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Alaska Substance Abuse Prevention and Treatment System Effectiveness Study Working Paper #2 Alaska Substance Abuse Prevention and Treatment System Effectiveness Study Working Paper #2 A Brief Summary of the Evolution of Substance Abuse Treatment and Prevention Services and the Approaches to Measuring their Effectiveness Alaska Mental Health Trust Authority William Herman, Program Manager Jeff Jessee, Director Institute for Circumpolar Health Studies Bernard Segal, PhD Brian Saylor, PhD, MPH, Director Institute for Circumpolar Health Studies University of Alaska Anchorage 3211 Providence Drive Anchorage, Alaska 99508 April 2003 This project was supported by a contract from the Alaska Mental Health Trust Authority TABLE OF CONTENTS TABLE OF CONTENTS .................................................................................................. i I. The Evolution of Substance Abuse Treatment and Prevention .......................... 1 A. Introduction......................................................................................................... 1 B. Paper Summary ................................................................................................. 1 C. Alcoholism: The Nature of the Problem ............................................................ 3 D. The Extent of the Problem ................................................................................. 3 II. Alcohol Treatment: Theory and Practice ............................................................. 5 A. Early Concepts of Alcoholism: The Pre-Prohibition Period ................................ 5 B. The Post-Prohibition Period: AA and Alcoholism as a Disease.......................... 7 C. The "Disease Concept" of Alcoholism................................................................ 9 D. Adoption of the Disease Concept of Alcoholism ............................................... 13 E. Unitary Disease Concept Changes ................................................................... 14 F. Dual Diagnosis/Comorbidity .............................................................................. 25 G. Multidimensional Concepts of Drinking-Related Problems ............................... 27 H. Examples of Alternative Approaches to Substance Abuse Treatment............. 29 III. Treatment Settings.............................................................................................. 33 A. Inpatient/Residential Treatment ....................................................................... 33 B. Transitional Care .............................................................................................. 35 C. Outpatient Treatment ....................................................................................... 35 IV. Treatment Approaches....................................................................................... 37 A. Alcoholics Anonymous (AA) ............................................................................. 37 B. Other Self-Help Groups.................................................................................... 40 C. Patient-Treatment Matching............................................................................. 40 D. Counseling or Psychotherapeutic Approaches ................................................. 42 E. Marital Counseling............................................................................................ 46 F. Adjunctive Treatments...................................................................................... 46 G. Behavioral Approaches to Alcoholism.............................................................. 49 H. Aversion Techniques........................................................................................ 49 I. Controlled Drinking (Moderation) Theory........................................................... 51 Evolution of Substance Abuse Treatment i April 2003 Institute for Circumpolar Health Studies J. Relapse Prevention........................................................................................... 57 V. Treatment of Drug-Related Problems ................................................................. 59 A. Historical/Philosophical Perspective on Drug Treatment.................................. 59 B. The Changing Role of the Federal Government............................................... 62 C. Approaches to Drug Treatment........................................................................ 64 VI. Measuring Treatment Success .......................................................................... 74 A. Effectiveness of Treatment Settings................................................................. 74 B. Measuring Drug Treatment Effectiveness ........................................................ 77 C. General Findings of Treatment Effectiveness .................................................. 78 D. Research Findings on the Value of Treatment................................................. 80 E. Concluding Remarks ........................................................................................ 82 VII. Science-Based or Best Practice Treatment.................................................... 84 VIII. Substance Abuse Prevention........................................................................... 87 A. Issues and Concerns Common to Both Alcohol and Drug Prevention ............. 88 B. Prevention of Alcoholism.................................................................................. 91 C. National Prevention Policies............................................................................. 94 D. Alcohol Prevention Programs........................................................................... 95 E. Prevention of Drug Abuse ................................................................................ 99 IX. Conclusions........................................................................................................ 103 Evolution of Substance Abuse Treatment ii April 2003 Institute for Circumpolar Health Studies I. The Evolution of Substance Abuse Treatment and Prevention A. Introduction Of our current social issues, few have as many different and competing perspectives as the issue of alcoholism and other forms of drug addiction and how we deal with them. The intent of this section is to review alcohol ism in America from the historical and current contexts of medical, psychological, and sociocultural knowledge and understanding. This purpose of this section is to provide background information about alcoholism, related disorders, and prevention of such addiction problems. The information synthesized here is intended to provide a larger context for understanding the problem of alcoholism and alcohol abuse and the impacts the conditions have on our social fabric. It also presents new thinking about the treatment and prevention of these serious problems which may influence our ability to amend current practices based on new knowledge. B. Paper Summary There is currently a serious rethinking taking place in the United States about the nature of alcoholism. Until recently, it has generally been accepted that "most alcohol-use problems are well characterized as representing one stage or another in the development of a single disease of alcoholism and] that a single-disease concept of alcoholism is the "officially correct view." This view has fostered a universal belief about alcoholism that can be summarized in the six following statements: 1. There is a unitary phenomenon that can be identified as alcoholism. 2. Alcoholics and pre-alcoholics are essentially different from non-alcoholics. 3. Alcoholics may sometimes experience a seemingly irresistible craving for alcohol or a strong psychological compulsion to drink. 4. Alcoholics gradually develop a process called "loss of control" over drinking, and possibly even an inability to stop. 5. Alcoholism is a permanent and irreversible condition. 6. Alcoholism is a progressive disease that follows an inexorable development through a distinct series of phases. The concept of a disease model, however, is being challenged by new and different approaches that offer an alternative to traditional beliefs about alcoholism. This alternate approach is reflected in the following statements: 1. Alcohol dependence summarizes a variety of syndromes defined by drinking patterns and the adverse physical, psychological, and/or social consequences Evolution of Substance Abuse Treatment 1 April 2003 Institute for Circumpolar Health Studies of such drinking. These syndromes, jointly denoted as alcohol dependence, are best considered as a serious health problem. 2. An individual's pattern of use of alcohol can be considered as lying on a continuum, ranging from to severely pathological. 3. Any person who uses alcohol can develop a syndrome of alcohol dependence. 4. The development of alcohol problems follows variable pattern over time and does not necessarily proceed inexorably to severe fatal stages. 5. Recovery from alcohol dependence bears no necessary relation to abstinence, although such a concurrence is frequently the case. 6. The consumption of a small amount of alcohol by an individual once labeled as "alcoholic" does not initiate either physical dependence or a physiological need for more alcohol by that individual. 7. Continued drinking of large doses of alcohol over an extended period of time is likely to initiate a process of physical dependence that will eventually be manifested as an alcohol withdrawal syndrome. 8. The population of persons with alcohol problems is multivariate. 9. Alcohol problems are typically interrelated with
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