (alcohol.org) or the Peace
Valley Recovery clinic (peacevalleyrecovery.com) cite 4 progressive stages, though some Alcohol Use Disorder and Key Factors in Successful Treatment 38 websites (novarecoverycenter.com, rosglasrecovery.com) name 3 stages, and others
(healthline.com, hazeldenbettyford.org) name 5. These stages are progressive in order, going from early stages, to late or end stage. Though scholarly articles most often refer to the DSM V characterization, many popular websites still use a paradigm proposed by E.M. Jellinek in his paper, “Phases of Alcohol Addiction” (1952), a more detailed account of the phases of alcoholism which he initially outlined in 1946 (Jellinek, 1952).
6.1 Jellinek’s Phases of Alcohol Addiction
Elvin Morton Jellinek is considered to be one of the founders of modern addiction science (Ward et al., 2016), and his later book, The Disease Concept of Alcoholism (1960) was prescient in its descriptions of AUD- then referred to as alcoholism, already shining a light on the inextricable interplay of individual cultural, socio-economical and biological contexts, and further detailing his description of AUD as described in his 1952 paper, Phases of Alcohol
Addiction. The 4 phases through which AUD/alcoholism developed according to Jellinek are the pre-alcoholic phase, the prodromal phase, the crucial phase, and the chronic phase.
In a tribute to Jellinek’s book, The Disease Concept of Alcoholism (1960), Dr. John
Kelly, Professor of Psychiatry of Addiction at Harvard University, writes that Jellinek’s characterizations will resonate with anyone who has spent time working with AUD patients
(Kelly, 2019). Brief summarizations of each of Jellinek’s phases as described in Jellinek’s paper,
Phases of Alcohol Addiction (1952) are as follow:
1. Pre-alcoholic phase: the individual drinks most often in social settings and looks forward
to the relaxing effects of alcohol. Soon, there is a clear connection between stress and Alcohol Use Disorder and Key Factors in Successful Treatment 39
alcohol use as a stress reliever, even though other people may use healthy coping
strategies to deal with stress. Jellinek states that between 6 month and 2 years, the
individual progresses to heavy, often daily drinking, though full-blown inebriation may
not always occur. The body develops a tolerance for the effects of alcohol.
2. Prodromal phase: Jellinek characterized this phase with the occurrence of blackouts, or
“alcoholic palimpsests” (Jellinek, 1952). He writes that while the individual still
continues to drink heavily and frequently, they will not necessarily appear to be severely
inebriated, though they now require increasingly larger amount of alcohol to achieve the
desired effect. It is in this phase that the drinker also becomes aware that their drinking
habits differ from that of those around them, and behaviors such as surreptitiously
drinking, and, not surprisingly, a preoccupation with alcohol. This phase can last
anywhere from 6 months, to 4 or 5 years. At this point, Jellinek writes that the only
realistic treatment goal is to aim for abstinence, though he believes that there is still an
good chance of successful treatment, as the drinker has not completely lost control over
his/her alcohol intake.
3. Crucial phase: The hallmark of this phase is a loss of control. However, in this phase, the
loss of control over drinking is not because the individual must drink every day; they may
still be able to abstain for days, or even weeks without having an alcoholic drink.
However, once they have had one drink, they are unable to discontinue drinking until
they are too inebriated or physically sick to ingest more. At this point, the drinker is
conscious of the fact that, though they still want to drink to achieve a certain effect, they
are not able to stop until they have reached a state of extreme intoxication and physical
illness, which was not the original goal. A cycle of abstinence and heavy drinking ensues, Alcohol Use Disorder and Key Factors in Successful Treatment 40
where the individual is determined to get their drinking under control, yet when social or
emotional pressures lead them to drink alcohol with the intent or just having a few drinks
at most, they are unable to maintain a limit, and the cycle perpetuates itself. There is also
accompanying guilt, shame and extensive rationalization; both to the self, and those
around; the individual claims that it is not the alcohol that is the problem, but the
situations in which they find themselves that lead to the excess, whether stress or
celebration. At this point, the destructive consequences of the individual’s drinking
become markedly evident. There are often problems with employment, family and
friends, and the individual may withdraw, both socially and physically. There is a
preoccupation with access to alcohol, and though the drinker may initially set certain
rules about when and where to drink, in an attempt to control their drinking, towards the
end of this phase, they will typically begin drinking regardless of time or place to satiate
perceived or real physical craving. Jellinek writes that the loss of control is the beginning
of the “disease process.”
4. Chronic phase: This is Jellinek’s final stage, also referred to as alcoholism, in which he
describes that the drinking has become a full blown disease, and that the individual is
unable to discontinue drinking, regardless of time, place or situation. It has become
necessary for the individual to drink in order to perform basic functions as withdrawal
symptoms – nausea, tremors, anxiety, sweating, racing heart among others, become so
intense as to be incapacitating. On a more optimistic note, Jellinek writes that at this
point, the individual’s rationalizations become impossible to maintain, even to
him/herself, and the individual “admits defeat” and becomes open to treatment.
Alcohol Use Disorder and Key Factors in Successful Treatment 41
6.2 The Jellinek Curve
The following is a graphic illustration of what is typically known as the “Jellinek Curve,” which charts the phases that Jellinek described above. However, the version pictured has a continued upswing, which was added by Dr. Max Glatt in 1958 (Richmond, 2002, Forceheim, et al. 2008). Glatt was a German-born psychiatrist who established medicalized treatment of alcoholism (as it was then known) in Britain, and did much to destigmatize addiction and advance its treatment (Richmond, 2002). Glatt edited Jellinek’s Curve to include recovery and rehabilitation as an up-swinging continuation of Jellinek’s descent into addiction. Despite Glatt’s contribution however, the curve is still popularly known as the “Jellinek Curve.”
Alcohol Use Disorder and Key Factors in Successful Treatment 42
(Hazelden Betty Ford Foundation, 2016)
One should note, however, that Jellinek’s claim that individuals in the depths of the
Chronic Phase of AUD will admit defeat and become open to treatment is variable at best. This points to one of the greatest criticisms of Jellinek’s Curve, which is that the progression of AUD, and recovery, for that matter, are often not linear, and may follow neither a completely corresponding timeline, nor chronology of events. Once again, heterogeneity is a theme, and different individuals may experience the progress in different timelines, in varying order of events (including a repetition of certain parts of the curve), or even skipping certain events altogether (Jellinek,1952; Venner & Felstein, 2008). To be fair, Jellinek himself called attention to this (Jellinek, 1952), though the curve and description of phases indicate a linear progression.
Another criticism is that the Jellinek Curve is not empirically supported with quantitative data, but is rather based on qualitative, clinical observation (Kelly, 2018; Venner & Feldstein, 2006)
Chapter 7
Diagnosing AUD – Diagnostic Tools
Apart from using the criteria as stated in the DSM V or the IDC 11, there are also a number of tests that are widely used in the assessment and diagnosis of AUD. Some the main screening tools include the Alcohol Use Disorder Identification Test (AUDIT), and the Fast
Alcohol Screening Test (FAST), which is composed of a subset of questions taken from the
AUDIT. Both the AUDIT and the FAST have been validated and have been found to be very useful in screening for alcohol abuse and possible dependency (Meneses-Gaya et al., 2010).
Other tests which are used are the Paddington Alcohol Test (PAT), or the CAGE. The name Alcohol Use Disorder and Key Factors in Successful Treatment 43
“CAGE” comes from key words in the 4 questions that comprise the test: “cut” (“Have you ever felt the need to cut down on the amount of alcohol which you are drinking?”), “annoy” (“Has you felt annoyed by anyone commenting about the amount you drink?” “guilt” (“Have you ever felt guilt in relation to your drinking?”) and “eye” (“Have you even felt the need for a morning
‘eye opener’?” An “eye opener” is a term used for an alcoholic beverage drunk in the morning to alleviate the discomfort of withdrawal from heavy drinking the night before (O’Brien, 2008).
Though both the AUDIT and FAST have been shown to have more accurate results than the PAT or CAGE (Meneses-Gaya et al., 2010), the FAST, CAGE or PAT may be used in favor of the AUDIT because they are shorter and may be easier to apply in settings where time is limited. However, the fact remains that many primary care professionals do not use these screening tools during routine check-ups with patients, or underestimate their importance
(Csemy & Sovinová, 2015). Alcohol Use Disorder and Key Factors in Successful Treatment 44
(Evidence-Based Addiction Treatment, 2009)
Alcohol Use Disorder and Key Factors in Successful Treatment 45
Chapter 8
Complicating Factors in AUD Diagnosis and Treatment
Apart from those already mentioned, for example the time frames and contexts of alcohol use (recall the example of the student who would qualify for AUD diagnosis during their years at university, but transitions into non-problematic drinking after graduation) there are other factors which can make diagnosing AUD and planning effective treatment difficult. Among these is the heterogeneity of AUD etiology among individuals, and thus within treatments that are targeted to the individual’s specific situation (Holzhauer et al., 2017).
While the diagnosis of other disorders or diseases often indicates a specific treatment, which may be similar and have a predictably similar effect from patient to patient, for example, prescribing antibiotics to target a bacterial infection, the variance of factors between AUD patients often indicates the necessity of “tailor-made” treatment from individual to individual in order for treatment to be most effective (Holzhauer et al., 2017). Environment may be a significant factor to address in the case of a particular patient who is a pub-owner, and this will likely require much broader considerations about employment possibilities, self-efficacy, or frequency of continued support, than for an office worker whose environment is not particularly conducive to drinking, but whose main stressor and trigger to drink are family dysfunctions. For yet another patient, the place of employment may have little to no direct bearing on their AUD, their relationships may not be particularly problematic, but they may have a dual diagnosis of depression which is a predisposing factor in their alcohol dependency (Boden & Fergusson,
2011; Connor et al., 2009; Kuria et al., 2012). In this case, it will also be necessary to address the Alcohol Use Disorder and Key Factors in Successful Treatment 46 patient’s co-morbid depression in order to facilitate or enable AUD recovery. If diagnosis informs the cure, it is not always so clear cut a situation with AUD.
8.1 Underdiagnosis of AUD
AUD may be under-diagnosed or often go unaddressed in the general population (Csemy
& Sovinová, 2015; Hallgren et al., 2020; Kranzler and Soyka, 2018; Mitchell et al., 2012).
Primary health care professionals working with patients during regular health checks or during visits to address other ailments typically do not have adequate training to identify substance use disorders, or may simply focus on treating the resulting health problems (Csemy & Sovinová,
2015). Csemy and Sovinová (2015) wrote that primary care professionals surveyed in the Czech
Republic cited a lack of time, training and an underestimation of the importance of preventative intervention when it came to screening for AUD. These findings were supported by studies in other countries as well (Kranzler & Soyka, 2018; Manthey et al., 2016; Mitchell et al., 2012;
Williams, et al., 2017).
8.2 AUD Research
In their 2015 paper titled “Translating Alcohol Research: Opportunities and Challenges,”
Batman and Miles a wrote a response to the question of why so few individuals with AUD receive FDA approved treatment, that is to say, namely pharmacological therapy. Their response, however, provides some insight into the reasons why there is not more research done on AUD etiology or treatment, despite the gravity and widespread nature of AUD. They wrote,
“Therefore, improved treatment for AUD requires not only increased identification of therapeutic targets and effective therapeutic strategies, but also improved communication of existing treatment options and their effectiveness” (Batman & Miles, 2015). In plain language, this means Alcohol Use Disorder and Key Factors in Successful Treatment 47 that many researchers or medical professionals have little information pertaining diagnosing
AUD in their patients, treatment options, or their effectiveness.
This brings us into a catch-22: Another problem with AUD is that the research is far from being sleek and sexy. It is complex, messy, deals with a population that is often in denial about having the disorder, is uncooperative, has high rates of attrition and relapse, and involves a plethora of variables which are nearly impossible to control for (Vaillant, 2005). In fact, relapse, though not something to necessarily hope for, is an expected part of recovery (Maisto et al.,
2016; Miller et al., 2001). If this is so, how does one measure effective recovery in clinical trials?
Is it measured by pure abstinence? For how long must the individual be abstinent in order for treatment to be considered successful? Can occasional lapses be counted as success, if the overall rate of drinking has decreased, and to what degree? How can the researcher be sure that the decreased level of drinking will be sustained, in what patient, and for how long? (Miller et al.,
2001; Ray et al., 2021) These types of complications may likely be enough to also dissuade those who do work in the AUD field from undertaking research projects (Beckett et al., 2011).
In addition to these challenges, there is also the financial and professional world of research to consider. Research takes time and financial backing, and unless there are promising indicators that the results of research will be fruitful and advance treatment options in a tangible way, many researchers or financial backers may be reluctant to engage in it. As a source from
Beckett et al.’s paper (2011), “Bridging the Gap Between Basic Science and Clinical Practice:
The role of Organizations in Addressing Clinician Barriers,” is quoted as saying in reference to clinical research, “People don't do this for the greater good. They don't have time, and they can't afford to do it. They do it because it's a reasonable business proposition that also blends with their medical interest. You really have to think about this as, am I going to be able to, at the end Alcohol Use Disorder and Key Factors in Successful Treatment 48 of the day, pay my staff, pay my rent, and bring home enough money to make this worth doing?
This is an additional possible activity to get involved in, and it's got to make some economic sense.”
Though advances in AUD research make a lot of sense from a societal point of view, and from the positions of those personally affected by AUD, whether directly or indirectly, AUD research may not make short-term commercial sense, either for the researchers doing the work, or for the organizations who might financially back them. Pervasive stigma around AUD may also contribute to a lack of research in this area (Huebner & Kantor, 2011).
Chapter 9
The Alcohol Burden
This section should be prefaced by saying that it is not only diagnosable AUD that can bring heavy social and health costs to the individual, their family and friends and to society at large, but also drinking that meets or somewhat exceeds the defined levels of moderation as stated by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The NIAAA states that moderate drinking is no more than three standard drinks (40 g of ethanol) on any single day and no more than seven drinks per week for women, and no more than four standard drinks (60 g of ethanol) on any one day, or 14 drinks per week for men (NIAAA, 2006).
9.1 Drinking Statistics in the Czech Republic
Unfortunately, current numbers indicate that few people who qualify for an AUD diagnosis (or who have been officially diagnosed) will seek treatment. The 2019 American
Survey of Drug Use and Health estimates that roughly 15 million Americans over the age of 18 Alcohol Use Disorder and Key Factors in Successful Treatment 49 had AUD; out of this number, approximately only 6.7% sought treatment for recovery. In the
Czech Republic, the 2016 National Survey indicated that an average of 12.3% of people engaged in heavy episodic drinking. Of this percentage, males comprised roughly 19.4%, females 5.6%.
Heavy episodic drinking was defined as 5 or more glasses of alcohol on one occasion, at least once per week (Mravčík et al., 2019). The WHO reported that in 2017, 55 % of drinkers engaged in heavy episodic drinking during a 1-month period, 6% qualify for AUD, and about 2.8% are alcohol dependent, that is, would be diagnosed as having severe AUD (WHO, 2018). In 2019,
Mravčík et al. wrote that an estimated 17% of the Czech population engages in hazardous alcohol consumption, and about 9% engage in harmful consumption of alcohol, based on a survey of drinking habits. This means that roughly 26% of Czechs, an estimated 2.8 million people, engage in drinking that is of serious concern to their own health and well-being, as well as to that of their environment.
As discussed earlier, the consequences of heavy drinking rarely affect only the individual drinking, but also have farther reaching effects on their surroundings. The 2019 National
Monitoring Center for Drugs and Addiction report stated that only about 21,000 individuals received treatment for alcohol disorders in the Czech Republic.
Even if these numbers are taken only as general indicators, this means that roughly
1,819,000 people in the Czech Republic use alcohol “hazardously” and 963,000 people used alcohol to a degree which was “harmful” to them; out of 963,000 people who drink harmfully in the Czech Republic, only about 2.2% (21,186 people out of 963,000, to be more precise) sought treatment for their drinking.
Alcohol Use Disorder and Key Factors in Successful Treatment 50
9.2 Consequences of Alcohol Consumption
Apart from alcohol dependence and the associated costs and health risks, both to the individual and those around him, even drinking in moderation has been shown to raise health risks, such as cancer, stroke or cirrhosis of the liver (Miovský et al. 2019). As a reminder, moderate or low risk drinking as defined by the NIAAA is no more than three standard drinks
(40 g of ethanol) on any single day and no more than seven drinks per week. For men, the maximum is defined as no more than four standard drinks (60 g of ethanol) on any one day and should not exceed 14 drinks per week; roughly one-quarter of the Czech population exceeds these recommendations.
As with Bronfenbrenner’s incrementally larger ecological systems, the consequences of heavy drinking and AUD are far reaching, starting with the individual, their physical, mental and spiritual health, but with a ripple effect that also impacts family and friends, workplace functioning and relationships, and other spheres of their life. In 2018, the World Health
Organization reported that about 3.2% of all deaths occur as a result of alcohol use every year, and of this, 45.7% of the deaths are a result of alcohol-related injuries. This includes not only the individual who has been imbibing, but also those who may be injured or killed as a result of the inebriated person’s actions. Alcohol is responsible for about 4.0% of disease world-wide
(WHO, 2018), which is in this case, directly related to the individual’s alcohol consumption, as opposed to secondary causes.
Globally, approximately 0.9 million deaths as a result of injury were attributable to alcohol, including around 370,000 deaths due to road injuries, 150,000 due to self-harm and Alcohol Use Disorder and Key Factors in Successful Treatment 51 around 90,000 due to interpersonal violence. Of the driving-while-under-the-influence related deaths, 187,000 were among people other than the intoxicated drivers (WHO, 2018).
In the Czech Republic, excessive use of alcohol is implicated in roughly 10.1% of deaths per year (Miovský et al., 2019). Alcohol-related mortality is directly related to a number of cancers, including cancers of the pharynx, esophagus, liver, colon, pancreas and breasts, as well as to strokes, digestive and cardiovascular diseases. (Dobiášová & Hnilicová, 2020;
Miovský et al., 2019). There are between 4000-5000 alcohol related accident hospitalizations in the Czech Republic per year, many of which will carry the consequences of the accident for the rest of their life (Dobiášová & Hnilicová, 2020). The damage attributable to alcohol does not stop at disease and accidents, however. Dobiášová and Hnilicová (2020) write that alcohol use is cited as being among the causes in roughly 60% of divorces in the Czech Republic and about
13% of criminal activities are perpetrated under the influence of alcohol. It is estimated that the general economic impact of alcohol related costs to the Czech Republic in 2016 were around 57 billion Czech crowns (Mlcoch et al., 2019).
Even before the effects of heavy alcohol use become so grave, however, they often have somewhat milder negative effects on the individual as well, for example, what many people know as the “hangover” state- the physical, as well as psychological effects of alcohol withdrawal during the morning after an evening (or night) of heavier alcohol consumption (note: what is considered as “heavy” will vary from individual to individual, depending on gender, body weight or tolerance, among other factors). Some hangover symptoms include headache, tiredness, diarrhea, nausea and sensitivity to light or sound, increased anxiety, impaired cognitive Alcohol Use Disorder and Key Factors in Successful Treatment 52 function, negative affect, as well as a poorer quality of sleep (Boschloo et al., 2012; Kinney &
Coyle, 2005; Park et al., 2015; Vitiello, 1997).
Apart from the physical repercussions, heavy drinking can also interfere with interpersonal relationships, family life, workplace performance (Kinney and Coyle, 2005,
Miovský et al. 2019) and it also often replaces healthy, functional activities and interests that once were a part of the individual’s life because greater amounts of time are devoted to the activity of drinking and recovering from the effects of over imbibing.
9.3 AUD Epidemic?
When one studies the numbers, the damage caused by alcohol on personal, health, interpersonal, societal, and economic levels is remarkable; it is not alarmist or an exaggeration to say that the alcohol burden to the Czech Republic is of epidemic proportions.
Yet, Czechs seem to be proud of their drinking. It is a part of their heritage, culture, and the national economy (The Czech Republic is in the top 10 of global beer exporters [Workman,
2021]). The vineyards and wine cellars in Moravia are a source of pride (if not quality), much like the spirits distilled out of everything from plums to pears to apricots. Alcohol use continues to be prevalent, and is associated with holidays, celebration, and a wide array of social gatherings, from (for some daily) after-work bonding over beer, to ladies’ nights accompanied by wine or cocktails.
Alcohol is truly a double-edged sword, one that is a source of proud cultural identity, associated with good times and friends, and is at the same time a source of great losses in life, health and finance on levels that are both personal and national. Unfortunately, alcohol’s positive Alcohol Use Disorder and Key Factors in Successful Treatment 53 reputation and associations, as well as the financial turnover it brings, makes dealing with the negative fall-out that much more difficult, both on personal and national levels.
In their study of alcohol use and its consequences in the Czech Republic, Mravčík et al.
(2019) wrote that the losses accrued from alcohol use are underestimated, and policies to address the issues above should be implemented and enforced. Unfortunately, unlike in other European countries, alcohol consumption and many alcohol related illnesses are on the rise (Hnilicová &
Dobiášová, 2000; Mravčík et al., 2019), and alcohol consumption as well as the positive ethos around it continues to exist in high levels.
Chapter 10
Personal Reflection
Why is alcohol use and abuse in the Czech Republic on the rise? What can or should be done in order to, at the very least, slow this rise if not reverse the trend altogether, and to de- romanticize the perceptions around alcohol?
As mentioned above, Mravčík et al. (2019) wrote that alcohol policy should be increasingly implemented, stating that pricing policies (including taxation) and marketing restrictions should be firmly enacted. Hnilicová and Dobiášová (2020) suggest that in addition to these suggestions, restrictions on availability could help to reduce consumption, and thus, alcohol related problems.
It is true that cost and availability can functionally limit the population’s access to a product, as studies on the price increased and taxation of tobacco products have shown (Bader et al., 2011; Wilson & Thomson, 2005), but there are questions that arise around this approach.
What function(s) does alcohol fill, and what would the repercussions of taking away this particular “tool,” coping mechanism, economic facet, or national identity that many Czechs hold Alcohol Use Disorder and Key Factors in Successful Treatment 54 dear, be? It seems naïve to think that there would be no negative effects of restricting such a significant part of popular culture and identity. If alcohol plays such a strong role in Czech life, and in individual’s lives, what will fill the vacuum? Once again, this issue brings to mind Gabor
Maté’s essential question, “We shouldn’t be asking why the addiction, but why the pain?” Why the national addiction to something that causes so much strife and loss? Why are the not- insignificant, negative consequences of alcohol seemingly downplayed in society, while the glorification of alcohol in the media and as a social stronghold continue to reinforce its societal status?
For many, alcohol use is not a take-it-or-leave it side perk; it is one of the pillars of everyday life, naturally associated with socialization, sought after to gain stress relief and relaxation. It is a generational constant, and one might even say that it is a valued way of life; the numbers provided by Mravčík at all (2019) as well as the National Survey (2016) are strong evidence of this. But why? And why has consumption risen since the end of the communist regime?
My own suspicion is that the social lubrication, stress release and numbing qualities that alcohol offers are highly valued. It loosens people’s feelings of anxiety and restriction, not to say repression, in a culture that may not allow for doing so otherwise- especially for those raised under Communism, or whose parents may have brought the influence of Communism even to children born after the fall of the regime. The socially acceptable excuse of drinking in order to relax and drop inhibitions or roles, namely for men, or simply finding the temporary relief that alcohol offers may be a salve to a way of life that does not teach or promote a natural processing or expression of emotions, tensions or self, and which then results in the necessity of finding a short-cut or outlet to do so, even if it is short-lived and comes with a cost. A study done by Alcohol Use Disorder and Key Factors in Successful Treatment 55
Malisauskaite & Klein (2018) found that levels of drinking in Communist countries were higher than those in the West, and that the higher rates persisted even after the fall of Communism.
Some of the reasons cited for this were cultural tradition and a lifestyle of frequent social interaction in a culture where social interaction is frequently associated with drinking alcohol.
Unfortunately, the study did not look at the psychological effects of Communism in relation to drinking alcohol, which I believe leaves out a key factor. Recalling the ACE Study, it has been repeatedly shown that substance use and abuse rates increase in adults who as children grew up in the presence of physical and emotional violence and neglect, substance abuse or other household dysfunction, among other adverse experiences. Drawing on Bronfenbrenner’s systems theory, could it be possible that the environment fomented and enforced by the Communist regime was one that also made for increased rates of substance abuse for its inhabitants, both on micro as well as macro scales? Under Communist rule, there was a pervasive societal atmosphere of fear, suspicion, repression, and disempowerment, quite the opposite of a warm, nurturing environment based on love and acceptance – essentially Carl Roger’s necessary elements for psychological healing and well-being (Rogers, 1957).
When one compares the importance of competing needs, in this case, a short-term relief from a stressful and repressive environment, it seems that alcohol use takes precedence over a long-term investment into health and well-being. Long-term health and well-being are concepts that may seem somewhat abstract in the present moment, both on an individual as well as a larger systemic scale. When dealing with acute stress, people may have a tendency to choose the most accessible, immediate solution in order to gain relief, even if it is temporary, especially if they are not aware of, or don’t have access to alternative options. Alcohol Use Disorder and Key Factors in Successful Treatment 56
In the same way that AUD’s etiology is being found to be multi-layered and complex
(Litten et al., 2015), the antidote to alcohol (ab)use in society will also need to be multi-layered and complex. One can detoxify an individual simply by taking away their access to alcohol.
However, this solution is most likely superficial and short-term. Some drinkers might realize the error of their ways if they find that their life is better without alcohol, and somehow develop healthier replacements for the parts of their life that alcohol used to fill (this is the utopian version). Others may turn to a pack-a-day smoking instead, which some may see as an improvement, and still others will still find different ways to procure alcohol, though perhaps at greater cost and risk to themselves and others, because it fills a vital role in their lives, one for which they have no apparent replacement.
The same can be said about restricting access to alcohol as a solution to the societal and national problems that it causes. It may have positive effects, and it may reduce alcohol-related harm to a point where society views the restriction is justified. At the same time, there may be negative repercussions or a lack of societal support that would not make serious restrictions on alcohol viable. The American Prohibition is a good illustration on both the negative and positive effects of attempting to remove alcohol from society.
Most people are aware of the perceived negative effects of the Prohibition, including an increase in organized crime around both alcohol production or procurement, unemployment resulting from the shutting down of breweries, distilleries, pubs and dependent industry, and a decrease in national revenue as a result of the lost income from alcohol taxes (Blocker, 2006;
Hall, 2010). However, what is often not highlighted is that the Prohibition also had significant positive effects, among them a substantial decrease in liver cirrhosis and other alcohol-related diseases and health issues, a decrease in domestic and other types of drunken violence, and a Alcohol Use Disorder and Key Factors in Successful Treatment 57 decrease in traffic accidents (Blocker, 2006; Hall, 2010; Šejvl et al., 2019). As has been discussed, the benefits of restricted alcohol availability may not impact only the individual, but may also have a ripple effect – in this case positive, on the individual’s environment.
Ultimately, however, the Prohibition was repealed. Blocker (2006) cites a lack of political uniformity and not enough co-operation between state and federal governments, difficulty of enforcement, plus disparity within the population over the banning of alcohol, and feelings of a restriction of civil rights, in addition to the loss of tax revenue and unemployment that the Prohibition brought (Blocker, 2006). Both Blocker and Hall argue that the benefits of the
Prohibition could have been achieved with partial restrictions, thereby also mitigating many of the negative impacts.
One aspect that I believe that has been grossly underestimated is public education. People respond to marketing – as we have seen in the increase of alcohol sales after manufacturers implemented wider, more aggressive marketing campaigns (Anderson et. al., 2009; Babor et al.,
2010), though it is often used in the name of capital gain, rather than consumer health. It is not surprising that a lack of awareness of the risks of alcohol use plus cultural reinforcement and the normalization of drinking lead to higher consumptions and thus, higher morbidity and mortality.
However, public awareness campaigns can work on the similar principles as marketing to effectively spread awareness and information if they are well planned and executed (Randolph &
Viswanath, 2004). Studies have shown that many people simply are not aware of the hazards of even moderate alcohol use, but that their drinking habits can be influenced for the better through public education (Christensen et al., 2019; Coomber et al., 2017; Mongan et al., 2020; Thorner,
1986). Alcohol Use Disorder and Key Factors in Successful Treatment 58
Perhaps if there was more government support for alcohol risk education, and greater sanctions on marketing which promotes drinking, countries could decrease the damage to human health and life, thereby improving the quality of life – or at least enabling the possibility, on many levels. The success of a comprehensive alcohol awareness program supported by the government should also entail research about and understanding of the roles that alcohol consumption plays, offering healthier alternatives and coping strategies to replace alcohol’s roles to its citizens.
Chapter 11
AUD - Is it a Disease?
“Such answers illuminate that the addiction is neither a choice nor a disease, but originates in a human being’s desperate attempt to solve a problem: the problem of emotional pain, of overwhelming stress, of lost connection, of loss of control, of a deep discomfort with the self. In short, it is a forlorn attempt to solve the problem of human pain. Hence my mantra: “The question is not why the addiction, but why the pain.”
-Dr. Gabor Maté (2017)
This suggestion from addiction specialist Dr. Gabor Maté (2017) which proposes that addiction is neither a choice nor a disease reflects an idea that is still hotly disputed (Goldberg,
2020; Hall et al., 2014; Lewis, 2018). However, Maté himself says that the concept of addiction as an illness is nevertheless useful, if not fully accurate (Maté, 2017).
Viewing AUD as a disease may be somewhat of a mixed blessing; the disease model de- stigmatizes AUD and the medicalization may make people more willing to seek treatment, much Alcohol Use Disorder and Key Factors in Successful Treatment 59 like they would for diabetes or heart issues. On the other hand, the disease model may also create the illusion that health problems are something that just “happen” to a person, and over which we have little control. People’s risk perception is often skewed in their own favor, especially when it comes to activities that they choose and enjoy or seek in order to fulfill a need (Ropeik, 2012).
People’s knowledge of the risks of alcohol consumption may be lacking, and the stigma that still surrounds drinking problems may in any event act as a strong motivator to ignore the possibility of having an addiction problem themselves, and may discourage the person from getting further information or seeking treatment (Glass et al., 2013; Hammarlund et al., 2018). The disease model may make other elements of AUD too easy to ignore or deny, both on individual as well as policy levels.
In his 2018 book, In the Realm of Hungry Ghosts, Maté writes:
“Viewing addiction as an illness, either acquired or inherited, narrows it down to a
medical issue. It does have some of the features of illness, and these are most pronounced
in hardcore drug addicts like the ones I work with in the Downtown Eastside. But not for
a moment do I wish to promote the belief that the disease model by itself explains
addiction or even that it’s the key to understanding what addiction is all about. Addiction
is “all about” many things.” (p.130)
11.1 The Brain Disease Model of Addiction
One of the predominant current models of addiction is the brain disease model of addiction (BDMA) (Heather et al., 2017; Volkow et al., 2016). This is based on the fact that after repeated exposure to certain stimuli, there are parts of the brain, namely in the reward center, that undergo change (Koob & Volkow, 2010). Addiction researcher Matt Field is critical of this view, Alcohol Use Disorder and Key Factors in Successful Treatment 60 pointing out that a brain response to pleasurable stimuli and the consequent restructuring is not in and of itself unnatural. In a paper published by Heather et al., (2017), Field writes that this is a normal and predictable response to most repeated stimuli which give us some type of reward
(Heather et al., 2017; Lewis, 2017), and is not necessarily inherently toxic or otherwise dangerous, nor is it necessarily a hallmark of a disease.
Field also examines Nora Volkow’s (Volkow is a prominent voice among those who support the “addiction as disease” model) argument that obesity should similarly be considered to be under the category of BDMA, as it shares many of the same neurological aspects as drug addiction (Volkow et al. 2008, 2013). Volkow argues that as with drug addiction, those who struggle with obesity may be biologically vulnerable to intense, short-lived increases of dopamine activity in the brain’s reward system. After these bursts of dopamine “hits” are repeated often enough, there is an eventual overriding of the natural control mechanisms that regulate the food intake, and this then leads to several changes in brain structure and function, which results in a loss of control, in this case, chronic overeating. Volkow purports that because the brain undergoes these shifts in structure and function in the areas responsible for reward sensitivity, incentive motivation and self-control, and because the changes are virtually identical to those which are seen in addiction, obesity should logically also fall under the BDMA (Volkow et al., 2008, 2013).
Field’s criticism of this approach, apart from pointing out that brain restructuring to repeated stimuli is an expected, natural response, rather one that is pathological, is that it leads to a reductionistic view of addiction as something that is anchored mainly in biology, rather than a much deeper and more complex interplay of the factors which the bio-psycho-social-spiritual model indicates. Field’s colleagues, Best and Kawalek go on to support the argument that not Alcohol Use Disorder and Key Factors in Successful Treatment 61 only is the BDMA model reductionistic in terms of etiology, but also from the point of view of recovery (Heather et al., 2017). They write that recovery is a social experience, that happens in the context of social relationships, and which encompasses more than simply a physical cessation of drug intake, but that it often happens on numerous levels which result in an improved quality of life (Heather et al., 2017). Best and Kawalek also point out that the recovery of many addicts happens without repeated rounds of formal treatment, which is also at odds with the idea of addiction as a biologically driven phenomenon (Heather et al., 2017). This is in line with studies which indicate that in numerous cases, addiction remits without treatment (Dawson et al., 2006;
Heyman & Mims, 2016; Lewis, 2017; Saunders & Kershaw, 1979; Tucker et al. 2020).
11.2 Brain Disease Model of Addiction vs. Biopsychosocial Model
If we reduce addiction to something that is primarily an ingrained disease of the brain, then how do we account for the fact that most addicts recover, either by abstaining or using only controlled amounts on their own and without treatment (Dawson et al. 2006; Heyman & Mims,
2016; Lewis, 2017)? And what of the fact that ultimately, in order to recover, the user must use his own brain in order to find conviction and arrive at the decision to make serious changes enabling recovery (Heather et al., 2017)?
Additionally, by putting a spotlight on the biological factors involved in addiction, whether it is to food, alcohol, or compulsive behaviors, we make the question of what causes the compulsion that then leads to the brain changes a secondary or perhaps even tertiary issue, when it should arguably be the primary issue. The reader may recall Felitti’s (2002) earlier-mentioned comparison of the typical medical approach to treatment with removing the smoke, rather than trying to discern the causes of the fire. Alcohol Use Disorder and Key Factors in Successful Treatment 62
One of Field’s colleagues, developmental psychologist and neurobiologist Marc Lewis, writes that using the medical model to inform treatment leads to overlooking or underestimating the importance of the psychological aspects of treatment, including cognitive, emotional and social skills (Lewis, 2017). In Lewis’ paper, “Addiction and the Brain: Development, Not
Disease” (2017), he writes “…addiction is often a partner or even an extension of a developmental pattern already set in motion, not simply a newcomer who happened to show up one day.” In relation to Lewis’ line of thinking, Dr. Maté (2018) writes in his book, In the Realm of Hungry Ghosts, “It is impossible to understand addiction without asking what relief the addict finds, or hopes to find, in the drug or the addictive behaviour” (p. 33). Hanna Pickard (2020) echoes this sentiment, writing that the importance of understanding the value of the drug in the individual’s life, despite negative consequences, cannot be overstated, especially when considering treatment/recovery support.
11.3 Personal Reflection
In writing this, I am led to wonder on which side the scales really do tip – towards a disorder that really is primarily a brain disease, despite other contributors? Or towards something which is a complex mélange of biological, social and psychological factors that come in different proportions in each individual, depending on their unique circumstances? It is hard to ignore the fact that alcohol itself as a chemical is a psychoactive substance that effects our brain and body chemistry in ways that other pleasurable activities, such as eating a delicious food, or having good sex, do not. Yes, there may be some crossover in certain areas of the brain, namely those concerned with pleasure and reward, but the biology, psychology and social contexts of these particular activities are nonetheless different in each case. Alcohol Use Disorder and Key Factors in Successful Treatment 63
At the same time, I find myself wondering about whether the mechanisms of how these issues manifest in each individual are more similar than different. Do the similarities or differences that we attribute to certain health problems have more to do with bio-medical- cultural zeitgeist, than the objective reality of the situation, regardless of whether one is discussing alcohol addiction or cancer? Perhaps addiction should not be the only phenomenon to be considered primarily through a biopsychosocial lens, but as Engel suggested in 1977, perhaps the majority of health issues, regardless of whether they are currently considered in somatic or psychological terms, should be viewed through this multidimensional lens as a matter of course.
The idea of accusing a cancer patient of getting what they deserve because of a moral failing, weakness of will, or a lack of self-control might be laughable to some, and blatantly offensive to others. Though many people are aware of the effects of lifestyle on health, many still believe that getting cancer is more a function of bad luck or an inevitable fate (Dumalaon-
Canaria et al. 2014; Dieng et al., 2014). However, a weakness of will or moral failing are what addicts are often accused of, if not explicitly, then subconsciously. This is in large part the reason why the moral model of addiction exists. Not for nothing does the word “moral” figure in the title, and not for nothing does it have its place as an established model of addiction (Heather,
2017; Pickard, 2020).
And yet, though at first it might seem like somewhat of a stretch to compare the etiology of cancer and addiction, isn’t it possible that the same- or very similar, factors are at play, whether one is looking at an individual who became addicted to alcohol, or another who has been diagnosed with colon cancer? Is it possible that these things have more in common than one would think, though the manifestations or diagnosis - addiction or cancer, are seemingly different? Alcohol Use Disorder and Key Factors in Successful Treatment 64
As far as biology is concerned, we know that some people have a genetic propensity for addiction; the same is true for cancer. Through epigenetics, we are starting to understand more about the catalysts which can turn certain genes “on” or “off,” thus activating them and making the individual more susceptible to addiction or cancer, or conversely, which provide protective measure against the activation of those genes. We know that the surroundings and culture in which we live have significant impacts on our behavior. Our environment can normalize and dictate the types of foods we eat and how we drink alcohol - amounts and frequency, the cultural roles that these foods and drinks play in our lives, families and friendships. Our cultures, both family cultures and the larger communities in which we live, can also shape how we interact with each other, and how we approach ourselves. Our standards for how we communicate, how we problem solve, how we build connection and with whom, are all shaped by where and how we grow up and live. In turn, these things also have a bearing on how we manage stress, our approach to problem solving, how we manage conflict or intimacy with those around us. These are our biopsychosocial realms.
To bring it back to cancer or addiction, suppose the cancer patient grew up in a family or culture where a diet that was heavy in saturated fats, red meats, and foods high in refined sugars was the daily norm. To make the parallel with addiction, what if the individual who eventually became addicted grew up grew up in a culture where people celebrated, ate, socialized and grieved in the constant company of alcohol? What if each individual had a respective genetic history that put them more at risk: cancer or addiction in previous generations? What if each individual turned to their respective comfort of food or drink in times of stress, because vulnerable communication was not taught as a problem solving skill, as a way of processing emotion, or as a way to build supportive, nurturing community? What if the unprocessed stress Alcohol Use Disorder and Key Factors in Successful Treatment 65 of living, compounded by coping mechanisms of drinking and eating raised the levels of inflammation (with regard to cancer: Il'yasova et al. 2005; Izano et al. 2016), continued to ingrain neuroadaptations around pleasure, reward and withdrawal more deeply, and reinforced harmful eating or drinking habits to levels the lowered the threshold for cancer or addiction? Is there really such a difference in the mechanisms that set the wheels of cancer or addiction in motion, or are our perceptions overwhelmingly influenced by the secondary consequences or societal associations with each? Perhaps the question should be less about whether it is most accurate to consider addiction as a biologically based disease that may be influenced by environmental and social factors, but rather why there is not a greater emphasis on the psycho- social realms when dealing with other diseases and their treatments.
11.4 The Benefits of Viewing AUD as a Disease
Where then, lies the motivation for categorizing addiction as a brain disease? Researchers
Hall, Carter and Forlini (2015) believe that the BDMA focus is based on a disordered neurobiology found in a minority of severely addicted individuals who are not necessarily representative of the broader picture of addiction problems in society. They suggest that the push for legitimizing the BDMA model in the public sphere is mostly driven by economic factors – namely those involving grant money for research, allowing certain agencies and individuals to enjoy generous subsidies in the question for better biological interventions. However, thus far, this research and development has not proven to lead to a better understanding of addiction; rather, it encourages a narrowing of the lens through which addiction – and thus treatment, is viewed. There is an influx of money into areas which are not particularly effective at targeting addiction prevention and treatment, ie. pharmaceutical research (Hall et al., 2015), and a shortage of resources for public policy and research in other treatment areas, for example, prevention, Alcohol Use Disorder and Key Factors in Successful Treatment 66 education, mental health and social support systems, which may be more useful in the addressing some of the root causes of addiction. University researchers from the Netherlands Boorsboom,
Cramer and Kalis share a similar view. They write: “In the past decades, reductionism has dominated both research directions and funding policies in clinical psychology and psychiatry.
The intense search for the biological basis of mental disorders, however, has not resulted in conclusive reductionist explanations of psychopathology.” (Borsboom et al., 2018)
Nonetheless, classifying addiction as a disease has allowed research into pharmacological approaches of treatment to continue, and thus far, there have been 3 drugs developed and approved which aid in addiction recovery, for example Disulfiram (Antabuse), Naltrexone and
Acamprosate (Swift & Aston, 2015). Other drugs not developed specifically for AUD treatment may also be used, for example anti-epileptics (Swift & Aston, 2015), anxiolytics or antidepressants.
Another advantage of viewing AUD and addiction in general as a disease may be the reduction of stigma. Historically, addictions have been often seen as moral failings (aka the moral model), or simply pertaining to a weakness of will (Heather, 2017; Pickard, 2020), and those struggling with addiction have often been castigated for being inferior, shamed or blamed for having deep character flaws (Frank & Nagel, 2017). Though Flanagan (2013) points out that shame is not necessarily a mistake in addiction, suggesting that it can often be a motivator for recovery, it may also be a hindrance to recovery. Many people are not forthrightly willing to expose and admit to their shame or its source, preferring rather to deny, minimize or hide the possibility of an addiction disorder than to address it head-on (Hammarlund et al., 2018)
Bilevicius et al. (2018) found that higher levels of shame were correlated with depression, and made the individual more vulnerable to developing an addiction. Alcohol Use Disorder and Key Factors in Successful Treatment 67
A supportive community is of vital importance to successful recovery (Beattie &
Longabaugh, 1999; Groh, 2007). People may like to think that penalty and punishment – also through shunning, will make the individual want to “behave,” “reform,” or realize the “error of their ways” and do better, but the reality is that penalty and punishment as a motivator for long- term healthy behavioral change is rarely effective. As Marc Lewis points out, “…despite the despicable things addicts sometimes do, intense shame and guilt are more likely to thwart recovery than facilitate it” (Lewis, 2017).
11.5 The Drawbacks of Viewing AUD as a Disease
In seeing AUD or other addictions through a lens of a more complex, medical diagnosis, those in need of treatment and their potential support communities may realize that addiction is more than a simple moral failing, and that there are factors that may be at least somewhat beyond the individual’s control that need professional support and treatment.
However, the argument for the medicalization of addiction is one that many of those working in the addiction field protest against because of the fear that in addressing one problem
– replacing the view of addiction as a moral failing with a medicalized model, another is created, namely, a focus that once again too narrow (Heather, 2017; Pickard, 2020). Medical researchers like neurobiologist and developmental psychologist Marc Lewis worry that by looking at addiction through a medical, biological lens, we are once again missing the larger picture: addiction is a heterogeneous phenomenon which is (often heavily) influenced by social and psychological factors (Heather, 2017; Lewis, 2017; Litten et al., 2015; Pickard, 2020).
Sociologists and addiction researchers Reinarman and Granfield (2015) write that in focusing on addiction as a biological disease, there is a whole host of crucial “contextual variables” that may be overlooked or underestimated. They go on to write that, “Continued use is far more likely Alcohol Use Disorder and Key Factors in Successful Treatment 68 when the person is using a drug to numb physical pain from chronic conditions or psychic pain from trauma, abuse, humiliation, violence, poverty, depression or despair” (Reinarman &
Granfield, 2015).
In order to be become aware of, explore and then address psychic dis-ease, the right questions have to be asked – and not just as peripheral information during an intake interview where biological process then takes the spotlight. This means that equal amounts of time and energy need to be devoted to the individual’s past history, relationships, emotional skills and health, their environment, their peers, etc., as is to their physiological workings. This, however, this is often not the case in the medical world because of lack of time, lack of funding, and lack of training on the part of the health care professional (Anderson et al., 2017; Csemy & Sovínová,
2015; Saitz & Daaleman, 2017). In many cases, the initial and main focus by the primary health provider is often the consequent health problem, rather than the substance abuse which led to it
(Anderson et al. 2017; McLellan et al., 2014; McLellan, 2017; Saitz & Daaleman, 2017).
This evidence leads us to the question of whether there really is significant payback in labeling addiction as a brain disease, and if not, why does the medicalized BDMA persist?
One reason has already been stated above– money. Research institutions are more likely to receive grants for bio-medical research, and insurance companies more likely to subsidize a classifiable disease; money does not typically flow as freely for issues which delve deep into the realms of the psycho-social.
Another reason for the medical model of addiction may be because for finding clear, high-confidence research results, a neurological model can be easier to work with than a model that at once encompasses bio, psycho, social and perhaps even spiritual dimensions in equal Alcohol Use Disorder and Key Factors in Successful Treatment 69 consideration, which, as I have discussed earlier in this paper, come in infinite variety according to the individual and their unique, respective circumstances and ways of being.
One could counter this by suggesting that the same could be said of studying cancer, and there are thousands of cancer studies which have been undertaken, biopsychosocial models notwithstanding. So, why should this be a problem in the field of addiction?
A possible answer could be that those studies of cancer – traditionally understood as a bio-medical illness, actually are incomplete and perhaps even inaccurate in their failure to take psycho-social and perhaps even spiritual dimensions into greater account. Unlike addictions, one could venture to say that cancer has never been viewed as a moral failing, or as a character flaw.
Rather, many people see getting cancer as something that is a function of bad luck, or factors other than those scientifically attributed by medical professionals (Dumalaon-Canaria et al. 2014;
Dieng et al., 2014)
With addictions, however, susceptibility is viewed as a much more personal issue, something that pertains to the individual’s power of choice. People generally do not believe that addiction happens as a twist of fate, but rather because of the individual’s conscious actions and choice, which brings us back to the moral model of addiction, whose spirit, though it has been in some measure replaced by the biopsychosocial model, or at least by the BDMA, still has a pervasive influence (Frank & Nagel, 2017; Hammarlund et al., 2018), despite what is known about the power and effect of psychological and social factors.
Other factors in why the medical model of addiction may persist are discomfort and shame – shame on the part of the addict, of their family and friends, the discomfort which primary health professionals may feel when faced with asking their patients probing questions about personal habits, familial relations, or informing the patient that there is a strong likelihood Alcohol Use Disorder and Key Factors in Successful Treatment 70 of addiction. It is much less personal, and thus easier to discuss headaches or insomnia, and to prescribe pain medication or sleeping pills. It is likewise easier for the addicted individual to blame biology and take a pill, rather than examine psychological pain or dysfunctional relationships, which might mean venturing into uncomfortable, uncharted, and vulnerable territory in order to face the possible root issues directly (Kohn et al., 2004; Ross et al. 2015).
Chapter 12
AUD Treatment
A: Does treatment have a role and is it in any way similar to what Alcoholics Anonymous does?
GV: Treatment has a very important role, but it is probably not the role that many of the treaters think they have. Griffith Edwards once asked me: ‘Your research shows that it doesn’t make any difference. How do you reconcile that?’ I think my reconciliation is really epitomized by this. ‘If you want to treat an illness that has no easy cure, first of all treat them with hope.
-Vaillant (2005)
George Vaillant is now a retired Harvard psychiatrist, psychoanalyst and researcher, and has also been involved in several studies on addiction, AUD (alcoholism) being of particular interest to him. The above quote from an interview with Vaillant (2005) may be seen as somewhat controversial because it suggests that professional treatment as such may not play an important a role in addiction recovery. The fact is that many cases of AUD will resolve on their own over time, without professional intervention (Dawson et al. 2006; Heyman & Mims, 2016;
Lewis, 2017), and that many individuals with AUD successfully recover with the help of non- professional treatment, for example by attending Alcoholics Anonymous (Kelly et al., 2020;
Vaillant, 1966). Alcohol Use Disorder and Key Factors in Successful Treatment 71
The other question that may be brought to mind is, how is successful treatment or recovery defined? Does the definition of successful treatment or recovery differ from individual to individual? Is recovery defined only as abstinence from alcohol, or can it include moderate or low alcohol consumption? Is AUD recovery solely based on the level of alcohol consumption, regardless of other areas of dysfunction in the individual’s life, or is recovery contingent on the individual learning to live more functionally over-all, for example in terms of coping mechanisms, communication skills or quality of relationships? Is successful treatment defined by the ideals of the treatment center, or by the individual’s assessment of their own well-being, functioning, and quality of life, with or without alcohol?
These may be somewhat philosophical questions to which there are– as with many things around addiction, no black or white, singular answers. In this section, I will explore traditional treatment methods and their history, but it may be valuable to the reader to bear in mind that
“successful treatment” implies a goal to be reached; for many treatment centers, this may officially mean abstinence. For some individuals, abstinence may be the best or only solution to their relationship with alcohol. But there may also be many individuals in the chasm between
“drinker” and “abstinent” for whom there may be goals other than total abstinence, or for whom abstinence may be only one facet of of getting to a place where the person feels like they have truly recovered.
12.1 AUD Treatment in the Czech Republic
There are 4 basic treatment approaches for AUD in the Czech Republic: inpatient treatment, day treatment, out-patient services and self-help/support groups. For the purposes of this paper, I will focus namely on AUD treatment in the Czech Republic, but one should note that there are many similarities between AUD treatment in the Czech Republic, America and Alcohol Use Disorder and Key Factors in Successful Treatment 72 other European countries. In fact, Jaroslav Skála, a pioneer in Czech addiction treatment, and also known as the “Father of Detox,” (Nerad & Neradová, 1991) established the first detoxification unit in the world where people were allowed to detox under medical care as a part of treatment, rather than in jails (in so-called “drunk tanks”) or on their own. Skála’s model was used as a template for other detox centers around the world (Burešová, 2013; Nerad & Neradová,
1991). Indeed, addictions specialists in America, Britain and Europe have been using each other for inspiration and guidelines since the mid-19th century when the first institutional alcohol treatment center was established in America and served as a model for centers established in
Europe in the later 19th century (Šejvl et al., 2019). Additionally, much like in the world of biologically focused medicine, a great deal of the research around alcohol and drug use and treatment, including AUD, is internationally published and professionals in the field gather at international conferences like those organized by the International Society of Substance Use
(ISSU) or the European Monitoring Centre for Drugs and Drug Addiction (EMCDD) to exchange ideas and experiences. Thus, while I will be focusing on treatment in the Czech
Republic, I will also draw on informational sources that originate outside of the Czech Republic.
12.2 A Brief History of AUD Treatment in the Czech Lands – Velké Kunčice
Some of the first self-help communities and treatment facilities in what is now the Czech
Republic were established in the first half of the 19th century, and were modeled on treatment facilities that were being developed in other countries such as Sweden, Switzerland and Germany
(Miovský et al., 2015). The first in-patient treatment center for alcoholics was established by
Father Bedřich Koňařík in 1911 in Velké Kunčice (Šejvl & Miovský, 2018). History has proved that the Velké Kunčice institution was a significant milestone in AUD treatment in the Czech Alcohol Use Disorder and Key Factors in Successful Treatment 73
Republic. Koňařík’s approach in the establishment and running of this treatment institution paved the way for modern AUD treatment in the Czech Republic.
Treatment for alcoholism in Velké Kunčice was multidimensional, one could almost say a forerunner of the biopsychosocial model decades before Engle officially proposed this way of looking at illness and treatment. Koňařík’s understanding of alcoholism was not one of unilateral moral and personal condemnation, but one which acknowledged that there were a number of factors at play which not only influenced the development of the addiction, but which were also necessary to take into account during its treatment. Koňařík took into consideration the individual’s social, work, health and family situations; his was a much broader and more complex view than simply looking at the addiction as a failing of personality and morals, as was common during the early 20th century (Šejvl & Miovský, 2017).
One of Koňařík’s biggest inspirations for the facility in Velké Kunčice was the Ellikon facility in Switzerland, directed by Jakob Bosshardt. In contrast to many other facilities in which the patients were held against their will, for example, those that Koňařík had visited in Northern
Germany (Šejvl & Miovský, 2017), or were shamed shamed and treated as inferior beings,
Ellikon was based on principles of respect, free will and support. It was with this vision that
Koňařík established the facility in Nové Kunčice. He believed that the facility must be a haven based on goodwill and freedom for its patients, one where their body and spirit was cared for and nurtured with support and love, and which included a regime to help the individual to put himself mentally and physically back in order, rather than a punitive institution for deranged or criminal elements, designed to punish and shame its inmates into sobriety (Šejvl & Miovský, 2017).
Unfortunately, the onset of World War I and the calling of men into battle brought about the dissolution of the Velké Kunčice institution. However, the die had been cast for what was to Alcohol Use Disorder and Key Factors in Successful Treatment 74 become the addiction treatment model in the Czech Republic, and alcoholism slowly came to be seen as something which merited professional, systematic treatment (Šejvl & Miovský, 2018).
Koňařík’s work and the program that he had established in the Velké Kunčice facility through much observation, learning, experience and thought paved the way for Jaroslav Skála’s establishment of the “Apolinář” treatment facility in Prague in 1948 (Polák, 2019).
12.3 Treatment at the Tuchlov Facility
The early 20th century saw attention being drawn to the issue of alcohol consumption and addiction treatment by President T.G. Masaryk, president of the First Czechoslovak Republic.
Masaryk, himself never a heavy drinker and an abstinent in later life, wrote the book On Ethics and Alcoholism (1920), and brought the problems associated with alcoholism into a brighter public spotlight (Šejvl & Miovský, 2018). It was during Masaryk’s presidency that the Tuchlov treatment facility was established in 1923 (Šejvl & Miovský, 2018). The Tuchlov facility was significant because, after Velké Kunčice, it was the next institution to approach alcohol dependency treatment in a multi-faceted way, addressing the addiction at biological, psychological, social and spiritual levels. It also came into being under the auspices of the
Czechoslovak government’s Ministry of Public Health and Physical Education (Šejvl &
Miovský, 2018).
It is interesting to learn about the treatment regimen established in Tuchlov in 1936, as it, like its predecessor the Velké Kunčice treatment facility, was a forerunner of the treatment programs in the Czech Republic today. Indeed, some may say that most of the basic premises and routines have not changed significantly, which is not necessarily meant to denigrate treatment today, but rather to laud the work of the professionals at Velké Kunčice and Tuchlov who were pioneers ahead of their time. Alcohol Use Disorder and Key Factors in Successful Treatment 75
As at Velké Kunčice, Bedřich Koňařík helped to establish the Tuchlov treatment facility and acted as manager of the institution, in addition to being a patient educator (Šejvl and
Miovský, 2018).
Before being admitted to treatment in Tuchlov, patients were given a thorough medical examination which encompassed assessing both the physical and mental state of the patient.
Patients who were found to have mental illnesses were not accepted (Šejvl & Miovský, 2018). If a patient was accepted into treatment, he (only men were treated in Tuchlov) underwent a period of detoxification. If necessary, medications to help with withdrawal symptoms such as delirium tremens or insomnia were administered. As soon as the patients were able, they entered into a strict regime of work and chores, physical exercise, as well as intellectual pursuits such as book, attending lectures about alcohol treatment, travel, or other scholarly themes (Foustka et al., 1935, as cited in Šejvl & Miovský, 2018).
Apart from a regular work routine, which was seen as an essential part of not only cultivating patient’s confidence in their own abilities, but also for building feelings of pride and satisfaction in a job well done, the patients engaged in regular fitness activities such as hiking, traditional spa therapies including massages, hydrotherapy (hot and cold), steam baths or sunbathing. The evenings offered opportunities to relax and interact while playing billiards, attending plays or going to the cinema (Šejvl & Miovský, 2018).
Koňařík felt that a regular routine, one that included care and cultivation of mind, body and soul, as well as a rigorous work schedule was essential in supporting patients in their healing and recovery. He wrote:
“The most powerful support for any psychological treatment is systematic and
uncompromising work. Work is the pivotal element of self-discipline. Our efforts to Alcohol Use Disorder and Key Factors in Successful Treatment 76
educate patients towards abstinence, whether by means of self-exploration and hypnotic
suggestion, psychoanalysis, or other techniques and methods, can only be successful if
we bring the patients back to systematic work, make them feel good about what they have
accomplished during the day, and replace the false overestimation caused by alcohol with
healthy confidence.” (Koňařík, 1934, p.20, as cited in Šejvl & Miovský, 2018)
One can see that Koňařík’s and his cohort’s idea of AUD treatment as a holistic, complex and multi-faceted approach was already being employed in the 1930’s (and even earlier, if we recall Koňařík’s work in Nové Kunčice), even though Engel was to present the “landmark” idea of the biopsychosocial approach to disease nearly 50 years later (Smith, 2002).
12.4 Inpatient Treatment in the Czech Republic Today
In many ways, in-patient treatment today is similar to what it was in Tuchlov; there are components that address the biopsychosocial elements of the patient, treatment strives to bring order and routine into the patient’s life, to teach responsibility over one’s self and actions, to become more familiar with one’s self, one’s own behaviors, emotions and triggers, and how to interact socially and cope with stress in various situations, all without using alcohol (Dvořáček,
2019; Klinika adiktologie, 2021).
Jaroslav Skála, however, added some important elements to alcohol dependency treatment, and he is regarded as the founder of the modern-day version of addiction treatment and the field of addictology in the Czech Republic (Polák, 2019), not only for establishing the first alcohol treatment unit to be part of a Czechoslovak hospital in 1948, but also for establishing a “sobering-up center,” also known as a detoxification center, as a part of this unit 3 years later in 1951. detox center was the first of its kind in the world (Polák, 2019; Burešová et al., 2013). Today, however, though detoxification is still a part of AUD treatment after the Alcohol Use Disorder and Key Factors in Successful Treatment 77 individual has been officially admitted, the number of “sobering-up stations” in the Czech
Republic as originally proposed by Skála has diminished, mostly because of financial and staffing issues (Burešová et al., 2013).
After detoxing, patients join what is known as a “therapeutic community.” This is a treatment approach that is common for inpatient addiction recovery in the Czech Republic
(Klinika adiktologie, 2021). It is also another element established by Skála as a part of the
Apolinář treatment facility, showing his prescience in the field. The EMCDDA states that therapeutic communities were developed in Europe to address addiction treatment in the 1960s
(Vanderplassche et al., 2014, p. 9); Skála was already running addiction treatment based on the therapeutic community approach in the 1940s, and it remains popular today. The average length of treatment is between 3 and 5 months (Červený Dvůr, 2019), though this length can vary from patient to patient, may depend upon the severity of the addiction, or the program of a particular treatment facility.
12.5 Therapeutic Communities
The idea behind the therapeutic community (TC) approach is to recreate a microcosm of society so that the individuals in treatment can learn to function within a collective, including building relationships, learning how to communicate effectively, navigating conflict and managing stress, all in an alcohol-free environment. Abstinence may be viewed as a “resource,” but not necessarily a “prerequisite” for recovery (Vanderplasschen et al., 2013). This approach recognizes that addiction is one facet of a larger web of dysfunction, a coping mechanism that is the result of stressors that have not been managed or resolved productively. The therapeutic community is a sort of training environment where the individual learns, healthier ways of coping and functioning within a society through a variety of therapeutic activities that cultivate Alcohol Use Disorder and Key Factors in Successful Treatment 78 the patient’s biological, psychological and social spheres. The intention is that s/he will be able to transfer the skills developed in the therapeutic community into their own lives, while helping to mitigate, or eliminate dysfunctional coping mechanisms, including alcohol or other substance use or abuse (Vanderplasschen, Colpaert et al., 2013; Vanderplasschen, Vandevelde et al., 2014).
Patients go through treatment programs which include work regimes, therapy (for example regular group therapy and meetings, known as ‘community time,’ one-on- one psychotherapy, art therapy, journaling, or other modes of therapeutic activity), fitness and recreational activities, alcohol education, somatic treatment – much like the previously described program at the
Tuchlov facility, all within the greater context of the therapeutic community. The schedule is regular, which is also an intentional and important feature of treatment as it is meant to instill systematic, healthy routines to help create a new life approach that does not revolve around drinking or drinking rituals (Červený Dvůr, 2019; Klinika adiktologie, 2019).
There are mixed reviews of the success of the therapeutic community approach, though overall, the results seem to be positive. One narrative review of 24 studies (Vanderplasschen et al., 2013) focusing on the effectiveness between different types of therapeutic communities and interventions for treating addiction found the following results:
-The rates of relapse are generally lower for those who complete the TC program
- Lower rates of legal entanglements, such as crime, after TC treatment
-Improved employment rates
-Improved social and family relationships.
-More intensive TC programs generally garnered better results
However, the authors of the study were also careful to point out that these were general findings, and outcomes among the studies varied. They cited “substantial heterogeneity” among Alcohol Use Disorder and Key Factors in Successful Treatment 79 the studies as one of the limitations (indeed, a limitation in many addiction treatment studies, as noted earlier in the paper). The authors summarized the study by writing that they found the more important question was not about the type of TC treatment was effective, but rather about matching the individual with the most appropriate type of TC for them. Results were also influenced by where the individual was in the recovery process. The researchers wrote that when looking at longitudinal results, there were indications that no one particular type of intervention was superior to the other. Vanderplasschen et al. summarized their findings by emphasizing that it was not the respective effectiveness of various TCs that were of greatest consequence, but rather the individual’s personal qualities, what type of community support they had, as well as personal needs and objectives which indicated whether TC treatment would be beneficial to recovery (Vanderplasschen et al., 2013).
12.6 Personal Reflection
The Vanderplasschen et al. (2013) study stood out to me because it seems to summarize a theme that I have repeatedly encountered throughout the process of writing this thesis. As with
AUD etiology, there is also heterogeneity in treatment approaches, with a variation between individual results. AUD really is a phenomenon which operates on biological, psychological, social, and perhaps even spiritual levels, the features and measures of which are individual to each person, their unique psyche and their respective history, culture and circumstances. The question of how each individual chooses to go forward within these domains, and the changes that they do, or do not, make will also have an impact on their recovery in the future.
What does this mean for the people working to support the AUD individual in their recovery? It seems to me that one needs to be curious and flexible in outlook and approach, that the approach employs sensitivity and attention to detail – both where factual, objective Alcohol Use Disorder and Key Factors in Successful Treatment 80 information is concerned, as well as to the subjective issues that concern the humanity of the individual. Attention should be paid to areas such as childhood, trauma, current relationships and comorbid health issues, among other subjects that may be of bearing, and the interventions which are appropriate to that case should be applied accordingly. Those interventions will likely vary from person to person.
I think that the treatment process could be compared to a detective trying to put together the pieces of a mystery and slowly putting the case together with each additional piece of evidence, or a ship navigating waters that are not well known, with the goal of reaching firm land. The difference is, that in this story, it is both the AUD professional and the person with
AUD who are ultimately working in co-operation towards the same goal, the professional initially taking the lead to set the course, and eventually handing over the responsibility of the journey’s continuation to the patient. Both use the tools that they are familiar with, exchanging, adjusting or learning about new tools in order to gain better results, doggedly staying the course, and sometimes improvising in order to navigate obstacles in hopes of reaching terra firma, or at the very least, terra firmer. It’s a journey that may have a basic map, but can be reached by using many different vehicles – often more than one, via many possible routes, and with any number of barriers or detours.
12.7 Outpatient Day Treatment
Day treatment is a mid-way step between full inpatient treatment and out-patient appointments to address various aspects of AUD treatment. Day programs often include similar therapeutic activities that inpatient therapeutic communities encompass, for example group therapy, one-on-one therapy, work activities, somatic health care, or fitness regimes. Out-patient day treatment might be a good option for those who have stable living situations, and who are Alcohol Use Disorder and Key Factors in Successful Treatment 81 able to maintain the course of therapy without 24-hour surveillance or care, and who are able to manage a somewhat less institutionally structured approach than inpatient care provides. Day treatment typically happens only during weekdays, and does not include treatment on weekends
(Galbicsek, 2021; Klinika adiktologie, 2019).
12.8 Ambulatory/Outpatient Care
This type of treatment does not typically happen on a daily basis, but is predicated on appointments made independently by the client with various healthcare professionals in order to support their own AUD recovery, though the individual may be referred or recommended to certain types of treatment by their primary care provider, or an addictions counselor. Types of care can include private therapy sessions, group therapy sessions, family or couple’s therapy, medical appointments, or any other type of therapeutic care which the individual and/or their care providers may recommend or see as beneficial. The frequency and nature of appointments will vary from individual to individual, depending on personal needs, preferences or possibilities
(Galbicsek, 2021; Klinika adiktologie, 2019).
12.9 Self-Help Groups
“We are not capable of healing in isolation. We need other people....We are hurt in relationship and we heal in relationship....Our brain and nervous system are not isolated, but interconnected and social....At our core, we are social beings who regulate through connection with others....Being comfortable in your own skin and having tools that help you relax is a really big deal, but learning how to feel safe with others is revolutionary.”
-Dr. Diane Poole Heller, from The Power of Attachment (2019)
Alcohol Use Disorder and Key Factors in Successful Treatment 82
It would be remiss to also not mention the long tradition and history of self-help groups in the Czech lands for those struggling with alcohol dependency. Some of the first established groups appeared toward the mid-19th century and were mainly associated with church and charity organizations (Miovský et al., 2015). Gabrhelík and Miovský (2009) write that these groups formed a rich foundation for the continuation of self-help groups into the 20th century, and the tradition and active existence of these groups has been present ever since. Indeed, Jaroslav Skála established the “KLUS” group meetings (KLUS, is an acronym, the letters of which translate into “club for those striving for sobriety”) shortly before he founded what was to become another great landmark in Czech alcohol treatment institutions, the first in-patient alcohol treatment facility to be a part of the psychiatric wing of the Charles University Faculty Hospital (Šejvl &
Miovský, 2017).
At the beginning of his medical career, Skála was sent to Brussels to attend a conference on alcoholism, an area that was new to him, but which evidently piqued his interest. Upon returning, Skála began researching alcoholism on his own, poring over all related material that he could find. Among his findings was information about Alcoholics Anonymous (AA), which had been established in America some 10 years earlier, in 1935 (Gabrhelík & Miovský, 2009). Skála was apparently taken by the idea of an independent self-help group which operated on member participation, and which provided free and easy access to support, guidance, information, and community for those for whom alcohol use had become problematic. Skála’s group, KLUS, was inspired by the principles of AA in many ways, but one of the major differences was the absence of any religious connotation, due to the Communist regime’s intolerance of spirituality or religion (Gabrhelík & Miovský, 2009). The KLUS groups are still in existence, though they are Alcohol Use Disorder and Key Factors in Successful Treatment 83 more closely affiliated with treatment clinics, and are organized by professionals, rather than being 100% member organized and led as is the case with AA (Gabrhelík & Miovský, 2009).
Chapter 13
Alcoholics Anonymous
“As time went on I had more relatives, more friends and more patients who recovered and seemed to benefit from AA. I began to look more closely at it. By then my study had started and it was clear something was going on there. My findings suggested that AA was not just a magical collection of recovering alcoholics but that it embodied certain principles that worked quite separately.”
-George Vaillant, from “Conversation with George Vaillant” (2005)
Alcoholics Anonymous was established in the United States in 1935, and despite the fact that, at least initially, AA was regarded skeptically by many medical professionals, it continues to be an important support for those wishing to achieve and maintain sobriety (Groh et al., 2007;
Humphreys, et al., 2004; Krentzman, 2008 ).
AA is based on the principle of “working the 12-steps” within a community of people who, as diverse as they may be otherwise, all have the common goal of sobriety. There are no fees or dues to pay for going to AA, they are not affiliated with any political or religious groups and the only requirement for attending is a desire to be sober.
AA and the 12-steps were originally inspired by The Oxford Group, an evangelical society which also supported individuals in becoming sober. Two of its members, Bob Smith and
Bill Wilson broke with the Oxford Group and formed their own gathering, which came to be known as Alcoholics Anonymous. Unlike the Oxford Group, however, AA was much less focused on religion or piety, and though many believe in a “higher power,” the AA approach Alcohol Use Disorder and Key Factors in Successful Treatment 84 allows for all people to attend, regardless of religion, race or creed, as long as they desire to stop drinking (Gross, 2010).
13.1 The Twelve Steps
The twelve steps evolved from the original 6 tenets of the Oxford Group, which Wilson expanded into 12 steps (Gross, 2010). These are the guidelines which AA offers to its members to use to help them to achieve and maintain sobriety. Wilson then expanded on his 12 steps to create the 12 traditions, which explain the principles behind the 12 steps (White & Kurtz, 2008).
Members follow each of the steps, examining their lives using the steps as a guideline, and reflecting on how to apply the steps in order to make amends, adjustments or the appropriate reparations in their own lives. The following image shows the 12 steps and traditions as listed by
Alcoholics Anonymous in 1972: Alcohol Use Disorder and Key Factors in Successful Treatment 85
(Alcoholics Anonymous World Services, 1972, as cited in Gross, 2010)
There are copious amounts of literature about AA available online. The “mothership” website, aa.org, is a rich and extensive repository of all things AA, and includes everything from historical information, numerous versions of the basic tenets, group and meeting information, and printable materials (pamphlets, booklets, signs, etc.). AA has a presence in over 180 nations around the world (AA, 2021), and many of these groups have their own websites. However, the Alcohol Use Disorder and Key Factors in Successful Treatment 86 amount of research focusing on the AA process or results, and AUD in general, is relatively limited, (Gabrhelík &Miovský, 2009; Kelly et al., 2011; Krentzman, 2008; Vaillant, 2005), which makes finding scientifically rigorous, empirical information around AA, its functions and effectiveness challenging.
13.2 Honza - AA
In the researching of this work, I spoke with a leader in the Prague AA community,
Honza. I wanted to find out more information pertaining to Prague AA groups that proved to be challenging to find through online sources. The following information is what resulted from my conversation with Honza, which ended up being more informative than expected.
Honza has been now sober for nearly 23 years. Before that, Honza went through intense drinking, trying to cut back and relapsing for over 6 years, refusing to accept that he was unable to drink in moderation. He went into treatment for the first time, but was not invested in the process and eventually even drank “through” his Antabuse therapy, and went back to trying to manage on his own, unsuccessfully. Honza’s situation reached a crescendo and his neighbors had to call an ambulance for the second time to take him away. Honza went back into outpatient day treatment again and then started regularly attending AA meetings. He has been sober ever since, and has become one of the AA organizers. What he told me is based on his experience of how
AA in Prague functions.
Because AA is member run, each group has its own “flavor” which comes from the particular dynamic of individuals of the group and may also be partially dependent on the group organizer. Some groups may have members who are more inclined, for example, to talk about the higher power or “God aspects” of the program, or alternately other themes, and in a different group, one may find themself to be surrounded by atheists. The group make-up can change from Alcohol Use Disorder and Key Factors in Successful Treatment 87 meeting to meeting, though there is often a core group of those who regularly attend. Honza told me that there is no set way for groups to be; it all depends on the nature of a particular group, or even on the composition of a group on a particular day.
Some AA meeting groups are closed, which means that only those who are trying to stop drinking or maintain sobriety are allowed to attend and are often regulars, while other groups are open, and welcome anyone who is interested in joining or finding out more. The only stipulation for open groups is that those who are there as observers, and not actively trying to achieve or maintain sobriety, may not speak or join discussion. One can find out whether a group is open or closed, as well as meeting times and places, through visiting the Czech AA website of meetings in Prague or calling an AA organizer at one of the numbers listed on the site.
When I asked Honza why he thinks that AA works, he said that he believes that primarily, the core requisite comes from within the individual. It is the desire to not want to drink. That doesn’t mean that the individual has achieved sobriety, or doesn’t struggle, but it means that even despite not having reached sobriety or struggling, the individual wants to quit drinking, and has hope that this is possible. Honza said that the group is what helps with this hope and shows the individual that they are not alone, that there are others to lend support along the way, people who have been there before and who have managed to get further along. Regular attendance helps to keep the individual on track.
Honza told me that sometimes the inspiration for being sober and examining yourself and your life comes in the form of the member who “irritates the shit out of you,” and makes you realize that you have a choice to not behave the way that they do. Sometimes hope comes in the form of simply stepping foot into the meeting room where there are people who are there for the same reason that you are- to try and maintain sobriety. He mentioned that different groups may Alcohol Use Disorder and Key Factors in Successful Treatment 88 have different dynamics; members are encouraged to visit various meetings to find the one which suits them best. Ultimately, however, Honza said that the particular meeting itself was less important than the desire to quit drinking.
Something else that Honza mentioned about the AA philosophy is keeping sight of the here and now. “If I can manage to not drink for the next 5 minutes, that is 5 more minutes of my life that I am sober. And if I can manage to not drink for another 5 minutes after that, that is another chunk of time that I have been able to maintain sobriety. And if I can manage to find meaningful things to structure my day with, in order to keep from drinking, that is another day that I have made it through without taking a drink.” Honza spoke about not taking the long view, because no one has any guarantees about anything that may or may not happen a few years, a few months or a few weeks from now. By focusing on what one can do to make their life better right now, one has a chance to make the most of what is happening at present, and to help set the scene for what happens next.
As far as the question of whether the idea of “God” in a religious sense predominates AA philosophy, one should take into account that one of the reasons that the original AA founders
Smith and Wilson split from the Oxford Group was because of the intense focus on religiosity.
Wilson in particular was willing to accept the idea of a force greater than humans in a spiritual sense, but was at odds with the dogmatic approach of the Oxford Group (White & Kurtz, 2008).
For this reason, Wilson wrote the second of the twelve steps to mention a “higher power,” and explicitly stated, “God, as we understand him” in the third. Honza told me that he was a skeptic around the question of God or a higher power during the first 6 months that he started attending
AA meetings. Ultimately, however, he said that he realized that the point of going to meetings was not to debate about God, but about maintaining sobriety. He said that he also came to Alcohol Use Disorder and Key Factors in Successful Treatment 89 recognize that there was a power larger than himself at work – that he by himself was powerless over drink, the problem which had necessitated seeking help with achieving and maintaining sobriety. Whether one sees this power as the power of the collective, the power of a God, or an overarching force that is larger than one’s efforts alone is secondary; the important part of the realization is that this belief in a higher power gives the individual hope, support and strength in striving for sobriety.
13.3 AA Sponsorship
One of the important tenets of attending AA is mutual support among members, something that the twelfth step talks about – alcoholics helping other alcoholics on the road to sobriety. One way in which this can happen is in the form of sponsorship. A sponsor is an AA member who has been sober for a minimum of a year (AA, 2019), and who takes newer members under their wing to offer guidance, support or information, also outside of meeting times. The AA pamphlet on sponsorship states that this can happen officially, with a particular person being asked to be a sponsor, or unofficially, through members offering their support by giving a new member their phone number and encouraging them to call if they should have questions or need support in resisting the urge to drink. There are no official sponsorship rules
(AA, 2019). Sponsorship can also happen unofficially between members during meetings, namely among more seasoned members and those who are new. Some groups may have a more formal interpretation of sponsorship, while others may have a more informal approach.
13.4 AA in the Czech Republic
Alcoholics Anonymous had a late start in the Czech Republic, mainly due to political reasons, and had their first, fledgling meetings in Prague in 1988. The first AA group was established by a handful of Czechs and Czech Americans who joined forces with Skála’s “U Alcohol Use Disorder and Key Factors in Successful Treatment 90
Apolináře” treatment facility to host the first AA meeting. Soon after, following the fall of the
Communist regime, the first official and independent AA group was established in 1989 (AA-
CR, 2021). In 2008, there were 21 different municipalities throughout the Czech Republic where meetings were held (AA-CR, 2021), and AA, or “Áčka,” as the group is familiarly known by members, continues to be a strong presence in the Czech Republic today. Meetings are co-ed, may be open or closed depending on the particular group, and while most meetings are discussion meetings, some meetings devote themselves to examining and concentrating on working the 12 steps. One can find a short description of the meetings, times and locations on the
Czech AA chapter’s website at https://www.anonymnialkoholici.cz/nove-prichozi/jak-to- funguje/ . Anyone can call the phone numbers noted on the website’s home page to find out more information about AA, meetings, or simply to ask for support or guidance for AA related questions. Sponsors or sponsorship as such is not mentioned on the Czech AA website’s pages.
However, the importance of service to others is mentioned as anything that can help a member to get closer to a struggling alcoholic. The section on service goes on to state that the idea of what service means is very broad and can encompass anything from working the 12 steps, to keeping in telephonic contact with another alcoholic, or preparing coffee at a meeting (AA – CR, 2021).
Chapter 14
Effectiveness of AUD Treatment
At this point, it may be clear that, though AUD is a serious and widespread problem, there are no clear-cut treatment strategies, and those that are available cannot promise guaranteed results. The question of how recovery is actually defined is also pertinent, whether it encompasses complete abstinence, controlled drinking, or other criteria which result in an improved quality of life, and for what length of time. Alcohol Use Disorder and Key Factors in Successful Treatment 91
The path through which recovery may happen is also not clear for most individuals. A recent study by Tucker et al., (2020) looks at recovery in those with AUD. They found that in roughly 70% of individuals with AUD, remission occurred spontaneously, and often did not involve complete abstinence, but happened through a return to controlled drinking. Less than
25% of individuals sought alcohol-focused treatment; the degree of AUD severity in these individuals was generally higher than in other populations (Tucker et al., 2020). Of these, roughly 26% had continued (persistent) AUD, 43% were reported as being abstinent without symptoms, and the remainder were able to drink at various levels, some without any continued symptoms of AUD, and some with symptoms (Tucker et al., 2020). Tucker et al. (2020) also found that the treatment gap is significant; those who need treatment often do not seek out services to address their AUD. They suggest making non-medical services more easily accessible to at-risk populations and increasing information dissemination about alcohol use to raise awareness around the associated risks, as well as treatment and recovery options.
Though Huebner and Kantor write that there have been significant advances in AUD treatment in the last 20 years (2011), there may be ample reason to dispute this claim.
Firstly, as far as pharmacological interventions, the main drugs associated with treating
AUD (apart from anxiolytics, antidepressants or soporifics to help with withdrawal symptoms or comorbid conditions) are disulfiram (Antabuse), naltrexone and acamprosate (Swift & Aston,
2015). Disulfiram, known commercially as Antabuse, produces severely unpleasant side effects after alcohol consumption; thus, it is often used to support behavior modification, to help to break the cycle of craving and drinking. Naltrexone serves to inhibit pleasurable feelings derived from drinking alcohol, so reducing the motivation and making it easier for the individual to not over-imbibe. Acamprosate helps to support brain normal function and reduce feelings of craving. Alcohol Use Disorder and Key Factors in Successful Treatment 92
(Kennedy et al., 2010; Swift & Aston, 2015). Studies have shown that the combined use of naltrexone and acamprosate have better results than either drug used alone, though other concurrent AUD treatment interventions, such as psychotherapy are strongly recommended for optimal results (Kiefer & Wiedemann, 2004).
Apart from these drugs, there seem to be no significant newcomers onto the AUD treatment pharmacological scene; disulfiram has been in use since the 1950’s, naltrexone was
FDA approved in 1994 (Swift & Aston, 2015), and acamprosate was approved in Europe in
1989, though the FDA approved it for American use in 2004 (Center for Substance Use
Treatment, 2009).
Swift and Aston note that, in any case, pharmacotherapies are far from a magic bullet for
AUD treatment (2015) and can at best be used to support a wider range of complex therapy. As has also been previously discussed, there is in fact no one treatment method that has proved to be a guaranteed cure for AUD, though some approaches may be more important for certain individuals, while other treatment modes are more effective for others. Because of this, a scattershot approach is often used in the hopes of finding some treatment, or combination of treatments, that will result in better chances of a successful AUD recovery, however that may be defined for the particular individual.
As far as inpatient and outpatient treatments are concerned, the methods used have not undergone major changes since their inception in the Czech Republic in the first half of the 20th century as discussed earlier in the paper, excepting the use of the drugs noted above. It is estimated that only about 9% of AUD patients in professional treatment receive any of the drugs mentioned above (Kranzler & Soyka, 2018). Alcohol Use Disorder and Key Factors in Successful Treatment 93
One of the treatment approaches that has been found to have relatively good results with
AUD is cognitive behavioral therapy, commonly referred to as CBT. (Coates et al., 2018; Coriale et al., 2019; McHugh et al., 2010). However, this endorsement of CBT for AUD treatments comes with a number of caveats.
Firstly, CBT is one of the few modes of psychotherapy that is more easily used in research, as it is easier to replicate and to control for variables. This means that there is a tendency to focus research on CBT, rather than other modes of therapy that are difficult to undertake or control for in scientifically rigorous ways (Tolin, 2010). Consequently, the efficacy of CBT under carefully controlled circumstances may be good, but it does not necessarily mean that its effectiveness in a variety of real-world, uncontrolled settings will correspond to controlled research results (McHugh et al., 2010). It also leaves the possibility that other, more difficult to research and control for therapies may be equally as effective, though more difficult to quantify and replicate.
Secondly, as Roos et al. (2017) commented, findings regarding CBT as a treatment for
AUD are not consistent, depending on the variables of the particular study. Their own research showed CBT to be effective for severe versions of AUD after a one-year period, but not for moderate or mild AUD (Roos et al., 2017).
Chapter 15
The Cochrane Review
At this point, I am going to come back to the study which originally inspired this thesis, the Cochrane Group’s systematic review of research comparing Alcoholics Anonymous and twelve step facilitation versus other AUD treatment approaches, Alcoholics Anonymous and
Other 12-step Programs for Alcohol Use Disorder (Kelly et al., 2020). Alcohol Use Disorder and Key Factors in Successful Treatment 94
The study was a collaboration between 3 researchers in the addiction field – John Kelly of the Recovery Research Institute, Center of Addiction Medicine, Harvard Medical School;
Keith Humphreys of the Stanford University Medical Centers, Stanford School of Medicine and
Marica Ferri of the European Monitoring Center for Drugs and Drug Addiction. The purpose of the study was to compare the results of twelve-step facilitation (TSF) of AA meetings as the primary treatment method against other treatment methods, in particular cognitive behavioral therapy (CBT), motivational enhancement therapy (MET) and as well as other “TAUs”
(treatment as usual, meaning a combination of psychological interventions, behavioral interventions, group therapy, medical care, etc.). The study also examined the results of using
AA/TSF as a follow up of other treatment methods. Some of the comparison groups were outpatient, while others were inpatient.
The team searched numerous databases which also included international studies.
Ultimately, they chose 27 of the highest quality studies which were comprised of 21 random control trials (RCTs) or quasi-RCTs, 5 non-randomized trials and 1 study which looked primarily at the economic aspects of treatment. The studies included a total of 10,565 participants who all met the DSM V criteria for AUD.
The key findings were as follow: The clients who underwent intensive AA/TSF – that is, clients were introduced to AA by a facilitator who could discuss the AA program, answer questions, give other information which the client may need, provide the client with contacts and specific recommendations, and followed up with the client about AA attendance, had significantly better results than all other groups in terms of abstinence (measured in PDA – percentage days abstinent), including against CBT and TAU groups, particularly in the long term follow-ups. Alcohol Use Disorder and Key Factors in Successful Treatment 95
TSF programs might consist of one hour-long session, or they might be comprised of several meetings over a number of months. While the TSF is not counted as the actual AUD treatment per se (that is the AA meetings’ function), it can be an important part of the process as far as facilitating and supporting continued attendance to AA. It was found that the TSF programs which were of greater intensity, meaning that facilitators worked with clients to facilitate understanding of the AA process and who supported attendance more rigorously, had better results than those who were less rigorous at implementation and follow-up around AA attendance. However, the study also showed that in general, even when the TSF/AA was less rigorous, and the comparative treatment methods were well-established and effectively delivered, participants still achieved similar results as far as decreasing drinking intensity, severity of addiction or alcohol-related consequences.
The study’s findings suggested that treatment accompanied by a rigorous TSF/AA program may have the best overall results as far as increasing abstinence, as well as decreasing drinking intensity and the severity of addiction. In cases where finances or logistics may prohibit more complex or intensive treatment, it seems that a dedicated adherence to AA attendance can produce results that are comparable to professional therapies or TAUs (Kelly et al., 2020).
Financially, providing treatment that is low/no cost, is frequently accessible to everyone, and which results in lower rates of relapse, means that the costs of alcohol treatment, damages and health-related expenses could be greatly reduced.
15.1 Possible Explanations for TSF/AA Success
The authors of the Cochrane study discussed possible reasons for the fact that TSF/AA success rates are competitive, and in some cases superior to, CBT, MET or other treatment modalities. They wrote that social support as well as peer modeling and mentorship likely play a Alcohol Use Disorder and Key Factors in Successful Treatment 96 role, as does the group meeting format, which may confer many of the same benefits of group therapy, for example, a lessening of shame and feelings of loneliness, or by alleviating the individual’s feeling of isolation in their struggle (Kelly et al., 2020). Further to this, the AA format provides a “real-life” training ground in which to practice communication and coping skills, while learning from the experiences of others. AA’s 12 steps are intended to foment and cultivate psychological, emotional and spiritual change (Alcoholics Anonymous, 2021). Even though the spiritual aspect is one that AA touts as being central to its belief system, the AA FAQ pages also state that they are not a religious organization, and that many of its members are atheists or agnostic. Kelly et al. (2020) also noted that though the TSF is not AUD treatment per se, it helped to increase AA attendance, which in turn resulted in higher AUD treatment success rates.
Another one of AA’s strengths may lie in its easy accessibility. Sullivan (2020) writes that timing may be a critical component in AUD recovery. During early abstinence, each extra day of abstinence decreases the chance of relapse from a neurological perspective; if the individual can abstain long enough for brain function to improve, and for levels of self- awareness, as well as a greater awareness of the impact of their drinking to increase, there may be increased motivation to continue abstaining. However, this is also a period during which the individual may be the most vulnerable to relapse emotionally as well as socially, as they may not have adequate coping skills with which to deal with negative affect, to replace drinking activities or to deal with situations that incite alcohol use (Sullivan, 2020). The waiting list for many alcohol treatment facilities or programs may require that a prospective client wait a number of weeks or even months until capacities allow for the intake of another client. This is not the case with AA, where the individual can join meetings unannounced, without appointment, and for Alcohol Use Disorder and Key Factors in Successful Treatment 97 free. Additionally, AA meetings can be found happening nearly every day of the week in many cities around the world; there are over 118,000 AA groups in approximately 175 countries around the world (AA, 2021). According to the Czech AA website
(https://www.anonymnialkoholici.cz/pro-cleny/skupiny/), there are roughly 57 meeting groups across the Czech Republic (AA-CR, 2021).
Chapter 16
Important Factors in AUD Recovery
George Vaillant, cited earlier in this work, wrote that his research has repeatedly shown that there are 4 main factors present in effective relapse prevention: external supervision, a regular adherence to a competing behavior, newly found loving relationships, and increased spirituality (Vaillant, 1988; Vaillant, 2005). His findings are also supported by numerous other studies (Kaskutas et al., 2002; Kelly et al., 2011; Morgenstern et al.,1997; Owen et al. 2003; Stall
& Biernicki, 1986; Stevens et al., 2014), which have also looked at the factors that have helped to support addiction treatment and prevent relapse.
If these researchers’ findings are to be believed, they would be in congruence with the
Cochrane Groups’ findings and would help to explain AA’s strong performance as far as treating
AUD is concerned. AA provides external supervision in the form of meeting groups and sponsors, both of which help to hold the individual accountable for his/her drinking and behavior, and the added element of TSF can help to reinforce this. Regular attendance of meetings, and/or adherence to following the 12-step practice provides not only routine and structure, but also activities and relationships with which to replace time spent drinking with previous cohorts. These new friendships, as well as any other relationships that serve to motivate the individual towards abstinence and a healthier lifestyle can also provide important support. It Alcohol Use Disorder and Key Factors in Successful Treatment 98 may not be too difficult to imagine that, at least for some people, this improvement in an overall approach to living may bring about newly realized life philosophies, and possibly a deepened spirituality, or belief in a force that is greater than one’s self.
All of these factors – accountability to an outside social network, daily rituals and newly- formed meaningful relationships, and possibly a new-found or deepened spirituality, can be seen as revitalizing and improving numerous dimensions of one’s life, perhaps at different levels. This multivariate complexity may be what enables these factors to influentially address the heterogeneous etiology and thus, positively promote recovery from AUD. As Kelly et al., wrote in the their 2011 paper, “Determining the Relative Importance of the Mechanisms of Behavior
Change within Alcoholics Anonymous: A Multiple Mediator Analysis,” though AA seems to be effective by activating a number of processes concurrently, it seems that the power of the social processes are of particularly significant importance.
Chapter 17
Methods
As a part of this research, I also wanted to gain information from people in my own extended community who have struggled with alcohol use. Some of them used the support of AA as a way to achieve sobriety, others used different outpatient or inpatient services. I was curious about their responses as to what had helped them most in successfully managing their AUD, and how this would (or would not) align with the findings above. The method I used was a simple, anonymous questionnaire in both the Czech and English language, depending on the target audience. The questionnaire was comprised of the basic questions:
1. What are the most important factors in helping you to quit drinking?
2. Why and how have these factors been important? Have they continued to be important? Alcohol Use Disorder and Key Factors in Successful Treatment 99
I sent this questionnaire to various treatment facilities, directly addressed friends or public figures who I knew were open about their abstinence or AA attendance, and also sent the questionnaire to my connections on social media. Four of the questionnaires were filled out by addictions professionals working with AUD clients, in order to gain information about the clinician’s point of view concerning what they felt most supported their clients’ recovery.
Ultimately, I received 7 replies from people who themselves sought treatment for AUD, and 4 replies from professionals working with AUD patients/clients. While these replies did not provide me with an exhaustive source of information, I did find certain trends, themes that reoccurred throughout the responses to my questions.
In order to analyze the results, I used a grounded theory approach, as introduced by
Strauss and Glaser in 1967 (Brown, 2012; Dunne, 2011). The premise of this qualitative approach is that, rather than testing an a priori hypothesis, the researcher analyzes qualitative data using a technique called “coding” in order to discern patterns and trends which arise from the information. Data is collected and coded until the point of saturation is reached. Saturation means that there are certain themes which continue to arise from the data repetitively, and despite ongoing information gathering, there are no significant other themes which arise to compete with the primary themes. Coding is done by grouping concepts that emerge from the data collection under headings, or themes (Corbin & Strauss, 1990), ideally until no new themes arise (saturation). The researcher then proposes a theory which is based on the actual data collected.
Initially, when Strauss and Glaser first proposed the concept of grounded theory research, they warned against doing a literature prior to data collection and analyses because they felt that it could bias, or contaminate the researcher’s view of the information collected, as well as how it Alcohol Use Disorder and Key Factors in Successful Treatment 100 is analyzed. However, Glaser and Strauss later split on this issue (Dunne, C., 2011) as Strauss felt that an initial literature review could help the researcher to familiarize themselves with the subject in order to better conceptualize the study, as well as to to avoid doing research which had already been undertaken, among other reasons. Strauss felt that it was up to the researcher to check their own biases regardless of when the literature review was performed (Dunne, C.,
2011). In the case of my own research, an important part of the process was simply to familiarize myself with AUD, its etiology, treatment approaches and their effectiveness as researched thus far through a literature review. This not only provided me with practical information, but also helped to put my consequent research into comparative context.
For my own data analyses, I coded the data in the questionnaires by first identifying and color-coding words and themes which appeared most frequently throughout the replies, and then grouping them under headings. The following section is a break-down of my findings.
Chapter 18
Results
Out of my 11 respondents, 7 were people who had problems with drinking and are now sober, and 4 were people working with clients in the addictions field. The questionnaires were distributed to an outpatient addiction recovery facility (total of 6 respondents, 3 clients, 3 workers) and via direct email/communication platform (1 worker, 4 currently sober individuals).
Between these 2 groups, the 4 most frequently mentioned factors for being important for reaching recovery, in order of importance, were:
1. Persistence- patience with the process, attending treatment or group meetings
regularly, being conscientious about following routine or healthy rituals. (7 out of 11
respondents- 63.6%) Alcohol Use Disorder and Key Factors in Successful Treatment 101
2. Having someone to talk to who cares (6 out of 11 respondents- 54.5%)
3. Resolution – making the decision to quit drinking (6 out of 11 respondents- 54.5%)
4. Group support, either of a self-help group, or via a supportive community of friends
and family (3 out of 11 respondents- 27.2%)
These replies appeared among those working with addictions were as follows, in order of importance:
1. Persistence (3 of 4 respondents- 75%)
2. Having someone who cares to talk to (2 of 4 respondents- 50%)
3. Resolution, (2 of 4 respondents- 50%)
4. Group support (0 of 4 respondents- 0%)
The replies regarding key factors in reaching recovery among those who
recovered from AUD appeared as follows, also in order of importance:
1. Someone to talk to (4 out of 7 respondents- 57.1%)
2. Resolution (4 out of 7 respondents- 57.1%)
3. Persistence (4 out of 7 respondents- 57.1%)
4. Group support, via self-help groups, or family/friends (3 out of 7 respondents- 42.8%)
Other themes which appeared, though not in as high a concentration, were new information/education, change of lifestyle/addition of healthy activities such as meditation or running, and not being judged.
Alcohol Use Disorder and Key Factors in Successful Treatment 102
Chapter 19
Discussion
The findings of my study indicate that 9 out of 11 (87%) of respondents felt that social support, whether in the form of a caring individual or a supportive group, was crucial to addiction recovery. In examining the mechanisms through which AA is posited to be effective, the Cochrane Group wrote: “Rigorous reviews of the mechanisms of behavior change through which AA enhances recovery have found that AA typically confers benefits by mobilizing multiple therapeutic factors simultaneously - mostly through facilitating adaptive changes in the social networks of participants, but also by boosting members’ recovery coping skills, recovery motivation, abstinence self-efficacy, and psychological well-being, and by reducing impulsivity and craving.” (2019) If we recall George Vaillant’s summarization of what he and others found to be the 4 key factors in addiction recovery, they are: External supervision, a regular adherence to a competing behavior, newly found loving relationships, and increased spirituality (Vaillant,
1988; Vaillant, 2005). Vaillant’s findings also show that the social aspect plays an important role in 2 of his 4 key factors.
In comparing Vaillant’s findings and the findings of the Cochrane study to the findings which surfaced in my own modest survey, there are some themes which appear repeatedly throughout all of these studies, namely the importance of caring and supportive social connections, regular adherence, new skills/information (acquired with the help of others) as well as positive feelings of belonging. The statements made by questionnaire respondents who considered themselves recovered from AUD were largely in line with these themes. Some of the descriptions of key factors stated included “People that you can reach out to when you’re struggling,” or “The people I was living with (and also a lovely ex-girlfriend) never judged and Alcohol Use Disorder and Key Factors in Successful Treatment 103 nagged me, but they did communicate worry and also just accepted where I was at,” and
“Replacing that [drinking] with an active social circle is one of the greatest gifts of AA.”
If one considers that having someone to talk to and group support, two of the main themes which arose in my research, are closely enough related so as to be combined under one heading of “social support and connection,” 9 out of 11 respondents (nearly 82%) overall cited this as a key factor to recovery. This would by far make social support and connection the most important factor in recovery as reported by those who have recovered from AUD, as well as by those who work with them.
British journalist Johann Hari is known for his TED Talk titled “Everything You Think
You Know About Addiction is Wrong” (2015), his book, Chasing the Scream (2015), and has also written a provocatively titled article, “The Likely Cause of Addiction Has Been Discovered and it is Not What You Think” (2015) which, despite not being a scholarly article, can be found through Google Scholar. Hari examines addiction and addiction recovery in these publications, and his extensive research has led him to believe that the majority of addiction is rooted in a lack of authentic, positive social connection. As a result, he posits that a crucial element of treatment must be a re-building – or building, of authentic positive social connection. Hari cites a series of studies undertaken by Dr. Bruce Alexander (Alexander et al., 1980) during the 1970s, familiarly referred to as the “Rat Park” studies, which found that rats who had the company of other rats, as well as healthy, stimulating environments were much less likely to ingest freely provided drugs, whereas rats who were isolated in cages devoid of comfort or positive stimulation were vastly more inclined to “self-medicate” by ingesting the available drugs, even to the point of overdose.
Though it may seem a bit of a stretch to compare drug use in unstimulated, isolated rats versus drug use in rats with social connections and positive engagement to human drug use, numerous Alcohol Use Disorder and Key Factors in Successful Treatment 104 studies have shown the importance of social support and activity to addiction recovery in humans, as well (Groh et al., 2007; Hammarlund et al. 2018; Kaskutas et al., 2002; Kelly et al.,
2011; Morgenstern et al., 1997; Owen et al., 2003; Stall & Biernacki, 1986; Stevens et al., 2011;
Vaillant, 1988; Vaillant, 2005).
Though there are also biological factors to consider, it seems that the importance of the role that psychosocial health and connection plays addiction and recovery cannot be overstated, whether in rats or humans. Hari states that the opposite of addiction is not sobriety, but connection, echoing the essence of Roger’s (1957) core conditions for successful therapy.
If we look at what AA offers through this lens, perhaps the fact that it seems to fare so well against other complex and professional therapies is not so surprising.
Chapter 18
Limitations of the Study
Retrospectively, I realized that one of the things that was missing from my study was the ability to follow-up with those who answered the questionnaires, to ask for further clarification in those cases where the individual was not a prolific writer, or who perhaps may have been able to explain themselves more clearly and with more detail during a verbal interview; clear and descriptive communication through written expression does not come easily to many people, and it is likely difficult to obtain the nuance of experience through a short, written questionnaire.
Further, I would have been interested to find out about the severity of each individual’s addiction, how they felt this impacted their recovery, and how the severity of their AUD may have interacted with the factors that they felt were important to recovery. Would there be a difference in answers between moderate and severe AUD, as was the case in the study done by
Roos et al. (2017)? How long did it take the individuals to be confident in their recovery, or how Alcohol Use Disorder and Key Factors in Successful Treatment 105 did they actually define their own recovery, reminiscent of the question that Witkiewitz et al.
(2020) pose in their study, “What is Recovery?”
It is possible that these issues could have been addressed by a more detailed questionnaire meant to elicit more information. However, it is also possible that a longer questionnaire might have been off-putting to some participants, or could have restricted spontaneity and authenticity of expression, thus influencing the results.
Another shortcoming is lack of documentation of my conversation with Honza. It occurred spontaneously and was informative, but apart from a number of related, follow-up text messages, I have no recording of the conversation, clearly a weakness as far as providing concrete evidence and documentation is concerned.
Another limitation was the number of responses that I received. Had there been more information to work with, for example, 100 responses, there would have been more opportunity for the themes which did arise to be further supported, or alternately, for different, competing themes to appear.
A factor that I became aware of while going through the responses, was whether the responses would have been different if they had been gathered over the course of an unstructured interview. I found myself wondering how often people have ready answers which may be in part true, but which, after a longer reflection or analysis, prove to be only a part of the equation.
Perhaps after conversation and reflection, one may realize that there are actually other factors at work which may not be immediately apparent, but which nevertheless have a significant impact on the situation. An example of this could be someone who says that they attend meetings because it is the structure that helps them to keep sober, but perhaps upon further analysis, they may realize that it is actually the feeling of belonging to a social network, one that accepts and Alcohol Use Disorder and Key Factors in Successful Treatment 106 listens without judgment, which provides a larger motivation for staying sober. It would also be easier to address whether a respondent’s reply that “not being judged” is commensurate with
“talking with someone who cares” or “being supported,” which could also influence study results.
This exercise of data collection helped to drive home the point of how difficult it can be to study AUD treatment; how can one reliably measure something which may be ever changing and evolving, which can mean different things at different times, and which the individual themselves may not even be clearly aware of? And yet, there are mechanisms at work which help to support the individual in their journey to sobriety or decreased drinking – they may simply be different things at different times for different people. However, when done in a large enough scale over a long enough time, there are reoccurring patterns which become evident, as the Cochrane Group’s study and others like it have shown.
Chapter 19
Conclusion
The results of this study on AUD have highlighted a number of things, which I would like to summarize in three main points: 1. The etiology of AUD is extremely heterogeneous, and etiological factors may vary in their impact from individual to individual, depending on the individual’s particular situation. 2. Though there are multiple approaches to treating AUD, from individual therapy, to inpatient or outpatient programs, or self-help groups, there is no guarantee about when, or whether, or in what combination of any of these approaches will be successful in bringing the person struggling with AUD into recovery, and to what degree. 3. There is strong evidence that non-judgmental and caring social support, persistence, a conviction about the importance of working towards recovery on the part of the individual with AUD, and possibly, a Alcohol Use Disorder and Key Factors in Successful Treatment 107 sense of deepened spirituality, which some may define as a connection or awareness of something greater than one’s self, appear to be key facets to successful AUD recovery.
For me personally, this study has provided a deeper insight into how AUD can develop, as well as of the treatment methods that are used. As an aspiring psychotherapist, it has made me aware that I also have the potential to make a positive difference to a client struggling with AUD, whether through providing Rogers’ core conditions of empathy, congruence and unconditional positive regard, working through past trauma, teaching my clients alternative and healthier coping methods, or providing information, support and follow-up around attending local AA meetings. I may not be able to provide a panacea for my clients’ AUD, but I can provide them with what will hopefully be effective support towards recovery.
Alcohol Use Disorder and Key Factors in Successful Treatment 108
References
Alcoholics Anonymous World Services, Inc. (2021). Questions and Answers about Sponsorship
[Pamphlet]. (2019). https://www.aa.org/assets/en_US/p-15_Q&AonSpon.pdf
Alcoholics Anonymous World Services, Inc. (2021). Contact International Desk.
https://www.aa.org/pages/en_US/contact-international-desk
Alexander, B. K., Hadaway, P., & Coambs, R. (1980). Rat park chronicle. British Columbia
Medical Journal, 22(2), 32-45.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596
American Psychological Association. (2005, July 14). Men: A Different Depression.
American Psychological Association. https://bit.ly/3eePIJy
Anderson, P., Coulton, S., Kaner, E., Bendtsen, P., Kłoda, K., Reynolds, J., Segura, L.,
Wojnar, M., Mierzecki, A., Deluca, P., Newbury-Birch, D., Parkinson, K.,
Okulicz-Kozaryn, K., Drummond, C., & Gual, A. (2017). Delivery of brief
interventions for heavy drinking in primary care: Outcomes of the ODHIN 5-
country cluster randomized trial. Annals of family medicine, 15(4), 335–340.
https://doi.org/10.1370/afm.2051
Anderson, P., de Bruijn, A., Angus, K., Gordon, R., & Hastings, G. (2009). Impact of alcohol
advertising and media exposure on adolescent alcohol use: a systematic review of Alcohol Use Disorder and Key Factors in Successful Treatment 109
longitudinal studies. Alcohol and alcoholism (Oxford, Oxfordshire), 44(3), 229–243.
https://doi.org/10.1093/alcalc/agn115
Anonymní Alkoholici (2021). Jak to funguje? https://www.anonymnialkoholici.cz/nove-
prichozi/jak-to-funguje/
Anonymní Alkoholici (2021). Historie AA v ČR. https://www.anonymnialkoholici.cz/o-
nas/historie-aa-v-cr/
Anonymní Alkoholici (2021). Skupiny. https://www.anonymnialkoholici.cz/pro-cleny/skupiny/
Babor, T.F., et al. (2010). Alcohol: no ordinary commodity. Research and public policy, 2nd ed.
Oxford, Oxford University Press.
Batman, A. M., & Miles, M. F. (2015). Translating alcohol research: Opportunities and
challenges. Alcohol Research: Current Reviews, 37(1), 7–14.
Bader, P., Boisclair, D., & Ferrence, R. (2011). Effects of tobacco taxation and pricing on
smoking behavior in high risk populations: a knowledge synthesis. International Journal
of Environmental Research and Public Health, 8(11), 4118–4139.
https://doi.org/10.3390/ijerph8114118
Beattie, M. C., & Longabaugh, R. (1999). General and alcohol-specific social support
following treatment. Addictive Behaviors, 24(5), 593–606.
https://doi.org/10.1016/s0306-4603(98)00120-8
Beckett, M., Quiter, E., Ryan, G., Berrebi, C., Taylor, S., Cho, M., Pincus, H., & Kahn, K.
(2011). Bridging the gap between basic science and clinical practice: the role of Alcohol Use Disorder and Key Factors in Successful Treatment 110
organizations in addressing clinician barriers. Implementation Science: IS, 6, 35.
https://doi.org/10.1186/1748-5908-6-35
Bellis, M. A., Lowey, H., Leckenby, N., Hughes, K., & Harrison, D. (2013). Adverse
childhood experiences: retrospective study to determine their impact on adult health
behaviours and health outcomes in a UK population. Journal of Public Health, 36(1), 81–
91. https://doi:10.1093/pubmed/fdt038
Berkel, T. D., & Pandey, S. C. (2017). Emerging role of epigenetic mechanisms in alcohol
addiction. Alcoholism, Clinical and Experimental research, 41(4), 666–680.
https://doi.org/10.1111/acer.13338
Bilevicius, E., Single, A., Bristow, L. A., Foot, M., Ellery, M., Keough, M. T., & Johnson, E. A.
(2018). Shame mediates the relationship between depression and addictive behaviours.
Addictive Behaviors, 82, 94–100. https://doi:10.1016/j.addbeh.2018.02.023
Blocker J. S., Jr. (2006). Did prohibition really work? Alcohol prohibition as a public health
innovation. American Journal of Public Health, 96(2), 233–243.
https://doi.org/10.2105/AJPH.2005.065409
Boden, J. M., & Fergusson, D. M. (2011). Alcohol and depression. Addiction, 106(5), 906–914.
https://doi:10.1111/j.1360-0443.2010.03351.x
Borsboom, D., Cramer, A., & Kalis, A. (2018). Brain disorders? Not really… Why
network structures block reductionism in psychopathology research. The Behavioral
and Brain Sciences, 1–54. Advance online publication.
https://doi.org/10.1017/S0140525X17002266 Alcohol Use Disorder and Key Factors in Successful Treatment 111
Boschloo, L., Vogelzangs, N., Van den Brink, W., Smit, J., Veltman, D., Beekman, A., &
Penninx, B. (2012). Alcohol use disorders and the course of depressive and anxiety
disorders. British Journal of Psychiatry, 200(6), 476-484.
https://doi:10.1192/bjp.bp.111.097550
Boyce, W. T., Sokolowski, M. B., & Robinson, G. E. (2020). Genes and environments,
development and time. Proceedings of the National Academy of Sciences of the United
States of America, 117(38), 23235–23241. https://doi.org/10.1073/pnas.2016710117
Briggs, E. C., Amaya-Jackson, L., Putnam, K. T., & Putnam, F. W. (2021). All adverse
childhood experiences are not equal: The contribution of synergy to adverse
childhood experience scores. American Psychologist, 76(2), 243–
252. https://doi.org/10.1037/amp0000768
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design. Cambridge, Mass: Harvard University Press.
Brown B. (2012). Daring greatly: how the courage to be vulnerable transforms the way we
live, love, parent, and lead. Penguin.
Burešová, Z., Mravcík, V., Popov, P., & Miovský, M. (2013). Institutional analysis of
sobering-up stations in the Czech Republic. Česká a Slovenská Psychiatrie. 109.
115-121. https://bit.ly/3nKSKZq
Carruth, B., & Burke, P.A., (2006). Psychological trauma and addiction treatment,
Journal of Chemical Dependency Treatment, 8:2, 1-14.
https://doi:10.1300/J034v08n02_01 Alcohol Use Disorder and Key Factors in Successful Treatment 112
Center for Substance Abuse Treatment (2009). Incorporating alcohol pharmacotherapies into
medical practice. Treatment Improvement Protocol (TIP) Series, No. 49. Chapter 2—
Acamprosate. Substance Abuse and Mental Health Services Administration, Rockville,
MD. https://www.ncbi.nlm.nih.gov/books/NBK64035/
Chandler, G. E., Kalmakis, K. A., & Murtha, T. (2018). Screening adults with substance use
disorder for adverse childhood experiences. Journal of Addictions Nursing, 29(3), 172–
178. https://doi.org/10.1097/JAN.0000000000000233
Christensen, A. S. P., Meyer, M. K. H., Dalum, P., & Krarup, A. F. (2019). Can a mass media
campaign raise awareness of alcohol as a risk factor for cancer and public support for
alcohol related policies?. Preventive Medicine, 126,
105722. https://doi:10.1016/j.ypmed.2019.05.010
Coates, J. M., Gullo, M. J., Feeney, G., Young, R. M., Dingle, G. A., & Connor, J. P. (2018).
Alcohol expectancies pre-and post-alcohol use disorder treatment: Clinical
implications. Addictive Behaviors, 80, 142–149.
https://doi.org/10.1016/j.addbeh.2018.01.029
Corbin, J. M., & Strauss, A. (1990). Grounded theory research: Procedures, canons, and
evaluative criteria. Qualitative Sociology, 13(1), 3–21. doi:10.1007/bf00988593
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F.
(2004). Adverse childhood experiences and the risk of depressive disorders in
adulthood. Journal of Affective Disorders, 82(2), 217–225.
https://doi.org/10.1016/j.jad.2003.12.013 Alcohol Use Disorder and Key Factors in Successful Treatment 113
Conner, K. R., Pinquart, M., & Gamble, S. A. (2009). Meta-analysis of depression and
substance use among individuals with alcohol use disorders. Journal of Substance
Abuse Treatment, 37(2), 127–137. https://doi:10.1016/j.jsat.2008.11.007
Coomber, K., Mayshak, R., Curtis, A., & Miller, P. G. (2017). Awareness and correlates of
short-term and long-term consequences of alcohol use among Australian drinkers.
Australian and New Zealand Journal of Public Health, 41(3), 237–
242. https://doi:10.1111/1753-6405.12634
Coriale, G., De Rosa, F., Battagliese, G., Gencarelli, S., Fiore, M., Ferraguti, G., Vitali, M.,
Rotondo, C., Messina, M., & Attilia, M. (2019). Motivational enhancement therapy
versus cognitive behavioral therapy in a cohort of men and women with alcohol use
disorder. Biomedical Reviews, 30, 125-135. http://dx.doi.org/10.14748/bmr.v30.6393
Crews, F. T., Lawrimore, C. J., Walter, T. J., & Coleman, L. G. (2017). The role of
neuroimmune signaling in alcoholism. Neuropharmacology, 122, 56–
73. https://doi:10.1016/j.neuropharm.2017.01.031
Csemy, L., & Sovinová, H. (2015). Alkohol v primární zdravotní péči: zkušenosti, názory
a postoje českých praktických lékařů [Alcohol in primary health care: experiences,
opinions and views of Czech primary care physicians]. Praktický Lékař. 95(2):
77-82. https://bit.ly/3xKAnZ3
Dawson, D. A. (2011). Defining risk drinking. Alcohol Research: Current Reviews, 34(2),
144–156. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860565/ Alcohol Use Disorder and Key Factors in Successful Treatment 114
Dawson, D.A., Goldstein, R.B. & Grant, B.F. (2013), Differences in the profiles of DSM‐
IV and DSM‐5 alcohol use disorders: implications for clinicians. Alcohol Clin Exp Res,
37: E305-E313. https://doi.org/10.1111/j.1530-0277.2012.01930.x
Dawson, D. A., Grant, B. F., Stinson, F. S., & Chou, P. S. (2006). Maturing out of alcohol
dependence: The impact of transitional life events. Journal of Studies on Alcohol, 67(2),
195–203. https://doi.org/10.15288/jsa.2006.67.195
Deak, J. D., Miller, A. P., & Gizer, I. R. (2019). Genetics of alcohol use disorder: a
review. Current Opinion in Psychology, 27, 56–61.
https://doi.org/10.1016/j.copsyc.2018.07.012
Dieng, M., Watts, C.G., Kasparian, N.A., Morton, R.L., Mann, G.J., & Cust, A.E. (2014).
Improving subjective perception of personal cancer risk: Systematic review and meta‐
analysis of educational interventions for people with cancer or at high risk of cancer.
Psycho‐Oncology, 23: 613-625. https://doi.org/10.1002/pon.3476
Dobiášová, K., & Hnilicová, H. (2020, December 7). Alkohol v české společnosti. Časopis
Vesmir, 99 (701). https://vesmir.cz/cz/casopis/archiv-casopisu/2020/cislo-12/alkohol-
ceske-spolecnosti.html
Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003).
Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the
adverse childhood experiences study. Pediatrics, 111(3), 564–572.
https://doi.org/10.1542/peds.111.3.564
Alcohol Use Disorder and Key Factors in Successful Treatment 115
Dumalaon-Canaria, J. A., Hutchinson, A. D., Prichard, I., & Wilson, C. (2014). What causes
breast cancer? A systematic review of causal attributions among breast cancer survivors
and how these compare to expert-endorsed risk factors. Cancer Causes & Control :
CCC, 25(7), 771–785. https://doi.org/10.1007/s10552-014-0377-3
Dunne, C. (2011). The place of the literature review in grounded theory research. International
Journal of Social Research Methodology, 14(2), 111–124.
doi:10.1080/13645579.2010.494930
Duke University. (2012, August 8). Big question: Can your environment change your DNA?.
Duke Magazine, Jul-Aug. 2012. https://bit.ly/3xGbca4
Dvořáček, J. (2019, March 03). Léčba: Červený dvůr. https://cervenydvur.cz/?page_id=5
Emerson, J.A. (2019). Screening for Adverse Childhood Experiences in Primary Care:
Recommendations for Practice. North Dakota State University, North Dakota.
https://bit.ly/3vH0ZbB
Engel G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science
(New York, N.Y.), 196(4286), 129–136. https://doi.org/10.1126/science.847460
Felitti V. J. (2002). The relation between adverse childhood experiences and adult
health: Turning gold into lead. The Permanente Journal, 6(1), 44–47.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220625/
Alcohol Use Disorder and Key Factors in Successful Treatment 116
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss,
M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household
dysfunction to many of the leading causes of death in adults: The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–
258. https://doi.org/10.1016/S0749-3797(98)00017-8
Field, M., Heather, N., & Wiers, R. W. (2019). Indeed, not really a brain disorder:
Implications for reductionist accounts of addiction. The Behavioral and Brain
Sciences, 42, e9. https://doi.org/10.1017/S0140525X18001024
Fink, D. S., Gallaway, M. S., Tamburrino, M. B., Liberzon, I., Chan, P., Cohen, G. H.,
Sampson, L., Shirley, E., Goto, T., D'Arcangelo, N., Fine, T., Reed, P. L., Calabrese, J.
R., & Galea, S. (2016). Onset of alcohol use disorders and comorbid psychiatric disorders in a
military cohort: Are there critical periods for prevention of alcohol use
disorders?. Prevention Science: The Official Journal of the Society for Prevention
Research, 17(3), 347–356. https://doi.org/10.1007/s11121-015-0624-1
Flanagan O. (2013). The shame of addiction. Frontiers in Psychiatry, 4, 120.
https://doi.org/10.3389/fpsyt.2013.00120
Forcehimes, A., Feldstein S. & Miller, W. (2008). Glatt's curve revisited: A pilot study
investigating the progression of recovery in Alcoholics Anonymous. Alcoholism
Treatment Quarterly. 26. 241-258. https://doi:10.1080/07347320802071596
Foustka, B., Hroch J., and Konarik, B. (1935) Výroční zpráva za rok1935 [1935 Annual
Report]. Praha: National Museum Archives
Alcohol Use Disorder and Key Factors in Successful Treatment 117
Frakt, A. & Carroll, A. E. (2020, March 11). Alcoholics Anonymous vs. Other Approaches: The
Evidence Is Now In. The New York Times.
https://www.nytimes.com/2020/03/11/upshot/alcoholics-anonymous-new-
evidence.html
Frank, L. E., & Nagel, S. K. (2017). Addiction and moralization: the role of the underlying
model of addiction. Neuroethics, 10(1), 129–139. https://doi.org/10.1007/s12152-017-
9307-x
Gabrhelík, R., & Miovský, M. (2009). History of self-help and “quasi-self-help” groups in the
Czech Republic: Development and current situation in the institutional context of drug
services. Journal of Groups in Addiction & Recovery, 4(3), 137-158
https://doi:10.1080/15560350903038718
Gage, S. H., & Sumnall, H. R. (2018). Rat Park: How a rat paradise changed the narrative of
addiction. Addiction. doi:10.1111/add.14481
Galbiscek, C. (2021, April 07). Outpatient rehab for alcoholism.
https://www.alcoholrehabguide.org/treatment/outpatient-rehab/
Ghaferi, H. A., Bond, C., & Matheson, C. (2017). Does the biopsychosocial-spiritual model of
addiction apply in an Islamic context? A qualitative study of Jordanian addicts in
treatment. Drug and Alcohol Dependence, 172, 14–20.
https://doi.org/10.1016/j.drugalcdep.2016.11.019
Glass, J. E., Mowbray, O. P., Link, B. G., Kristjansson, S. D., & Bucholz, K. K. (2013).
Alcohol stigma and persistence of alcohol and other psychiatric disorders: a
modified labeling theory approach. Drug and Alcohol Dependence, 133(2), 685– 692.
https://doi.org/10.1016/j.drugalcdep.2013.08.016 Alcohol Use Disorder and Key Factors in Successful Treatment 118
Goldberg, A.E. (2020). The (in)Significance of the Addiction Debate. Neuroethics 13, 311–324.
https://doi.org/10.1007/s12152-019-09424-5
Groh, D. R., Jason, L. A., Davis, M. I., Olson, B. D., & Ferrari, J. R. (2007). Friends, family, and
alcohol abuse: an examination of general and alcohol-specific social support.
The American Journal on Addictions, 16(1), 49–55.
https://doi.org/10.1080/10550490601080084
Gross M. (2010). Alcoholics Anonymous: still sober after 75 years. 1935. American Journal of
Public Health, 100(12), 2361–2363. https://doi.org/10.2105/AJPH.2010.199349
Hall W. (2010). What are the policy lessons of National Alcohol Prohibition in the United States,
1920-1933?. Addiction (Abingdon, England), 105(7), 1164–1173.
https://doi.org/10.1111/j.1360-0443.2010.02926.x
Hall, W., Carter, A., & Forlini, C. (2015). The brain disease model of addiction: is it
supported by the evidence and has it delivered on its promises?. The Lancet.
Psychiatry, 2(1), 105–110. https://doi.org/10.1016/S2215-0366(14)00126-6
Hallgren, K. A., Witwer, E., West, I., Baldwin, L. M., Donovan, D., Stuvek, B., Keppel, G. A.,
Mollis, B., & Stephens, K. A. (2020). Prevalence of documented alcohol and opioid use
disorder diagnoses and treatments in a regional primary care practice-based research
network. Journal of Substance Abuse Treatment, 110, 18–27.
https://doi.org/10.1016/j.jsat.2019.11.008
Hammarlund, R., Crapanzano, K. A., Luce, L., Mulligan, L., & Ward, K. M. (2018).
Review of the effects of self-stigma and perceived social stigma on the treatment- Alcohol Use Disorder and Key Factors in Successful Treatment 119
seeking decisions of individuals with drug- and alcohol-use disorders. Substance Abuse
and Rehabilitation, 9, 115–136. https://doi.org/10.2147/SAR.S183256
Hari, J. (2015). The Likely Cause of Addiction Has Been Discovered, and It Is Not What You
Think. The Huffington Post. https://bit.ly/3baCT0W
Hari, J. (2015). Chasing the scream: The first and last days of the war on drugs. Bloomsbury
Publishing USA.
Hari, J. (June 2015). Everything you think you know about addiction is wrong [video]. TED
Conferences. https://bit.ly/3eYJIUM
Hazelden Betty Ford (2016) Stages of Alcoholism. Signs, Symptoms, Treatment.
https://www.hazeldenbettyford.org/articles/stages-of-alcoholism
Heather, N., Best, D., Kawalek, A., Field, M., Lewis, M., Rotgers, F., Wiers, R., & Heim, D.
(2017). Challenging the brain disease model of addiction: European launch of the addiction
theory network. Addiction Research & Theory, 26(4), 249–
255. https://doi:10.1080/16066359.2017.1399659
Heather N., Raistrick D., & Godfrey C. (2006). A summary of the review of the effectiveness
of treatment for alcohol problems. The National Treatment Agency for Substance Misuse.
2006. https://www.drugsandalcohol.ie/6178/1/3275-3458.pdf
Heyman, G.M., & Mims, V. (2017). What addicts can teach us about addiction: a natural history
approach. Addiction and Choice: Rethinking the Relationship. Oxford (UK): Oxford
University Press; p. 385–408. https://doi:10.1093/acprof:oso/9780198727224.003.0021 Alcohol Use Disorder and Key Factors in Successful Treatment 120
Holzhauer, C. G., Epstein, E. E., Cohn, A. M., McCrady, B. S., Graff, F. S., & Cook, S.
(2017). Heterogeneity in pathways to abstinence among women in treatment for alcohol
use disorder. Journal of Substance Abuse Treatment, 75, 1– 9
https://doi:10.1016/j.jsat.2017.01.002
Huebner, R. B., & Kantor, L. W. (2011). Advances in alcoholism treatment. Alcohol
Research & Health : The Journal of the National Institute on Alcohol Abuse and
Alcoholism, 33(4), 295–299. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860532/
Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., Jones, L., &
Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A
systematic review and meta-analysis. The Lancet. Public health, 2(8), e356–e366.
https://doi.org/10.1016/S2468-2667(17)30118-4
Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., Horvath, A.
T., Kaskutas, L. A., Kirk, T., Kivlahan, D., Laudet, A., McCrady, B. S., McLellan, A. T.,
Morgenstern, J., Townsend, M., & Weiss, R. (2004). Self-help organizations for alcohol and
drug problems: Toward evidence-based practice and policy. Journal of Substance Abuse
Treatment, 26(3), 151–158. https://doi.org/10.1016/S0740-5472(03)00212-5
Jellinek, E. M. (1952). Phases of alcohol addiction. Quarterly Journal of Studies on
Alcohol, 13(4), 673–684. https://doi.org/10.15288/qjsa.1952.13.673
Jellinek, E. M. (1960). The disease concept of alcoholism. Hillhouse.
Juergens, J. (2021, March 25). Genetics of Alcoholism: Hereditary Factors of Alcohol Use.
Addiction Center. https://www.addictioncenter.com/alcohol/genetics-of-alcoholism/ Alcohol Use Disorder and Key Factors in Successful Treatment 121
Kalina, K., & Vácha, P. (2013). Dual Diagnoses in Therapeutic Communities for Addicts –
Possibilities and Limits of Integrated Treatment. [Duální diagnózy v terapeutických
komunitách pro závislé – možnosti a meze integrované léčby]. Adiktologie, 13(2),
144–164. https://bit.ly/3eoyhXp
Kalmakis, K. A., Shafer, M. B., Chandler, G. E., Aponte, E. V., & Roberts, S. J. (2018).
Screening for childhood adversity among adult primary care patients. Journal of the
American Association of Nurse Practitioners, 30(4), 193–200.
https://doi.org/10.1097/JXX.0000000000000033
Kaskutas, L. A., Bond, J., & Humphreys, K. (2002). Social networks as mediators of the effect of
Alcoholics Anonymous. Addiction (Abingdon, England), 97(7), 891–900.
https://doi.org/10.1046/j.1360-0443.2002.00118.x
Kelly J. F. (2019). E. M. Jellinek's Disease Concept of Alcoholism. Addiction (Abingdon,
England), 114(3), 555–559. https://doi.org/10.1111/add.14400
Kelly, J. F., Humphreys, K., & Ferri, M. (2020). Alcoholics Anonymous and other 12-step
programs for alcohol use disorder. The Cochrane Database of Systematic Reviews, 3(3),
CD012880. https://doi.org/10.1002/14651858.CD012880.pub2
Kelly, J. F., Stout, R. L., Magill, M., & Tonigan, J. S. (2011). The role of Alcoholics
Anonymous in mobilizing adaptive social network changes: a prospective lagged
mediational analysis. Drug and Alcohol Dependence, 114(2-3), 119–126.
https://doi.org/10.1016/j.drugalcdep.2010.09.009 Alcohol Use Disorder and Key Factors in Successful Treatment 122
Kennedy, W. K., Leloux, M., Kutscher, E. C., Price, P. L., Morstad, A. E., & Carnahan, R. M.
(2010). Acamprosate. Expert Opinion on Drug Metabolism & Toxicology, 6(3), 363–380.
https://doi.org/10.1517/17425251003641975
Kiefer, F., & Wiedemann, K. (2004). Combined therapy: What does acamprosate and
naltrexone combination tell us?. Alcohol and Alcoholism (Oxford, Oxfordshire), 39(6),
542–547. https://doi.org/10.1093/alcalc/agh093
Kilanowski J. F., PhD Rn Aprn Cpnp Faan. (2017). Breadth of the Socio-Ecological
Model. Journal of Agromedicine, 22(4), 295–297.
https://doi.org/10.1080/1059924X.2017.1358971
Klinika adiktologie (2019). Léčba závislosti: Jak probíhá léčení [Treating addictions: the course
of treatment]. https://www.alkoholpodkontrolou.cz/jak-zvladnout-problem-s-pitim/lecba-
zavislosti/
Knopf, A. (2018). Koob: ACE‐ AUD link, and challenges of medication
development. Alcoholism & Drug Abuse Weekly, 30(43), 3–5.
https://onlinelibrary.wiley.com/doi/full/10.1002/adaw.32167
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental
health care. Bulletin of the World Health Organization, 82(11), 858–866.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2623050/
Konařík, B. (1934). Léčení alkoholismu v cizině a u nás [Treatment of Alcoholism Abroad and
Home]. Praha. Československý abstinentní svaz. Alcohol Use Disorder and Key Factors in Successful Treatment 123
Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology:
official publication of the American College of Neuropsychopharmacology, 35(1), 217–
238. https://doi.org/10.1038/npp.2009.110
Kuria, M. W., Ndetei, D. M., Obot, I. S., Khasakhala, L. I., Bagaka, B. M., Mbugua, M. N., &
Kamau, J. (2012). The association between alcohol dependence and depression before
and after treatment for alcohol dependence. ISRN Psychiatry, 2012, 482802.
https://doi.org/10.5402/2012/482802
Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use
disorder. JAMA, 320(8), 815. https://doi:10.1001/jama.2018.11406
Krentzman, A. R. (2008). The evidence base for the effectiveness of Alcoholics Anonymous:
Implications for social work practice. Journal of Social Work Practice in the
Addictions, 7(4), 27-48. https://doi.org/10.1300/J160v07n04_03
Lewis, M. (2018). Brain change in addiction as learning, not disease. New England
Journal of Medicine, 379(16), 1551–1560. https://doi:10.1056/nejmra1602872
Litten, R. Z., Ryan, M. L., Falk, D. E., Reilly, M., Fertig, J. B., & Koob, G. F. (2015).
Heterogeneity of alcohol use disorder: Understanding mechanisms to advance
personalized treatment. Alcoholism: Clinical and Experimental Research, 39(4), 579–
584. https://doi.org/10.1111/acer.12669
Maisto, S. A., Roos, C. R., Hallgren, K. A., Moskal, D., Wilson, A. D., & Witkiewitz, K.
(2016). Do alcohol relapse episodes during treatment predict long-term outcomes?
Investigating the validity of existing definitions of alcohol use disorder relapse.
Alcoholism: Clinical and Experimental Research, 40(10), 2180–
2189. https://doi:10.1111/acer.13173 Alcohol Use Disorder and Key Factors in Successful Treatment 124
Malisauskaite, G., & Klein, A. (2018). Drinking under communism: Why do alcohol
consumption habits in Eastern Europe differ from the west in the long run?
Journal of Comparative Economics, 46(3), 821- 837.
https://doi:10.1016/j.jce.2018.07.010
Manthey, J., Gual, A., Jakubczyk, A., Pieper, L., Probst, C., Struzzo, P., Trapencieris, M.,
Wojnar, M., & Rehm, J. (2016). Alcohol use disorders in Europe: A comparison of
general population and primary health care prevalence rates. Journal of Substance Use,
21(5), 478–484. http://dx.doi.org/10.3109/14659891.2015.1063719
Martin, L. A., Neighbors, H. W., & Griffith, D. M. (2013). The experience of symptoms of
depression in men vs. women: analysis of the National Comorbidity Survey
Replication. JAMA Psychiatry, 70(10), 1100–1106.
https://doi.org/10.1001/jamapsychiatry.2013.1985
Masaryk, T. G., (1920). O etice a alkoholismu [On Ethics and Alcoholism], 2nd Edition. Brno:
Studentska Klinika v Brne.
Maté, G. (2008). In the realm of hungry ghosts: Close encounters with addiction. Toronto:
Knopf Canada.
Mate, G. (2017, May 08). Opioids and universal experience of addiction.
https://drgabormate.com/opioids-universal-experience-addiction/
McKinney, A., & Coyle, K. (2005). Alcohol hangover effects on measures of affect the
morning after a normal night’s drinking. Alcohol and Alcoholism, 41(1), 54–60.
https://doi:10.1093/alcalc/agh226 Alcohol Use Disorder and Key Factors in Successful Treatment 125
McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for
substance use disorders. The Psychiatric Clinics of North America, 33(3), 511–525.
https://doi.org/10.1016/j.psc.2010.04.012
McLellan A. T. (2017). Substance misuse and substance use disorders: Why do they matter in
healthcare?. Transactions of the American Clinical and Climatological
Association, 128, 112–130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525418/
McLellan, A. T., Starrels, J. L., Tai, B., Gordon, A. J., Brown, R., Ghitza, U., Gourevitch,
M., Stein, J., Oros, M., Horton, T., Lindblad, R., & McNeely, J. (2014). Can
substance use disorders be managed using the chronic care model? Review and
recommendations from a NIDA consensus group. Public Health Reviews, 35(2).
https://doi.org/10.1007/BF03391707
Meaney, M.J. (2010), Epigenetics and the biological definition of gene× environment
interactions. Child Development, 81: 41-79.
https://doi.org/10.1111/j.1467-8624.2009.01381.x
Meneses-Gaya, C., Crippa, J. A., Zuardi, A. W., Loureiro, S. R., Hallak, J. E., Trzesniak, C.,
Machado de Sousa, J. P., Chagas, M. H., Souza, R. M., & Martín-Santos, R. (2010). The
fast alcohol screening test (FAST) is as good as the AUDIT to screen alcohol use
disorders. Substance Use & Misuse, 45(10), 1542–1557.
https://doi.org/10.3109/10826081003682206
Miller, P. M. (2009). Evidence-based addiction treatment. Elsevier/Academic Press.
Miller, W. R., Walters, S. T., & Bennett, M. E. (2001). How effective is alcoholism
treatment in the United States? Journal of Studies on Alcohol, 62(2), 211–
220. https://doi:10.15288/jsa.2001.62.211 Alcohol Use Disorder and Key Factors in Successful Treatment 126
Miovsky, M., Miller, P., Grund, J.-P. C., Belackova, V., Gabrhelik, R., & Libra, J. (2015).
Academic education in addictology (addiction science) in the Czech Republic: Analysis
of the (pre-1989) historical origins. Nordic Studies on Alcohol and Drugs, 32(5),
527–538. https://doi.org/10.1515/nsad-2015-0050
Miovský, M., Táborský, M., Popov, P., Linhart, A., & Zima, T. (2019). Alcohol use in the
Czech Republic – Joint statement of the Society for Addiction Medicine of the J. E.
Purkyně Czech Medical Association and the Czech Society of Cardiology. Central
European Journal of Public Health, 27(Suppl), S3–S5.
https://doi.org/10.21101/cejph.a5972
Mitchell, A., Meader, N., Bird, V., & Rizzo, M. (2012). Clinical recognition and recording of
alcohol disorders by clinicians in primary and secondary care: Meta-analysis. British
Journal of Psychiatry, 201(2), 93-100. https://doi:10.1192/bjp.bp.110.091199
Mlcoch, T., Chadimova, K., & Dolezal, T. (2019). Společenské náklady konzumace alkoholu v
České republice. iHETA. http://www.iheta.org/en
Mongan, D., Millar, S. R., O'Dwyer, C., Long, J., & Galvin, B. (2020). Drinking in denial: a
cross-sectional analysis of national survey data in Ireland to measure drinkers' awareness
of their alcohol use. BMJ open, 10(7), e034520.
https://doi.org/10.1136/bmjopen-2019-034520
Morgenstern, J., Labouvie, E., McCrady, B. S., Kahler, C. W., & Frey, R. M. (1997).
Affiliation with Alcoholics Anonymous after treatment: a study of its therapeutic effects
and mechanisms of action. Journal of Consulting and Clinical Psychology, 65(5),
768–777. https://doi.org/10.1037//0022-006x.65.5.768 Alcohol Use Disorder and Key Factors in Successful Treatment 127
Morris K. V. (2009). RNA-directed transcriptional gene silencing and activation in human
cells. Oligonucleotides, 19(4), 299–306. https://doi.org/10.1089/oli.2009.0212
Mravčík, V., Chomynová, P., Nechanská, B., Černíková, T., & Csémy, L. (2019). Alcohol use
and its consequences in the Czech Republic. Central European Journal of Public
Health, 27(Supplement), S15-28. https://doi: 10.21101/cejph.a5728
National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2006. National epidemiologic
survey on alcohol and related conditions. Alcohol: Research & Health 29:2.
https://pubs.niaaa.nih.gov/publications/aa70/aa70.htm
National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2020. Understanding
Alcohol Use Disorder. https://www.niaaa.nih.gov/publications/brochures-and-fact-
sheets/understanding-alcohol-use-disorder
National Institute of Mental Health (2017). Men and depression.
https://www.nimh.nih.gov/health/publications/men-and-depression/index.shtml
Nerad, J., & Neradová, L. (1991). Alcohol and drug problems in Czechoslovakia. Journal
of Substance Abuse Treatment, 8(1-2), 83–88.
https://doi.org/10.1016/0740-5472(91)90031-5
Obeid, S., Akel, M., Haddad, C., Fares, K., Sacre, H., Salameh, P., & Hallit, S. (2020). Factors
associated with alcohol use disorder: the role of depression, anxiety, stress, alexithymia
and work fatigue- a population study in Lebanon. BMC Public Health, 20(1), 245.
https://doi.org/10.1186/s12889-020-8345-1
O’Brien C.P. (2008). The CAGE questionnaire for detection of alcoholism. JAMA.
300(17):2054–2056. https://doi:10.1001/jama.2008.570 Alcohol Use Disorder and Key Factors in Successful Treatment 128
Owen, P. L., Slaymaker, V., Tonigan, J. S., McCrady, B. S., Epstein, E. E., Kaskutas, L. A.,
Humphreys, K., & Miller, W. R. (2003). Participation in Alcoholics Anonymous:
Intended and unintended change mechanisms. Alcoholism, Clinical and Experimental
Research, 27(3), 524–532. https://doi.org/10.1097/01.ALC.0000057941.57330.39
Paquette, D., Ryan, J. (2001). Bronfenbrenner’s Ecological Systems Theory, pp. 2-12.
Park, S. Y., Oh, M. K., Lee, B. S., Kim, H. G., Lee, W. J., Lee, J. H., Lim, J. T., & Kim, J. Y.
(2015). The effects of alcohol on quality of sleep. Korean Journal of Family
Medicine, 36(6), 294–299. https://doi.org/10.4082/kjfm.2015.36.6.294
Perry, B. D., & Pollard, R. (1998). Homeostasis, stress, trauma, and adaptation. A
neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics
of North America, 7(1), 33–viii.
Pickard, H. (2020). What we're not talking about when we talk about addiction. Hastings Center
Report 50, no. 4: 37– 46. https://doi.org/10.1002/hast.1172
Pickard, H., Ahmed, S. H., & Foddy, B. (2015). Alternative models of addiction. Frontiers
in Psychiatry, 6, 20. https://doi.org/10.3389/fpsyt.2015.00020
Pilowsky, D. J., Keyes, K. M., & Hasin, D. S. (2009). Adverse childhood events and
lifetime alcohol dependence. American Journal of Public Health, 99(2), 258–263.
https://doi.org/10.2105/AJPH.2008.139006
Polák, M. (2019, December 28). Jaroslav Skála.
https://encyklopedie.praha2.cz/osobnost/1339-jaroslav-skala Alcohol Use Disorder and Key Factors in Successful Treatment 129
Pucci, M., Micioni Di Bonaventura, M. V., Wille-Bille, A., Fernández, M. S., Maccarrone, M.,
Pautassi, R. M., Cifani, C., & D'Addario, C. (2019). Environmental stressors and
alcoholism development: Focus on molecular targets and their epigenetic
regulation. Neuroscience and Biobehavioral Reviews, 106, 165–181.
https://doi.org/10.1016/j.neubiorev.2018.07.004
Randolph, W., & Viswanath, K. (2004). Lessons learned from public health mass media
campaigns: Marketing health in a crowded media world. Annual Review of Public
Health, 25, 419–437. https://doi.org/10.1146/annurev.publhealth.25.101802.123046
Ray, L. A., Grodin, E. N., Leggio, L., Bechtholt, A. J., Becker, H., Feldstein Ewing, S. W.,
Jentsch, J. D., King, A. C., Mason, B. J., O'Malley, S., MacKillop, J., Heilig, M., &
Koob, G. F. (2021). The future of translational research on alcohol use
disorder. Addiction Biology, 26(2), e12903. https://doi.org/10.1111/adb.12903
Real, T. (1997). I don't want to talk about it: overcoming the secret legacy of male depression.
Scribner.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F.
K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results
from the Epidemiologic Catchment Area (ECA) Study. JAMA, 264(19), 2511–2518.
Reinarman, C., & Granfield, R. (2015). Addiction is not just a brain disease: Critical studies of
addiction. Expanding Addiction: Critical Essays. 1-21.
Richmond C. (2002). Max Meier Glatt. BMJ : British Medical Journal, 324(7350), 1399. Alcohol Use Disorder and Key Factors in Successful Treatment 130
Riley, C. (2020, June 06). Preventing and treating childhood trauma.
https://www.kvc.org/expertise/preventing-childhood-trauma/
Rogers C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103.
Roos, C. R., Maisto, S. A., & Witkiewitz, K. (2017). Coping mediates the effects of
cognitive-behavioral therapy for alcohol use disorder among out-patient clients in Project
MATCH when dependence severity is high. Addiction, 112(9), 1547–
1557. https://doi:10.1111/add.13841
Ropeik, D. (2012). The perception gap: Recognizing and managing the risks that arise when
we get risk wrong. Food and Chemical Toxicology, 50(5), 1222–
1225. https://doi:10.1016/j.fct.2012.02.015
Ross, L. E., Vigod, S., Wishart, J., Waese, M., Spence, J. D., Oliver, J., Chambers, J.,
Anderson, S., & Shields, R. (2015). Barriers and facilitators to primary care for people
with mental health and/or substance use issues: a qualitative study. BMC Family
Practice, 16, 135. https://doi.org/10.1186/s12875-015-0353-3
Rutter, M. (2012). Biology of environmental effects. Proceedings of the National Academy of
Sciences (Supplement 2) 17149-17153; https://doi.org/10.1073/pnas.1121258109
Sanchez-Roige, S., Palmer, A. A., & Clarke, T.-K. (2019). Recent efforts to dissect the genetic
basis of alcohol use and abuse. Biological Psychiatry.
https://doi:10.1016/j.biopsych.2019.09.011
Saitz, R., & Daaleman, T. P. (2017). Now is the time to address substance use disorders in
primary care. Annals of Family Medicine, 15(4), 306–308.
https://doi.org/10.1370/afm.2111 Alcohol Use Disorder and Key Factors in Successful Treatment 131
Saunders, W. M., & Kershaw, P. W. (1979). Spontaneous remission from alcoholism -A
community study. Addiction, 74(3), 251–265.
https://doi:10.1111/j.1360-0443.1979.tb01346.x
Šejvl, J., Gavurová, B., Barták, M., Mašlániová, M., & Miovský, M. (2019). First alcohol
treatment institutions in today's Czech Republic and Slovak Republic. Central European
Journal of Public Health, 27 Suppl, S55–S65. https://doi.org/10.21101/cejph.a5812
Šejvl, J., Miovský, M. (2017) Nejstarši specializované lůžkové zařízení pro léčbu závislosti na
alkoholu na historickém území Čech a Moravy” případová studie protialkoholní léčebny
ve Velkých Kunčicích (1911-1915). Adiktolog 17(2), 134-146. https://bit.ly/3eTvuEt
Šejvl, J. & Miovský, M. (2018). The First Inpatient Alcohol Treatment Facility in the Czech
Republic: Case study of the Tuchlov institution (1923-1938). Adiktologie, 18(2), 97–104.
https://bit.ly/3h3SSSf
Skewes, M., & Gonzalez, V. (2013). The Biopsychosocial Model of Addiction.
10.1016/B978-0-12-398336-7.00006-1. https://bit.ly/2POYvsn
Smith, R. C. (2002). The biopsychosocial revolution: Interviewing and provider-patient
relationships becoming key issues for primary care. Journal of General Internal
Medicine, 17(4), 309–310. https://doi.org/10.1046/j.1525-1497.2002.20210.x
Smith, R. C., Fortin, A. H., Dwamena, F., & Frankel, R. M. (2013). An evidence-based
patient-centered method makes the biopsychosocial model scientific. Patient
Education and Counseling, 91(3), 265–270. https://doi.org/10.1016/j.pec.2012.12.010
Soyka, M., & Müller, C. A. (2017). Pharmacotherapy of alcoholism – An update on
approved and off-label medications. Expert Opinion on Pharmacotherapy, (12),
1187–1199. https://doi:10.1080/14656566.2017.1349098 Alcohol Use Disorder and Key Factors in Successful Treatment 132
Stall, R., & Biernacki, P. (1986). Spontaneous remission from the problematic use of
substances: an inductive model derived from a comparative analysis of the
alcohol, opiate, tobacco, and food/obesity literatures. The International Journal of
the Addictions, 21(1), 1–23. https://doi.org/10.3109/10826088609063434
Stevens, E., Jason, L. A., Ram, D., & Light, J. (2014). Investigating social support and
network relationships in substance use disorder recovery. Substance Abuse, 36(4),
396–399. https://doi:10.1080/08897077.2014.965870
Sudhinaraset, M., Wigglesworth, C., & Takeuchi, D. T. (2016). Social and Cultural
Contexts of Alcohol Use: Influences in a Social-Ecological Framework. Alcohol
Research : Current Reviews, 38(1), 35–45.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872611/
Sullivan E. V. (2020). Why Timing Matters in Alcohol Use Disorder Recovery. The
American Journal of Psychiatry, 177(11), 1022–1024.
https://doi.org/10.1176/appi.ajp.2020.2009132
Sullivan, E. V., Harris, R. A., & Pfefferbaum, A. (2010). Alcohol's effects on brain and
behavior. Alcohol Research & Health, 33(1-2), 127–143.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625995/
Swift, R. M., & Aston, E. R. (2015). Pharmacotherapy for alcohol use disorder: current and
emerging therapies. Harvard Review of Psychiatry, 23(2), 122–133.
doi: 10.1097/HRP.0000000000000079
T, B. (2019, July 25). Diagnosis Manual Eliminates Alcohol Abuse and Dependence.
Verywell Mind. https://www.verywellmind.com/dsm-5-substance-abuse-disorders-
67882. Alcohol Use Disorder and Key Factors in Successful Treatment 133
Tawa, E. A., Hall, S. D., & Lohoff, F. W. (2016). Overview of the genetics of alcohol use
disorder. Alcohol and Alcoholism, 51(5), 507-514.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004749/
Temple, K. (2020, October 29). Alcohol use Disorder: Addressing stigma and
TREATMENT access in Rural America. Rural Health Information Hub.
https://www.ruralhealthinfo.org/rural-monitor/alcohol-use-disorder/
Thorner, G. (1986). A review of the literature on alcohol abuse, and college students and
the alcohol awareness program at SUNYAB. Journal of Alcohol and Drug
Education, 31(3), 41–53.
Tiffon C. (2018). The Impact of Nutrition and Environmental Epigenetics on Human
Health and Disease. International Journal of Molecular Sciences, 19(11), 3425.
https://doi.org/10.3390/ijms19113425
Tolin D. F. (2010). Is cognitive-behavioral therapy more effective than other therapies? A
meta-analytic review. Clinical Psychology Review, 30(6), 710–720.
https://doi.org/10.1016/j.cpr.2010.05.003
Tragesser, S. L., Sher, K. J., Trull, T. J., & Park, A. (2007). Personality disorder symptoms,
drinking motives, and alcohol use and consequences: cross-sectional and prospective
mediation. Experimental and Clinical Psychopharmacology, 15(3), 282–292.
https://doi.org/10.1037/1064- 1297.15.3.282
Tucker, J. A., Chandler, S. D. & Witkiewitz, K. (2020). Epidemiology of recovery from alcohol
use disorder. Alcohol Research: Current Reviews, 40(3), 02.
https://doi.org/10.35946/arcr.v40.3.02 Alcohol Use Disorder and Key Factors in Successful Treatment 134
Vanderplasschen, W., Colpaert, K., Autrique, M., Rapp, R. C., Pearce, S., Broekaert, E., &
Vandevelde, S. (2013). Therapeutic communities for addictions: a review of their
effectiveness from a recovery-oriented perspective. The Scientific World Journal, 2013,
1–22. doi:10.1155/2013/427817
Vanderplasschen, W., Vandevelde, S., Broekaert, E. (2014). Therapeutic communities for
treating addictions in Europe, EMCDDA, Publications Office of the European Union,
Luxembourg. doi:10.2810/25291
Vares, E. A., Salum, G. A., Spanemberg, L., Caldieraro, M. A., Souza, L. H., Borges, R., &
Fleck, M. P. (2015). Childhood trauma and dimensions of depression: a specific
association with the cognitive domain. Revista brasileira de psiquiatria (Sao Paulo,
Brazil : 1999), 38(2), 127–134. https://doi.org/10.1590/1516-4446-2015-1764
Vaillant G. E. (1988). What can long-term follow-up teach us about relapse and prevention of
relapse in addiction?. British Journal of Addiction, 83(10), 1147–1157.
https://doi.org/10.1111/j.1360-0443.1988.tb03021.x
Vaillant G. (2005). Conversation with George Vaillant. Addiction (Abingdon,
England), 100(3), 274–280. https://doi.org/10.1111/j.1360-0443.2005.00999.x van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of
trauma. Viking.
Venner, K. L., & Feldstein, S. W. (2006). Natural history of alcohol dependence and
remission events for a Native American sample. Journal of Studies on
Alcohol, 67(5), 675–684. https://doi.org/10.15288/jsa.2006.67.675 Alcohol Use Disorder and Key Factors in Successful Treatment 135
Verhulst, B., Neale, M. C., & Kendler, K. S. (2015). The heritability of alcohol use
disorders: a meta-analysis of twin and adoption studies. Psychological
Medicine, 45(5), 1061–1072. https://doi.org/10.1017/S0033291714002165
Vitiello, M. V. (1997). Sleep, alcohol and alcohol abuse. Addiction Biology, 2(2), 151–
158. https://doi:10.1080/13556219772697
Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic Advances from the
Brain Disease Model of Addiction. The New England Journal of Medicine, 374(4),
363–371. https://doi.org/10.1056/NEJMra1511480
Ward, J. H., Bejarano, W., Babor, T. F., & Allred, N. (2016). Re-Introducing Bunky at 125:
E. M. Jellinek's Life and Contributions to Alcohol Studies. Journal of Studies on Alcohol
and Drugs, 77(3), 375–383. https://doi.org/10.15288/jsad.2016.77.375
White W.L. & Kurtz E. (2008) Twelve defining moments in the history of Alcoholics
Anonymous. Recent Developments in Alcoholism, Vol 18. Springer, New York, NY.
https://doi.org/10.1007/978-0-387-77725-2_3
Williams, E. C., Achtmeyer, C. E., Young, J. P., Berger, D., Curran, G., Bradley, K. A.,
Richards, J., Siegel, M. B., Ludman, E. J., Lapham, G. T., Forehand, M., & Harris, A.
(2018). Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary
Care: A Qualitative Study in Five VA Clinics. Journal of General Internal
Medicine, 33(3), 258–267. https://doi.org/10.1007/s11606-017-4202-z
Wilson, N., & Thomson, G. (2005). Tobacco tax as a health protecting policy: A brief review of
the New Zealand evidence. The New Zealand Medical Journal, 118(1213), U1403. Alcohol Use Disorder and Key Factors in Successful Treatment 136
Witkiewitz, K., Montes, K. S., Schwebel, F. J., & Tucker, J. A. (2020). What is
recovery?. Alcohol Research: Current Reviews, 40(3), 01.
https://doi.org/10.35946/arcr.v40.3.01
Workman, D. (2021, February 18). Beer exports by country.
http://www.worldstopexports.com/beer-exports-by-country/
World Health Organization. (2018). International classification of diseases for mortality and
morbidity statistics (11th Revision).
https://icd.who.int/browse11/l-m/en
World Health Organization. (2020). International statistical classification of diseases and related
health problems (11th ed.). https://icd.who.int/
Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects:
Putative role of epigenetic mechanisms. World Psychiatry: Official Journal of the World
Psychiatric Association (WPA), 17(3), 243–257. https://doi.org/10.1002/wps.20568