Abstract
A review of the management strategies of alcohol-related disordersHeavy drinking and alcohol dependence are major public health and social problems in Thailand and worldwide. The alcohol-related problems may arise as a result of a single bout of drinking, alcohol abuse and dependence and may affect not only the drinker but also the drinker’s family, friends and associates as well as others with whom the drinker comes into contact. The enormous social, medical and economic costs of alcohol use and its related disorders have urged a lot of efforts to improve prevention and treatment techniques for alcohol-related disorders worldwide. Both alcohol consumption and alcohol dependence exists within continua, i.e.; consumption and problems range from abstainer without any problem to heavy drinker and alcohol dependent with substantial or serious problems. Likewise, there is a continuum of response to alcohol-related problems, ranging from primary prevention, secondary prevention to specialized treatment. The public health paradigm of prevention should concern the interacting elements of agent (alcohol), host (the drinker) and environment. Therefore, the prevention strategies should include measures taken to modify the environment and to change individual behaviours. The overall management components are consisted of prevention activities directed at drinkers in general, problem drinkers and those at risk for developing alcohol abuse and dependence, early identification and intervention of nondependent drinkers and treatment approaches for those with alcohol dependence problem.The purpose of this review was to analyse international scientific papers on existing prevention and treatment programs for persons at risk for developing alcohol-related problems and persons who already have had such problems. It aimed to provide an overview of the current state of the research on the effective intervention and management measures of alcohol-related disorders for general practitioners and other health professionals, for researchers, for non-health professionals and those responsible for making policy decisions on health care expenditure. The review was divided into five chapters: 1) Definitions and terminology of alcohol-related disorders and impact of the problems, 2) Primary prevention strategies, 3) Prevention strategies for alcohol-related traffic injuries, 4) Secondary prevention strategies, and 5) Tertiary prevention strategies.Primary prevention focuses on general population including non-drinkers, hazardous and harmful drinkers and alcohol dependent individuals. The comprehensive prevention policy of alcohol problems has three principal components; control, education and the provision of alternatives. Control measures comprise legislation and laws on the alcohol advertising and media portrayals of alcohol, alcohol beverage container warning labels, alcohol sales and price of alcoholic beverages and the minimum drinking age. Education measures include school and community-based programs and mass media campaigns aimed at changing individual behaviours.Prevention for alcohol-related traffic injuries is composed of four strategies; general deterrence, specific deterrence, community-based prevention programs and mass media campaign. General deterrence is based primarily on enforcement and publicizing of laws concerning driving under the influence of alcohol such as legal blood alcohol limits for drivers, zero tolerance law, random screening of drivers and administrative per se laws. Specific deterrence is based on changing the behaviours of those drivers who have been identified as driving under the influence of alcohol. The drivers’ behaviours are controlled to a certain degree by the imposition of a penalty like fine, loss of license, mandatory jail or remedial treatment. Examples of specific deterrence are mandatory jail, certified driver intervention program and alcohol ignition interlock. Other strategies used in the prevention of drunk driving are alcohol server training program to promote responsible beverage service, mass communication campaigns to increase the general public awareness of the risk of drunk driving accidents and change individual behaviours, designated driver and community action programs.Secondary prevention emphasizes early identification of those at risk for alcohol-related disorders and problems and providing appropriate intervention before they become dependent on alcohol which treatment yields unfavorable outcome. Early intervention is a proactive measure, composed of early detection of the problems by means of screening instruments such as questionnaires or laboratory methods and brief intervention for those detected as hazardous or harmful drinkers. The commonly used screening questionnaires for alcohol dependence and hazardous or harmful use are Michigan Alcoholism Screening Test, CAGE and AUDIT. Laboratory methods can be used to identify markers for recent alcohol intake (blood alcohol concentration), heavy or hazardous drinking (gamma glutamyl tranferase and other liver function tests), alcohol-related liver diseases and susceptibility to alcohol dependence (mitochondrial ALDH genotype). Brief intervention is a clinically based, cost effective, time efficient intervention designed to counsel nondependent problem drinkers about strategies to reduce their alcohol consumption. The ultimate goal of brief intervention is to prevent future alcohol-related health problems and injury. The principal components of brief intervention include 1) Feedback, 2) Responsibility, 3) Advice to change, 4) Menu of strategies, 5) Empathy, 6) Self-efficacy.Tertiary prevention includes treatment of the alcohol dependent individuals and a long-term management program to prevent their relapse to drinking. Treatment process can be divided into four phases; 1) preparation phase including history taking, physical and mental examination and laboratory tests, 2) detoxification phase as an out- or inpatient case, 3) rehabilitation phase and 4) post-rehabilitation phase when patients return to their families and society. Pharmacological treatment of alcohol dependence has five main objectives, i.e. reducing alcohol withdrawal symptoms, reducing alcohol intoxication symptoms, reducing alcohol consumption and preventing relapse, preventing alcohol craving, and treating co-morbid psychiatric illness. There are several methods used for psychosocial intervention of alcohol use disorders, including 1) cognitive behavioral therapy, 2) supportive psychotheray, 3) behaviour therapy, 4) community reinforcement approach, 5) psychodynamic/interpersonal therapies 6) brief intervention, 7) marital and family therapy, 8) interactional group therapy, 9) family psycho education and family therapy, 10) aftercare service, 11) Self-help group (Alcoholic Anonymous and Alanon).
