Alcoholism: Treatment and Recovery Published By Caron Treatment Centers 2 0 0 5

Treatment and Recovery
Published By Caron Treatment Centers
About Caron Treatment Centers…
Caron Treatment Centers is a leading provider of
addiction treatment services in the fight against
chemical dependency. Caron uses a comprehensive
treatment approach incorporating spirituality, the
family, and current medical/psychological
interventions to help those affected by addiction
begin a life of recovery. Since its founding in 1957,
Caron has pioneered the concept of residential
codependency treatment, and currently offers
expertise in treatment services for adults, young
adults and adolescents. These services include:
early intervention, medical evaluation and
detoxification, primary and extended residential
treatment, relapse treatment, outpatient treatment
and family education.
Caron has responded to the continued demand for
addiction treatment services by offering facilities
in Wernersville, Pennsylvania, and Boca Raton,
Florida. Caron also has regional offices in New
York City and Philadelphia.
Caron’s mission is “to provide an enlightened, caring
treatment community in which all those affected by
alcoholism or other drug addiction may begin a new life.”
Table of Contents
Section III: Risk Factors for Alcoholism.....................................13
Alcoholism:Treatment and Recovery.................................4
Genetic Risks ....................................................................................13
Section I:What is Alcohol?...............................................................4
Subtypes of Alcoholics....................................................................14
Environmental Influences...............................................................14
Co-occurring Psychiatric Disorders...........................................15
Alcohol’s Actions and Effects ..........................................................4
Special Populations ..........................................................................15
Alcohol Abuse and Dependence ...................................................5
The Disease Model ..................................................................5
Medical Diagnosis .....................................................................5
The Elderly ...............................................................................17
Progression of Alcoholism ...............................................................6
Section IV:Treatment and Recovery ..........................................19
Section II:The Costs of Alcohol Abuse........................................7
Settings for Alcohol Treatment.....................................................19
Medical Problems ...............................................................................7
Alcohol and Nicotine ..............................................................8
Behavioral Treatment ......................................................................20
Cognitive Impairment .......................................................................8
Brief Treatment .......................................................................20
Fetal Alcohol Exposure ...........................................................9
Disease Model of Treatment...............................................21
Vehicle Accidents................................................................................9
Alcoholics Anonymous .........................................................22
Workplace Issues.............................................................................10
Medications for Alcoholism ..........................................................23
Alcohol’s Impact on the Family....................................................11
Economics of Alcohol Abuse ........................................................10
Disulfiram .................................................................................23
Marital Issues ...........................................................................11
Children of Alcoholics ..........................................................12
Limitations of Pharmacotherapy........................................24
Treatment Effectiveness .................................................................25
Recovery Rates.......................................................................25
Predictors of Recovery ..................................................................26
Alcohol Treatment at the Caron Foundation .........................29
David C. Lewis, M.D.
Professor of Medicine and Community Health,
Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies,
Center for Alcohol and Addiction Studies, Brown University.
The significance of this comprehensive report on
evaluation? If addiction is
data to guide the therapy. As Scott Miller has
provided and the staffs of those programs will
Alcoholism: Treatment and Recovery goes
similar to other chronic
put it, rather than “evidence-based practice”
carry out the assessments.
beyond national statistics and information about
illnesses, then the
therapists should be guided clinically by
Thus we see in this publication, not only how
the patient population and treatment program at
evaluation of treatment
“practice-based evidence.”
patients at Caron compare with national data,
the Caron Foundation.
should be performed
Caron has laid the groundwork for such
but also an example of the sort of program-
I am struck by the degree with which Caron has
during the active
innovation. The focus of this new approach to
centered evaluation that I believe will become
integrated evaluation into its treatment
treatment phase, as it is
evaluation is on the patient’s functional
more prevalent, valued and refined over time.
programs. Such an integration of research is no
with other chronic
improvement; treatment is chosen and varied
I am encouraged by Caron’s capacity to conduct
mean feat. Much credit goes to Sue Gordon, the
diseases, not months after treatment is
not simply on the basis of a diagnosis, but on the
in-house research and believe that any facility
author of this report, but she is not alone. The
completed. For example, we measure the effect
basis of a patient’s needs. This provides the
that is able to follow their lead will not only
only way to successfully integrate research and
of hypertension or diabetes treatment while the
ability to modify treatment plans as those needs
improve the quality of care they provide but will
clinical programs is with widespread staff
treatment is in progress. Furthermore, we should
change. In the future, evaluation will be
make a contribution to our understanding of the
acceptance at all levels.
not routinely expect the effects of treatment to
internal to the programs in which care is
nature of treatment.
The gold standard for treatment outcome
last after treatment is discontinued. This raises
research is generally thought to be a controlled
the fundamental question of how we should
study, usually conducted by researchers outside
measure the success or failure of addiction
the treatment program. Typically, outcomes
treatment. Thanks to the work of Drs. Tom
have been measured months to years after the
McLellan, David Mee Lee, Scott Miller, Charles
completion of treatment. Now we are re-
O’Brien and others, we are now looking at
thinking the clinical relevance of the “gold
instituting evaluation methods that track patient
standard,” at least in part because we are now
improvement under different treatment
thinking of addiction treatment as being
approaches in real time and give prompt
comparable to the treatment of other chronic
feedback to clinicians about progress or the lack
diseases such as hypertension and diabetes.
of it in achieving treatment goals. This real-time
How does this new understanding relate to
evaluation is dynamic, using patient feedback as
Alcoholism:Treatment and Recovery
Alcohol may be the most widely used drug in human history. It has been consumed for millennia
worldwide for religious rituals and celebrations. Although judicious use of alcohol offers some
benefits, recorded history as far back as the ancient Egyptians also notes problems associated with
drunkenness. This report focuses primarily on the problems associated with excessive use of
alcohol and identifies current treatment strategies for alcoholism.
Section I:What Is Alcohol?
Alcohol is the most commonly used intoxicating substance
in the United States. Half of Americans, 119 million people,
drink alcohol.1 Binge drinking and heavy alcohol use are
most prevalent among 18 to 25 year olds and abusive use of
alcohol peaks at age 21. Heavy alcohol use also is strongly
related to the use of illicit drugs. Over 30 percent of heavy
drinkers also report illegal drug use.
The widespread use of alcohol makes it the most common
drug of abuse diagnosed among people who receive addiction
treatment. In the United States in 2003, 1.3 million people
received treatment for alcohol abuse and another 1.3 million
people received treatment for alcohol and drug problems,
compared to one-half million people who received treatment
only for illicit drug problems.1 At the Caron Foundation,
alcohol is the primary drug of abuse identified by most of the
adult patients upon admission (see Figure 1).2
Figure 1. Primacy Drug Addiction
of Adult Patients Admitted to
Caron Foundation Residential Treatment
4% 9%
Alcohol’s Actions and Effects
What makes alcohol so attractive? Also known as ethanol in
its pure form, alcohol is a colorless, volatile, and flammable
liquid with a simple molecular structure of two carbon
atoms, six hydrogen atoms, and one oxygen atom. Similar to
other drugs, alcohol’s impact on behavior is produced by the
effects it has on the brain. It is a relatively weak drug
compared with other substances of abuse, and larger
amounts of alcohol than other abused substances must be
consumed in order to achieve the desired effects.3 However,
unlike other substances that affect specific transmitter
systems in the brain, alcohol is believed to affect many
different neurotransmitter systems, and as its intensity
increases in the brain, alcohol involves multiple areas of
Alcohol is a depressant and suppresses certain brain
functions, although at low doses it feels like a stimulant.
Because alcohol suppresses certain inhibitory brain functions
in early inebriation, some people feel “loose” or uninhibited.
As the concentration of alcohol increases in the brain,
continued suppression of brain functioning produces
symptoms of intoxication.
Alcohol levels are difficult to measure in the brain. Instead,
the level of blood alcohol concentration (BAC) is used to
assess degrees of intoxication. Most people begin to show
measurable mental impairment at 0.01 to 0.02 percent
which can be produced by one standard alcoholic drink
consisting of as little as 12 grams of alcohol.5 Problems with
coordination and judgment develop as BAC increases.
Blackouts and other disordered behaviors occur at BACs
greater than 0.20 percent, and BACs above 0.40 percent
can produce anesthetic effects resulting in death.
Neurobiological research has expanded our understanding of
the neurological basis of alcoholism. Dr. Alan Leshner,
former director of the National Institute on Drug Abuse,
proposed that at some point during drug use the brain is
significantly altered through cellular adaptation and
functions fundamentally differently from its “pre-disease”
state.9 As we will see, this neurological switch from abuse to
dependence is caused by a combination of genetics and
environmental influences—not moral weakness.
Intoxication decreases with the passage of time as the body
metabolizes the alcohol. Since alcohol is toxic, our bodies
begin to dispose of it immediately upon consumption. First,
alcoholic beverages are passed through the stomach to the
small intestine where the alcohol is absorbed. Over 90
percent of the alcohol is then processed by the liver through
oxidation, which converts alcohol to acetaldehyde.
Acetaldehyde is subsequently converted to acetate by the
enzyme aldehyde dehydrogenase. This enzyme also is found
in the stomach, which is thought to be an important site of
alcohol metabolism.3
Medical Diagnosis
Throughout much of the nineteenth and twentieth
centuries, opponents of the disease concept of alcoholism
continued to favor a view that considered excessive alcohol
use to be a bad habit and sign of moral weakness. This view
points to a continuum of alcohol use, from abstinence to
excess, and does not differentiate between occasional use,
heavy abusive use, or chronic-use dependence.6
Alcohol Abuse and Dependence
The study of individuals who drink alcohol to excess has
been controversial. Alcoholism has not always been
considered a disease, and many people today continue to
view it as a moral weakness or as a learned behavior that can
be unlearned. This section describes the development of the
disease model of alcoholism and discusses the medical
diagnosis of alcoholism, which differentiates alcohol
dependence from alcohol abuse.
The Disease Model
Excessive alcohol use, called intemperance, was recognized
as a disease by Dr. Benjamin Rush, one of the signers of the
Declaration of Independence and first physician general to
the Continental Army. However, the term alcoholism was
not used until 1849 when Dr. Magnus Huss, a Swedish
physician, described many of the physical and mental
symptoms attributable to inordinate alcohol use.6 By the end
of the nineteenth century, most physicians generally viewed
alcoholism as a biological disease characterized by excessive
alcohol use.7 A comparison of alcohol and drug dependence
to medical illnesses, such as type 2 diabetes, hypertension,
and asthma, found that drug and alcohol dependence are
similar to these chronic illnesses in terms of genetic and
environmental etiological factors, patient compliance with
treatment recommendations, and relapse rates.8
However, the medical diagnosis of alcoholism clearly
distinguishes different types of harmful alcohol use. By the
mid-twentieth century, Jellinek delineated various subtypes
of excessive alcohol users, and made a distinction between
alcohol dependence and alcohol abuse.10 He identified
gamma alcoholism as the loss of control when drinking and
delta alcoholism as the inability to abstain from drinking.
These two characteristics became key criteria for the
medical diagnosis of alcohol dependence, the medical term
for alcoholism or alcohol addiction. (Alcohol dependence
and alcoholism will be used interchangeably in this report.)
Jellinek’s alpha, beta, and epsilon types foreshadowed the
diagnosis of alcohol abuse. Following Jellinek’s distinction
between a dependence process and abusive use of alcohol,
the American Psychiatric Association11 developed separate
categories to describe alcohol dependence and the
nondependent disorder of alcohol abuse.
Alcohol dependence is characterized by a harmful pattern of
alcohol use resulting in significant impairment or distress in
a number of areas of psychosocial functioning. These areas
include unsuccessful attempts to control or decrease alcohol
use, neglect of important social, occupational, or
recreational activities, increased time spent on alcohol use,
and perhaps most important, continued alcohol use despite
these alcohol-related problems.7
Withdrawal is a state of physical dependence that occurs
when the central nervous system requires the presence of
alcohol to function normally. Withdrawal symptoms that
appear when alcohol use is discontinued include mild
irritability, tremors, and insomnia to more severe
complications such as seizures, hallucinations, and delirium
tremens. Withdrawal symptoms can appear as soon as four to
eight hours following the cutback of alcohol use by a heavy
consumer of alcohol.5 The physiological state of craving
shown by a strong desire for alcohol also sometimes occurs
during withdrawal.4 Treatment of withdrawal will be
discussed in the section on detoxification.
Similar to alcohol dependence, alcohol abuse involves a
continued pattern of alcohol use that results in major
impairments in functioning related to alcohol use. Its
symptoms include failure to complete important
responsibilities, drinking in potentially dangerous situations,
and recurring alcohol-related legal problems. The major
distinctions between abuse and dependence are that the
alcohol abuser manifests fewer impairments in functioning,
does not have symptoms of tolerance or withdrawal, and is
able to abstain from alcohol when use becomes problematic.
Although related to alcohol dependence, alcohol abuse is a
separate condition, and is not considered “alcoholism.” A
number of research investigations have shown that alcohol
abuse usually does not develop into alcohol dependence.
These findings support the contention that alcohol abuse
and alcohol dependence are separate conditions with
overlapping symptoms.
retrospective methodology in which the researcher asks
alcohol-dependent individuals to recollect the sequence of
events leading to their disease. These studies generally have
found a progression in which alcoholism does not remit, but
becomes more severe over time. This result is
understandable because individuals whose alcohol-related
symptoms have decreased or abated usually would not be
included in the samples.12 However, in order to obtain a
more accurate understanding of the progression of
alcoholism throughout the life span, it is necessary to
conduct prospective research in which individuals are
studied prior to the onset of alcoholism, or to include more
representative samples that include individuals who do not
meet criteria for alcoholism.
One of the most noted prospective studies of the natural
course of alcoholism began in 1939 when privileged white
male students from Harvard were recruited for a longitudinal
study.13 This sample was compared to another group of
ethnically diverse lower-income males recruited from Boston
inner-city schools between 1940 and 1944. Both groups were
followed for the next 50 years. In addition to participating in
recurrent interviews, questionnaires, and physical
examinations, the study participants allowed researchers to
obtain information from their parents on childhood
development and family history. Additional information was
collected from public records, such as the criminal justice
Reporting on the results of this study, Vaillant concluded
that the development and prognosis of alcoholism varies
greatly among individuals who drink.13 He found that some
men with strong antisocial tendencies appeared to develop
symptoms of alcoholism only after a few months of heavy
drinking compared to others who drank heavily for years
before manifesting sufficient symptoms to be diagnosed with
alcoholism. He also found that some alcoholics did not show
a progression to more severe symptoms or improvement, but
remained static. Abstinence appeared to be the most
effective treatment goal because alcoholics who returned to
controlled drinking generally were unable to control their
alcohol use over time.
is its reliance on a totally male sample, and its inability to
inform us about the course of alcoholism among females.
The progression of alcoholism in females and other topics
regarding female alcohol abuse and dependence are covered
later in this report in the subsection “Special Populations”
under “Risk Factors for Alcoholism.”
Section II:The Costs of Alcohol Abuse
Individuals who abuse or are addicted to alcohol over time
can develop serious life-threatening medical conditions and
cognitive impairment. The combination of alcohol and
nicotine can be especially deadly. Women who drink during
pregnancy risk severe fetal damage and birth defects. In
addition to causing significant problems for the alcoholaffected individual, the consequences of alcohol abuse and
addiction also have severe economic and social costs to the
workplace, the larger community, and the family.
Figure 2. Medical Problems at Admission by
Adult Patients at the Caron Foundation
Medical Problems
Approximately 415,000 Americans are discharged from a
hospital every year with an alcohol-related condition.1 As
alcoholic individuals age, they increasingly suffer from
alcohol-related medical problems. Alcohol-related illnesses
generally affect people from 45 to 64 years of age, while
younger people (ages 15 to 24 years) have the lowest rates of
alcohol-related illnesses.1 Excessive chronic alcohol use
tends to decrease the life span by 10 to 15 years.2 Alcoholrelated mortality results from acute alcohol poisoning,
alcohol-related medical conditions, and alcohol-related
vehicle accidents. Over 100,000 Americans a year die from
alcohol-related causes.3 Alcohol is the third highest cause of
preventable death in the United States.4
Over half of alcoholic patients admitted to treatment at the
Caron Foundation report medical problems, and alcoholic
patients are more likely to be admitted with medical
problems than are drug addicted patients (see Figure 2).5
Drug Addiction
Source: on
Given the slow deterioration of functioning through chronic
alcohol abuse, it is not surprising that older alcoholdependent patients at the Caron Foundation are more likely
to report medical problems than younger patients. Although
most patients at the Caron Foundation successfully complete
treatment, alcoholic patients are more likely to
leave treatment due to medical reasons than are other
Our central nervous system, gastrointestinal system, and
cardiovascular systems are especially vulnerable to alcohol
abuse and most of the medical consequences of excessive use
occur in these systems. The major cause of alcohol-related
death is heart disease, and the second leading cause of death
among alcoholics is cancer.6 It is believed that chronic
alcohol use irritates the digestive tract and lungs, and results
in a high risk of cancers of the head, neck, esophagus,
stomach, and liver.
Since the 1880s, we have known that alcohol has a direct
and toxic effect on the heart.6 Chronic alcohol consumption
of more than two drinks daily is related to hypertension.
Unfortunately, one of the major limitations of this research
Progression of Alcoholism
Early studies on the lifetime course of alcoholism used a
Alcohol dependence also can be manifested by two
physiological characteristics—tolerance and withdrawal—
although these syndromes are not essential for the diagnosis.
Tolerance is a need for increased amounts of alcohol to
achieve intoxication or the effects that were originally
produced by a lower dose. It is due to increased activity of
the enzymes responsible for metabolizing alcohol, an ability
to function despite the presence of alcohol, and central
nervous adaptation to the effects of alcohol.3
Chronic alcohol use also can result in the weakening of the
heart muscle (cardiomyopathy) possibly leading to irregular
heart rhythms that could result in sudden death.6
Because alcohol is detoxified primarily in the liver, cirrhosis
(liver damage) is a major consequence of long-term
excessive alcohol use, and is one of the main causes of death
in the United States. Approximately four in every 100,000
Americans die every year from alcohol-related liver
cirrhosis.7 Hepatitis viral infections also involve the liver
and there is evidence of negative interactions between
alcoholic liver disease and hepatitis C.8 Hepatitis C appears
to be more common among persons with alcohol liver
disease than in persons who are not alcoholic or who do not
have alcohol-related liver disease, and is associated with
more severe liver disease. Chronic hepatitis also is related to
the development of cancer of the liver.
Usually, the onset of smoking precedes alcohol use for most
alcohol- and nicotine-dependent individuals, although this
is not always the case.6 Thus, it is difficult to pinpoint
whether alcohol is a causative factor in nicotine dependence
or whether early initiation to nicotine leads to alcohol
abuse. Instead, it seems that alcohol and nicotine serve as
risk factors for each other.
Alcohol and Nicotine
The medical risks of combining alcohol and nicotine pose a
health threat greater than using either drug independently.
The risks of developing mouth and throat cancer are seven
times greater for smokers, six times greater for alcohol users,
and 38 times greater for those who use alcohol and tobacco
together, compared to those who neither smoke nor drink.6
People who tend to abuse alcohol heavily also tend to be
heavy users of nicotine. Approximately 70 percent of
alcoholics smoke more than one pack of cigarettes per day,
compared to 10 percent of the general population.6
Interviews with over 43,000 Americans who took part in
the recent National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC) found that almost 13
percent of Americans are nicotine dependent, and over 22
percent of these nicotine dependent individuals also are
diagnosed with either alcohol abuse or dependence.9
Approximately 60 percent of alcohol-dependent patients
admitted to treatment at the Caron Foundation report they
currently use nicotine.5 As illustrated in Figure 3, younger
alcoholic patients are more likely to use nicotine than older
Percent of patients
reporting any nicotine
use at admission
Figure 3. Prevalence of Nicotine Use by Alcohol
Dependent Patients at the Caron Foundation
18 or
Age Group
65 or
Source: on
The high co-occurrence of nicotine and alcohol use might
be due to the way in which one drug enhances the
rewarding effects of the other drug, and decreases the other
drug’s unpleasant effects.6 For example, the stimulating
properties of nicotine might lessen the sedating effects of
alcohol. In addition, use of both substances might become
paired in the brain, so that alcohol becomes a cue to use
Cognitive Impairment
In addition to its negative effects on our bodies, alcohol also
impairs mental functioning in 50 to 80 percent of
individuals who abuse alcohol.10 Brain damage is common
among chronic heavy drinkers, and even mild to moderate
drinking can have negative effects on cognitive
functioning.11 Similar to most medical conditions, cognitive
impairment due to alcohol abuse occurs gradually over time.
This gradual deterioration makes it difficult for the impaired
individual or people close to the affected person to recognize
the impairments before they become severe.
Alcohol-related cognitive impairments reduce a person’s
abilities to reason, plan, and problem-solve, and have
negative impacts on short-term memory, judgment, speech,
emotional regulation, and movement. Alcohol use also
affects a person’s visual-spatial ability (the ability to
remember the locations of objects or places) and visualmotor ability (the ability to manipulate objects such as
puzzles). Excessive alcohol use over time negatively affects
these abilities, making it more difficult for alcoholic
individuals to locate objects, remember familiar routes, and
understand visual instructions, such as using a map for
Also, learning new skills and solving new problems could
take years to recover. Generally, older drinkers are less likely
than younger alcoholics to completely recover cognitive
Studies using autopsies and brain imaging techniques have
repeatedly confirmed that damage occurs in the brains of
alcoholics.12 The prefrontal cortex, the area of the brain
regarded as the center of higher intellectual functioning, is
smaller and less dense in alcoholics than in others, and this
difference is thought to be related to excessive alcohol use.10
The process of brain shrinkage tends to progress over time
and is related to the amount of alcohol a person consumes.12
Shrinkage in the frontal lobe area negatively affects
executive functioning tasks, such as reasoning, planning,
and problem solving. Shrinkage and decreased blood flow to
the cerebellum area of the brain is associated with impaired
balance and motor coordination.11, 12 Chronic alcohol abuse
is also related to lower rates of metabolism of glucose
(a simple sugar) in the frontal lobes and is associated with
poor performance on intelligence tests.10
Fetal Alcohol Exposure
Cognitive and physical impairments are not limited to the
excessive alcohol user. Consumption of alcohol during
pregnancy may cause irreversible damage to the developing
fetus and result in alcohol-related birth defects (ARBD).
ARBD includes any of the known mild to severe adverse
effects of alcohol on the developing fetus. ARBD can cause
deficiency in visual and verbal learning skills, slow
information processing ability, and deficits in the ability to
plan, organize, and solve problems.
Chronic abuse of alcohol is also related to a relatively rare
but severe condition known as Wernicke’s encephalopathy,
which usually occurs in combination with Korsakoff’s
psychosis. Wernicke’s encephalopathy is caused by poor
nutrition, specifically a deficiency of thiamine (vitamin B1)
and is characterized by difficulty walking, poor eye
movement, and global confusion. Korsakoff’s psychosis
results in a complete inability to learn new information.
Wernicke’s encephalopathy can be prevented by
administering thiamine during alcohol withdrawal.8
However, there is a likelihood that Korsakoff’s psychosis will
not be reversible.
Some cognitive impairment is reversible with abstinence.
Brain shrinkage can decrease and even show a partial
reversal, and cognitive functioning appears to improve
somewhat within three to four weeks of abstinence. With
continued abstinence most recovering alcoholics continue
to experience improvements in memory, visual-spatial
functioning, and attention. Verbal improvement usually
occurs within the first weeks of abstinence, compared to
visual skills, which sometimes take over a year to recover.10
Fetal alcohol syndrome (FAS) is the most severe form of
ARBD, and is the leading cause of preventable mental
retardation.13 Children born with FAS have a characteristic
pattern of facial abnormalities, growth retardation, and brain
damage resulting in intellectual deficiencies and behavioral
problems. One of the most prevalent symptoms of FAS is an
inability to pay attention; as a result, children with FAS are
often incorrectly diagnosed with attention deficit
hyperactivity disorder.
Scientists have studied ARBD and FAS for over 30 years.
However, we still do not know exactly the minimum
quantity of alcohol required to produce ARBD or FAS.
ARBD is commonly found in children whose mothers drank
less than five drinks at a time once weekly during
pregnancy.13 Vulnerability to alcohol during pregnancy
appears to vary significantly from woman to woman and may
be related to other factors, such as genetics, age, nutritional
status, and other co-occurring conditions.13 Therefore, it is
strongly recommended that all women who either know or
suspect they may be pregnant abstain from alcohol
throughout their pregnancies. Despite these
recommendations, in 2003 almost 10 percent of American
women reported they used alcohol during their pregnancy
and 4 percent reported binge drinking.14
Vehicle Accidents
Drunk driving is a major but preventable consequence of
excessive alcohol use. Almost one-quarter of Americans old
Over 40,000 Americans die annually from alcohol-related
car accidents,4 which are the leading cause of death in the
United States for young adults.16 In addition to high
mortality rates, alcohol-related vehicle accidents also are
associated with traumatic brain injuries. Head trauma
produces effects similar to those of cognitive impairments
caused by excessive alcohol use. Both types of brain
impairment often negatively affect intellectual functioning
and ability to control emotions.10
Alcohol-related car accidents are a serious problem for the
nation’s youngest drivers, young adults under 21 years of
age.16 The risk for mortality increases with each drink young
people consume. But even low levels of alcohol
consumption by young drivers are related to car accidents.
Young drivers are more likely than older drivers to be
involved in car crashes, possibly due to young drivers’ lack of
driving experience and tendency to engage in risky
behaviors.17 Young drivers also consume larger amounts of
alcohol prior to driving than do older drivers. While older
Americans on average consume fewer than three drinks
prior to driving, young drivers consume an average of five
drinks.15 Similar to adults, adolescent males are more likely
than adolescent females to drive after drinking.18
The consequences of drunk driving are not limited to
inebriated drivers. Approximately 70 percent of alcoholrelated vehicle mortalities are drivers, 25 percent are
passengers, and 5 percent are non-occupants, such as
pedestrians.19 One-third of American students have ridden
in a vehicle at least one time with a driver who had been
drinking alcohol.18
Fortunately, rates of alcohol-related driving accidents and
deaths are decreasing. Drivers and passengers are becoming
more aware of the hazards of driving while intoxicated.
Designated drivers, who consume little to no alcohol, are
increasing and people are less likely to allow an inebriated
person to drive.15
Workplace Issues
Alcohol is the primary source of drug-related workplace
problems. Over 60 percent of fulltime employees consume
alcohol, and an estimated 7 percent of those fulltime
employees are heavy drinkers.14, 20 Almost half of the adult
alcohol-dependent patients at the Caron Foundation are
employed fulltime (see Figure 4).5 Male patients are more
likely than females to be employed fulltime; female patients
typically report “homemaker” as their daily activity.5
Figure 4. Employment Status of Adult Alcohol
Dependent Patients at the Caron Foundation
6.6% 5.3%
Student Part-time
Also, in a research project conducted at the Caron
Foundation and sponsored by the National Institute on
Alcohol Abuse and Alcoholism, more severe employment
problems were reported by adult female patients than by
male patients in the study.30
A wide range of occupations has been identified as having
high rates of substance abuse. These occupations include
bartenders, entertainers, physicians, innkeepers, salespeople,
military personnel, construction laborers, carpenters, waiters,
transportation workers, and movers.21 Factors that may
increase the risk of substance abuse and dependence in these
occupations are the availability of drugs and alcohol,
attitudes of co-workers who accept or encourage substance
abuse, job-related stress, a sense of powerlessness at work,
uncertain income, and hazardous working conditions.22
Economics of Alcohol Abuse
Chronic medical problems, accidents, and death all
contribute to the high cost society pays for alcohol abuse.
Add poor work performance, absenteeism, truancy,
delinquency, and alcohol-related crimes, and the cost soars.
Almost 75 percent of the cost of alcohol abuse is attributed
to lost productivity of alcohol-impaired individuals due to
alcohol-related illnesses, premature death from alcoholrelated causes, and alcohol-related crime.23 An additional
nearly 15 percent of the cost goes toward treatment of
individuals for alcohol use disorders and alcohol-related
medical conditions. The remaining 10 percent goes into
associated expenses such administrative costs and property
damage caused by alcohol-related vehicle accidents, and
costs incurred by the criminal justice system for prosecution
and imprisonment of people who commit alcohol-related
(never married)
Percent of patients within addiction category
Source: on
Marital Issues
People who are separated or divorced are much more likely
to have been married to an alcoholic or alcohol-abusing
mate than people who remain married.24 One of the most
severe consequences of marital discord resulting from
excessive alcohol use is domestic violence, and alcohol
abuse consistently predicts marital violence.25 Although both
men and women can become perpetrators of domestic
violence, the abuser is more likely to be male, and the
victim female. At the Caron Foundation we have found that
female alcohol-dependent patients are more likely than male
alcohol-dependent patients to report histories of
victimization by domestic violence (see Figure 6).5
Figure 5. Marital Status of Adult
Caron Foundation Patients by Primary Addiction
The estimated overall economic cost of alcohol abuse in
1998 dollars is $185 billion annually.23
Economists estimate that almost half of the total cost of
alcohol abuse is carried directly by the alcohol-impaired
individuals and their families in the form of lost or reduced
earnings.23 An estimated percent is carried by the Federal
government in the form of reduced tax revenues resulting
from reduced work productivity.20 Close to another 20
percent is carried by state governments, which lose tax
revenues and administrate alcohol-related crimes and
vehicle accidents. Ten percent is assumed by private health
insurers who pay out for health care and car insurance
claims. Other costs are borne by the victims of
nonhomicidal alcohol-related crimes.
Figure 6. Reports of Domestic Violence
by Caron Foundation Patients
Although the economic costs of alcohol abuse are high, the
social and emotional costs to individuals and their families
exact an even higher toll. The following section describes
the major impacts of alcohol abuse on families.
Percent of
patients by
enough to drive, have driven a vehicle within two hours of
consuming alcohol.4 Males are twice as likely as females to
drive while intoxicated, and young adults in their twenties
are the most likely age group to drink and drive.14, 15
Alcohol’s Impact on the Family
Alcoholism is a family disease. 75 percent of Americans who
abuse alcohol live in families.24 This same percent is
reflected in the alcoholic patients admitted for treatment at
the Caron Foundation.5 As shown in Figure 5, adult
alcoholic patients admitted to the Caron Foundation are
more likely than drug addicted patients to be married.
Alcohol abuse is related to severe family problems and is
associated with marital discord, divorce, domestic violence,
and child abuse.
Source: on
Alcohol’s tendency to impair judgment, reduce inhibition,
and increase aggression appear related to the high incidence
of domestic violence among alcohol-impaired men. Other
important conditions related to domestic violence include
violence in the perpetrator’s family of origin and economic
Although men with drinking problems are at high risk to
abuse their partners, alcohol abuse does not cause domestic
violence. Many men who abuse alcohol do not abuse their
wives, and men who do not have problems with alcohol do
perpetuate abuse. Since there is no causal relationship
between domestic violence and alcoholism, recovery from
one condition may not alleviate the other condition.
Alcoholics who batter their partners require specific
treatment for both conditions.26
Children of Alcoholics
Most children of alcoholics (COAs) do not have significant
mental health or alcohol or drug problems in adulthood—
although they are more likely to exhibit these problems than
are adults whose parents were not alcoholic.27 In fact,
alcoholic families are more different from each other than
they are similar. Many other conditions besides alcoholism
exist in alcoholic families, and these factors can be as
important as parental alcoholism in predicting COA
Similar to the differences among alcoholic families, children
within the same alcoholic family also can significantly differ
from each other. For example, COAs who do not develop
serious problems tend to be able to relate well to other
persons, have a desire and intellectual ability to succeed, and
have a sense of their own effectiveness.28 In general,
however, COAs tend to report higher levels of depression,
anxiety, and stress than other children. They also tend to
have more behavioral problems, more impulsivity, and more
academic problems than do children from nonalcoholic
homes.28 Although much has been written about the
concept of codependency, or compulsive and dysfunctional
caretaking among COAs, additional research is necessary to
determine if codependency is unique to COAs or results
from being raised in any type of a disrupted home.29
Section III: Risk Factors for Alcoholism
development of alcoholism in biological sons.2 The evidence
is inconclusive regarding the role of heritability among
females because of inconsistent results of adoption studies
that have included female participants.3
As we have seen, most people consume alcohol at some
point during their lifetime, but most people do not become
alcoholic. Thus, a major question is: What causes
alcoholism? Is the development of alcoholism primarily due
to nurture (environmental conditions), or to nature (an
inherited fate to drink excessively). Identifying the
conditions that produce alcoholism has implications for
attitudes toward alcoholism, its treatment, and its
prevention. As this section will show, alcoholism develops
through a combination of environmental risks and genetic
Genetic Risks
The genetic risk for developing alcoholism for both men and
women appears to be moderate and is estimated to be
between 50 to 60 percent.1 The genetic basis of alcoholism is
found in research on families, through intergenerational
studies, adoption studies, and research on twins. Recent
research in molecular genetics has identified specific genes
responsible for alcohol-related behaviors.
Compared to nonalcoholic families, alcoholic families tend
to have poorer communication and social problem-solving
skills, which may lead to higher levels of family conflict.27
Higher rates of conflict and violence may be related to the
higher rates of divorce experienced by alcoholic families.
However, divorce often does not reduce parental conflict,
and it continues to be expressed through custody disputes
and other disagreements concerning child-rearing practices.
In addition, family dissolution often results in reduced family
income and less ability for either parent to effectively
supervise the children.
Studies of intergenerational alcohol abuse point to the
heritability of alcoholism. Rates of alcoholism are repeatedly
found to be higher among family members of alcoholic
individuals than among nonalcoholic persons, and the rate
of alcoholism drops as the biological distance between the
alcoholic individuals and their relatives increase.2 Research
has repeatedly found that alcoholics are much more likely
than nonalcoholics to have at least one parent who is
alcoholic.3 However, it is difficult to separate genetic factors
from environmental influences in these studies because the
close family relatives of the alcoholic individuals generally
share the same environmental conditions.2
The higher likelihood of COAs to exhibit psychological
problems, such as anxiety, depression, and conduct disorder
is related to a number of risk factors. For example, COAs
whose mothers suffered from depression are more likely to
have higher rates of mental health problems than COAs
with nondepressed mothers.27 Also, in many alcoholic
families both parents have psychiatric problems, and
children in these families are less likely to benefit from
appropriate nurturance and discipline by either parent.
Adoption studies separate environmental and genetic factors
because adoptees are reared separately from their biological
parents and in different parental environments. Thus, the
similarities between adoptees and their adoptive families
should reflect the effects of environment, while the
similarities between adoptees and their biological families
should be limited to genetic factors. Adoption studies have
found strong links between paternal alcoholism and the
Twin studies are also able to separate environmental and
genetic influences. Identical twins, who share the same
genes, would be expected to have higher concordance rates
for alcoholism than fraternal twins, who share only
approximately 50 percent of their genes. In fact, most twin
studies report that identical twins are twice as likely to share
a diagnosis of alcoholism than fraternal twins.1 Higher rates
of concordance for alcohol use also are found in twins who
are raised separately.2 These findings tend to be consistent
for both males and females.1
Alcoholism is a genetically complex disease. Unlike cystic
fibrosis and other genetic diseases that result primarily from
the actions of a single gene, alcoholism is believed to be
related to a number of genes.1 Instead of searching for one or
two genes responsible for alcoholism, scientists are seeking
to identify different groups of genes that underpin the
various behavioral manifestations of alcohol. For example,
genes responsible for how people metabolize alcohol have
been identified. Some ethnic groups, such as Asians, have
been found to have a variation in the genes that produce
unpleasant reactions to alcohol use, such as flushing, nausea,
and rapid heartbeat.1 These genes might serve as a protective
factor against alcohol abuse, since Asians also tend to have
lower rates of alcohol use than other ethnic groups.
Alcohol is related to a number of different activities. In
addition to physical effects of metabolism, alcohol also
affects brain functions such as memory, movement, response
to pain, and emotional state. Genetic research is focusing on
these areas to identify genetic variations that may be
responsible for genetic risks. Using genetic markers,
variations in the genetic material that make up
chromosomes, scientists are scanning the genome for areas
associated with risk for alcoholism.4 Multigenerational
studies of families with alcoholism also are identifying
genetic hot spots for the risk of alcoholism.1
Heritability is not totally responsible for the development of
alcoholism. Not all children of alcoholics develop
alcoholism, and even among pairs of identical twins both
twins do not always develop alcoholism.
Environmental conditions that influence alcohol use have
been identified through family studies. Studies conducted
internationally and in the United States consistently show
that the initiation of alcohol use among mid-aged
adolescents is primarily influenced by cultural factors, such
as interactions with peers and siblings.5 Even though some
adolescents might be genetically predisposed to initiate
alcohol use at an early age, actual initiation depends on the
availability and acceptability of alcohol use.6
Most American teenagers report that it is very easy for them
to obtain alcohol, as seen in the high rates of alcohol use in
the United States.7 However, certain areas of the nation
such as Utah, where it might be more difficult to obtain
alcohol and where residents hold more negative attitudes
toward alcohol abuse, have the lowest rates of binge
Social learning also influences a person’s attitudes toward
alcohol use. Although we have seen a strong genetic
component to alcoholism, environmental factors also play
an important role in the initiation to drinking for children
of alcoholics (COA). COAs have more opportunities to
learn about alcohol than children raised in nonalcoholic
environments, and by observing parental alcohol use COAs
may be more inclined to initiate use themselves.9
The development of alcoholism is an interaction between
environmental and genetic factors. Genetic predisposition
involving a variety of genes that influence a variety of
behaviors sets the stage for the development of alcoholism.
Environmental factors, such as the availability and learned
acceptability of alcohol consumption then sets the play in
Subtypes of Alcoholics
The interplay of environmental and genetic contributions to
alcoholism can be seen in subtypes of alcoholics. A number
of different classifications of alcoholics have been proposed
over time, and most of the classifications distinguish
between mild and severe forms of alcoholism. More severe
types of alcoholism, such as Cloninger’s Type 16 and Babor’s
Type B10 alcoholism, are likely to be characterized by a
family history of alcoholism, a high frequency of deviant
behaviors (such as childhood fighting or stealing) an early
onset of alcoholism, severe symptoms of alcohol dependence
(such as tolerance and withdrawal) and social and physical
alcohol-related problems. These deviant behaviors appear
early in childhood, continue into adolescence, are associated
with family histories of alcoholism, and appear in twin
studies suggesting their heritability.5
Co-occurring Psychiatric Disorders
Cloninger’s research also indicates a genetic link between
highly heritable temperament traits that are noticeable in
childhood and the development of alcoholism in
adulthood.6 Boys whose biological fathers have antisocial
personality disorders are likely to develop alcoholism at an
early age, even if they were adopted and lived apart from
their biological families.6 Similarly, people with antisocial
personality traits, such as high levels of activity, impatience,
aggressiveness, and novelty seeking behaviors, are likely to
initiate alcohol use early in adolescence and develop
Alternatively, alcoholism could lead to the onset of a mental
disorder.12, 13 In fact, excessive alcohol use over time may
produce anxiety, depressive, and psychotic symptoms that
could be mistakenly diagnosed as psychiatric disorders.14 For
example, Vallient’s longitudinal research on men supported
the hypothesis that psychiatric conditions are secondary to
alcoholism. He found that depression and anxiety tended to
develop as a consequence of alcoholism and remitted with
abstinence.15 Unlike males, females are more likely to
experience an episode of depression prior to development of
Babor’s original research was conducted on a sample of 321
male and female hospitalized alcoholics. He found that
males were more likely to be classified as the more severe
Type B alcoholics, although males and females have
comparable profiles within the Type B category.11
Subsequent research also has found a disproportionate
percentage of men classified as Type B alcoholics which may
contribute to the less consistent findings of genetic
influences on alcoholism in women.3
On the other hand, alcoholism and psychiatric conditions
could share a common pathway, such as genetic
predisposition or exposure to common environmental
conditions.12, 13 For example, exposure to stressful situations
might lead to initiation and use of alcohol to relieve stress.
However, repeated use of alcohol appears to increase the
negative effects of stress in the brain and leaves the brains of
alcoholics in a permanent state of stress.4
Interestingly, an analysis of Babor’s less severe Type A
alcoholism also suggests gender differences. Type A women
appear to have higher levels of depression and anxiety,
report more severe medical and social alcohol-related
problems, are more likely to use alcohol to self-medicate,
and abuse tranquilizers more frequently than Type A men.11
The personality traits of negative emotionality and
behavioral control could be inherited risk factors for Type A
alcoholism in women.3
Although psychiatric disorders commonly co-occur with
alcoholism, the exact relationship between alcohol and
psychiatric disorders is unclear. One explanation is that a
preexisting psychiatric disorder could lead to the
development of alcoholism. In general, it appears that
individuals with both conditions tend to develop psychiatric
problems at earlier ages than they develop substance use
disorders.12 This developmental course appears stronger for
women than for men, is stronger for conduct disorders, less
frequent for anxiety disorders, and least certain for mood
Regardless of the causal relationship, psychiatric cooccurring conditions are prevalent among alcoholics.
Almost 20 million American adults suffer from an emotional
disorder that substantially interferes with a major life
activity, and adults with a severe mental illness are almost
three times more likely to abuse or be dependent upon
alcohol than Americans without severe mental problems.17
Additionally, approximately 40 percent of individuals who
seek treatment for alcohol abuse or dependence also have a
mood disorder and one-third have an anxiety disorder.18
Bipolar disorder, also known as “manic depressive disorder”
because the symptoms fluctuate between periods of mania
and depression, is a common mood disorder found in
alcoholic populations.19
Co-occurring psychiatric disorders pose a great risk because
they tend to be more chronic and severe in substance
abusers than in people who suffer only from a psychiatric
disorder.12 For example, alcoholics have 10 times the risk for
suicide as people in the general population.14 Approximately
40 percent of alcoholic men and women experience serious
depressive symptoms of hopelessness and thoughts of suicide.
The disinhibiting qualities of alcohol combine with a
depressed mood to make suicide the fourth leading cause of
death among alcoholics.14 Significantly higher rates of
suicide attempts also are found in populations with cooccurring bipolar disorder and alcoholism compared to
nonalcoholics who have bipolar disorder.19 As shown in
Figure 7, approximately one-third of the alcoholic patients
admitted to the Caron Foundation report prior thoughts of
Figure 7. Percent of Alcohol Dependent Patients at the
Caron Foundation with History of Suicidal Thoughts
Percent of patients
Environmental Influences
Source: on
Special Populations
The unfortunate stereotype of an alcoholic is an adult male
on Skid Row. Too often when we read or hear about
alcohol-related problems we bring this picture to mind and
we do not consider the effects of alcohol on other
populations. Although much that has been written about
alcoholism is universal, different subgroups of people have
specific risk factors and vulnerabilities to alcohol. This
section discusses alcohol’s impact on the special populations
of females, adolescents and the elderly.
Males are twice as likely as females to use, abuse, or be
dependent on alcohol. However, females are more sensitive
than males to the immediate effects and long-term health
consequences of alcohol.21 The same amount of alcohol
produces a higher blood alcohol concentration in females
than it does in males even if their body weights are the
same, because females tend to have less body water than
Women are more likely than men to progress to alcoholism
once they begin abusing alcohol—a phenomenon known as
“telescoping” of the disease—and to suffer physical damage.
Thus, compared to men, women are more likely to develop
hepatitis and die from cirrhosis and more likely to develop
brain damage.22 Female reproductive functions also are
impaired by the excessive use of alcohol. Premenopausal
women who drink excessively are at risk for a cessation or
dysfunction of menstruation and ovulation, spontaneous
abortion, and early menopause.23 In addition, heavy alcohol
use is associated with osteoporosis, a condition of low bone
mass and increased risk of fractures.24 Women who
excessively abuse alcohol also are at higher risk of breast
cancer than women who drink moderately.22
Both male and female alcohol abusers and alcoholics
commonly experience co-occurring psychiatric conditions.
The most prevalent co-occurring disorders exhibited by
alcoholic women are anxiety and depression, although the
eating disorder, bulimia, also is common. Unlike men,
women often experience a psychiatric problem before they
begin to abuse alcohol. Although depression is not
predictive of alcohol abuse in men, it is a major risk factor
for heavy drinking in women.21
The most common co-occurring psychiatric symptoms of
adult female patients at the Caron Foundation are
depression, anxiety, obsessive-compulsive, and somatic
symptoms.35 Adult female patients at the Caron Foundation
who participated in the NIAAA-sponsored research study
mentioned earlier reported greater overall psychiatric
severity, higher symptoms of depression, and higher levels of
learned helplessness than did male patients in the study.34 As
shown in Figure 8, female patients at the Caron Foundation
report higher rates of psychiatric distress than male patients
upon admission.20
Figure 8. Mental Health History of Alcohol
Dependent Patients at the Caron Foundation
History of
Prior inpatient
mental health treatment
Prior outpatient
mental health treatment
Prior emotional problems
Percent of patients by gender
Source: on
Women also tend to differ from men in the progression of
alcoholism. As we have seen, women suffer from a
telescoping of alcoholism and progress to the disease state
more quickly than men. However, women tend to begin
their drinking careers later than men. Female alcoholdependent patients at the Caron Foundation generally
report they initiated alcohol use approximately two years
later than male alcohol-dependent patients.20
Alcohol-dependent women appear to proceed through four
stages: (1) abuse of alcohol, (2) attempts to abstain
following negative consequences of use, (3) accommodation
to alcoholism, and (4) physiological dependence.25 In
women who do not proceed to alcoholism, drinking patterns
and alcohol-related problems appear more severe among
younger women and tend to decrease as women age.16
Age of onset of alcohol use is an important risk factor
highlighted in the more severe alcoholism subtype.
Heritable personality traits, such as high novelty-seeking
behavior, increase the risk of early experimentation with
drugs and alcohol. Likewise, environmental factors, such as
the availability and acceptability of different drugs, strongly
influence the specific drugs a vulnerable individual will
choose to abuse.26
Preadolescence and early adolescence alcohol use have been
identified as risk factors for the development of alcohol
abuse or dependence later in life. The National Longitudinal
Alcohol Epidemiologic Survey27 interviewed over 27,500
current and former alcohol users in the early 1990s. It found
that the prevalence of developing alcohol abuse or
dependence decreased dramatically the longer individuals
waited to begin alcohol use. For example, more than 40
percent of individuals who began drinking before 15 years of
age developed alcoholism, while only 10 percent of
individuals who postponed alcohol use until they were 21 or
22 years old became alcoholic. The risk factor of early age at
onset of alcohol use did not vary much between males and
females or among various racial groups.
Adolescent and young adult alcohol-use patterns often are
characterized by episodes of binge drinking five or more
drinks in succession. A recent study of adolescent drinking
patterns found that any type of binge drinking in
adolescence increased the risk of developing substance abuse
or dependence later in life.28 Teens who initiated alcohol use
early in adolescence and who were heavy binge drinkers
were at highest risk for young adult onset of substance abuse
or dependence. These early onset heavy bingers resemble
the more severe types of alcoholics, in that their risk factors
include parental alcoholism and antisocial personality
disorders. However, even teens who began drinking later in
adolescence and who moderately binged were at greater risk
for substance use problems compared with adolescents who
did not binge drink.
More than one-quarter of American youth have had more
than a few sips of alcohol before they reached 13 years of
age,29 and by twelfth grade, 80% of students use alcohol.30
Adolescent alcohol-dependent patients at the Caron
Foundation generally report they initiated alcohol use
between 13 to 14 years of age, although some patients have
reported use as young as eight years old.20
found in the 1970s,31 certain signs indicate that underage
alcohol use might be on the increase. Heavy drinking
among high school seniors is increasing, and disapproval and
beliefs about the harmfulness of heavy drinking are
decreasing.31 Adolescent patients in treatment at the Caron
Foundation report high frequencies of use, as shown in
Figure 9.20
Figure 9. Frequency of Alcohol Use
by Alcohol Dependent Adolescent
Patients at the Caron Foundation
1-2 Times
Less than
3-6 Times/
Daily use
Binge Drinking
Adolescent alcohol use is common among all socioeconomic
and demographic groups in the United States. Only minor
differences have been found among different subgroups by
region, population density, socioeconomic status, and family
structure.31 Teens report a number of reasons for using
alcohol, including enjoyment with friends, satisfaction of
curiosity, and escape from boredom or problems.31
Alcohol use among adolescents is not without danger.
Approximately 6 percent of high school students can be
diagnosed with an alcohol-use disorder.14 Teens who drink
are more likely to have higher truancy rates and poorer
grades than students who do not drink or who do not drink
excessively.31 As mentioned earlier, teenage drinking also is
associated with vehicle accidents. In addition, alcohol use
among adolescents is also closely linked to other drug use.
Some researchers consider alcohol to be a “gateway” drug
because longitudinal studies show that most teens initiate
alcohol use prior to the use of other illicit drugs.31
Similar to adult males, male teens are more likely than
female teens to report alcohol use, although the gender
difference is slight. However, almost four in ten male
adolescents report getting drunk compared to less than one
in three female adolescents.31 In addition, more adolescent
boys than girls are heavy drinkers or report binge drinking
episodes.17 Boys account for two-thirds of the Caron
Foundation’s adolescent alcohol-dependent patients.20
The Elderly
In general, persons over the age of 65 tend to consume less
alcohol and report fewer alcohol-related problems than
younger people.32, 33 However, alcohol is the primary
substance of abuse for older individuals admitted to
substance abuse treatment programs.33 Ninety percent of
Although rates of underage drinking today are much lower
than the high rates of adolescent alcohol consumption
patients 65 years or older admitted to the Caron Foundation
report alcohol as their primary drug of abuse.20
Some research suggests that aging may increase sensitivity to
the health consequences of alcohol. Elderly people tend to
reach higher blood-alcohol concentrations (BAC) than
younger people when they have consumed the same
amounts of alcohol because older people have lower
amounts of body water. The higher BAC indicates a higher
risk for inebriation.32 In addition, aging interferes with a
person’s ability to tolerate alcohol, leading to more
pronounced signs of intoxication at lower doses than
younger people experience.32
Alcohol use among older people contributes to a number of
potentially severe medical consequences. For example,
intoxication impairs balance, which puts the elderly person
at risk of falling. Because elderly alcoholics have decreased
bone density compared to nonalcoholic older people, they
experience a higher incidence of hip fractures.32 Also,
adverse alcohol-medication interactions are common among
the elderly who drink, reducing the effectiveness of
medications and sometimes causing medical harm.33 As
shown in Figure 10, elderly patients admitted to the Caron
Foundation report much higher rates of medical problems
than are reported by younger patients.20
can be due to a pattern of lifetime alcohol abuse, increased
alcohol use in later life, or the increased likelihood of being
admitted to a healthcare facility because of the adverse
consequences of excessive alcohol use. As discussed earlier,
medical and cognitive alcohol-related conditions often
emerge slowly over time with the most severe consequences
not appearing until middle and old age.
Older age is a significant barrier to treatment. Older
alcoholics appear to have the lowest rates of access to
addiction treatment for several reasons. Many can not afford
the cost of treatment. At the Caron Foundation elderly
patients are more likely to be unemployed due to retirement
or disability than younger patients.20 Also, specialized
treatment programs for the elderly are scarce. In addition,
healthcare providers and family members often are not
aware of alcohol-related problems and therefore do not
intervene and recommend treatment.32
Percent of patients
reporting any medical
problem at admission
Figure 10. Prevalence of Medical Problems of Alcohol
Dependent Patients at the Caron Foundation
18 or
Age Range
Section IV:Treatment and Recovery
Approximately 18 million Americans, who represent almost
8 percent of the population, required alcohol treatment in
2003.1 Unfortunately, only slightly more than 7 percent of
these individuals (1.3 million people) were able to receive
treatment at a program dedicated to addiction treatment.1
This section describes settings for alcohol treatment, special
concerns of detoxification, the various methods for treating
alcohol disorders, and treatment effectiveness, and concludes
with a discussion of the predictors of recovery.
Source: on
Older Americans who require specialized healthcare may be
at greater risk for alcohol abuse. Surveys of the elderly
admitted to healthcare facilities, such as hospitals,
psychiatric wards, emergency rooms, and nursing homes,
show higher rates of alcoholism than are found in older
people residing in the general population.32 The prevalence
of excessive alcohol use by the elderly in healthcare facilities
Detoxification is an important first step in alcohol treatment
because the sudden cessation of alcohol use may result in
alcohol withdrawal syndrome. As mentioned earlier in this
report, alcohol withdrawal is characterized by a range of
symptoms from mild irritability, tremors, and insomnia to
more severe complications such as seizures, hallucinations,
and delirium tremens.2 More severe symptoms, including
death, are more likely to occur if the patient has other
medical or nutritional complications.3
Settings for Alcohol Treatment
Alcohol treatment can be conducted in inpatient or
outpatient settings. Selection of the appropriate level of care
is determined by the severity of the patient’s alcoholism and
the degree to which the patient can function. Programs
differ in the intensity of care and ability to provide a wide
array of services essential for severely impaired individuals.
Inpatient programs, like the Caron Foundation, provide
professional staff members 24 hours a day to manage the
patient’s acute medical, psychological, and addiction
problems.2 Inpatient programs immerse the patient in an
intensive treatment program that includes therapeutic,
educational, and rehabilitation services. Inpatient programs
can be hospital based or freestanding residential programs.
While most inpatient programs are based on the traditional
one-month model of care, programs vary in duration. Some
programs, such as the Caron Foundation, include less
intensive but longer duration extended care programs.2
Other inpatient programs, such as halfway houses, provide a
supportive environment for transition into the community.
Outpatient programs provide a less intensive level of care
and tend to focus mainly on addiction treatment.
Outpatient programs include intensive day treatment in
which patients attend treatment up to eight hours every day,
intensive outpatient programs in which patients attend
treatment part of the day, and outpatient programs that
meet once or twice a week. Most alcoholic patients receive
treatment in outpatient programs.2 They can be admitted
initially to the outpatient program or transferred to
outpatient care following discharge from an inpatient or
extended care program.
65 or
A medically supervised outpatient detoxification is effective
for many alcoholics, but others require a more intensive
inpatient detoxification program.3 Barber and O’Brien
identified four conditions that indicate the necessity of
inpatient detoxification: (1) inability to abstain from alcohol
despite treatment; (2) co-occurring medical or psychiatric
problems that require attention; (3) inadequate social
supports; and (4) need to leave a disruptive environment
that reinforces alcohol use.3 In these cases, an inpatient
program that provides around-the-clock medical supervision
is the preferable site for detoxification.
The primary objective for a medically supervised
detoxification is to prevent severe life-threatening
withdrawal symptoms of seizures, delirium, and arrhythmias.
Since detoxification also relieves other disturbing symptoms
of anxiety, restlessness, and insomnia, it may increase the
patient’s retention in treatment.2 Medications are often used
to treat patients with moderate to severe withdrawal
symptoms. Benzodiazepines, a type of sedative that affects
the brain in a similar fashion to alcohol, are often used to
alleviate the symptoms of withdrawal. Although abusive use
of benzodiazepines can become addictive, controlled and
medically supervised short-term use has been found to be
effective and safe.2
Although most acute withdrawal symptoms generally cease
within a week of abstinence, some symptoms, such as
anxiety and sleep disturbance, can take months to
disappear.4 Cognitive impairment associated with alcohol
use usually subsides, too. However, it tends to be most severe
in the first few weeks following detoxification, making
normal functioning difficult for impaired patients.5 Alcoholfree, low-stress environments, such as inpatient programs,
can be the most beneficial treatment settings for patients
who continue to exhibit cognitive problems following
Detoxification alone does not represent a complete course of
alcohol treatment. Its goal is to remove alcohol from the
body and helps to clear the mind for continued treatment.
Alcohol treatment that follows detoxification focuses on
strategies to continue abstinence from alcohol.
Behavioral Treatment
Behavioral treatment strategies for alcohol abuse and
dependence focus on cognitive and behavioral techniques to
induce positive changes in alcohol use. A number of
behavioral strategies have been scientifically developed in
academic institutions. These strategies are usually detailed in
treatment manuals that describe how to conduct the
intervention so that it can be used in different conditions
and maintain fidelity.
Effectiveness of behavioral strategies is measured by clinical
trials that randomly assign participants to the treatment or
to a “control” intervention, such as a waiting list for
treatment or a different type of treatment. Effective
treatments are those with repeated clinical trials that show
the treatment has stronger results than its comparison.
Behavioral strategies that have strong effectiveness for
alcoholism include the community reinforcement approach,
motivational enhancement therapies, use of selected selfhelp manuals, behavioral self-control training, behavioral
contracting, social skills training, behavioral marital therapy,
and case management.6
The most commonly used behavioral strategies in the
alcohol treatment field are: brief treatment interventions
that educate and motivate people about alcoholism and
professional treatment; the disease model of treatment,
which is the most prevalent type of behavioral strategy but
with little empirical validation; and Alcoholics Anonymous,
which is not a treatment, but a widely used self-help
approach to recovery.
Brief Treatment
Disease Model of Treatment
Brief treatment interventions generally consist of a few
sessions. The goals of brief treatment are to educate patients
about the negative consequences of their alcohol use, and to
motivate alcohol abusers to reduce use and alcoholics to
engage in formal treatment.6 Brief interventions may be
especially useful in the initial identification of patients with
alcohol-related problems because brief interventions can be
effectively utilized by health care providers who practice
outside of the traditional alcohol-treatment field.
The disease model of treatment is one of the most widely
used treatments in the United States. Over 95 percent of
addiction treatment centers in the United States follow a
model of care based on the disease model.9 It was developed
as a one-month inpatient treatment modality, but has
successfully been implemented in extended care and
outpatient programs.
Motivational enhancement therapy (MET), a relatively
short treatment approach, can consist of one to four
motivational interviewing sessions. MET was scientifically
developed for a national alcohol treatment comparison
study, Project MATCH. The four-session model of MET
consists of building motivation for change, strengthening
commitment to change, involving a significant other person
in the change, and following through on the strategies
developed to change.7 Therapists work closely with their
patients to identify the benefits of abstinence, review and
select appropriate treatment options, and design a plan to
implement treatment goals.2
This treatment approach is based on the disease model of
addiction. It assumes that alcoholism is a chronic disease
that can worsen if not treated. It realizes that alcoholism has
severe negative effects on the alcoholic’s physical,
psychological, and spiritual health, and on the person’s
family, employment, and social relationships. Treatment
programs based on the disease model of treatment, such as
the Caron Foundation, provide a comprehensive treatment
approach. A multidisciplinary team, often consisting of
medical and psychological health care providers, addiction
counselors, and spiritual guides, collaborate to develop
treatment plans that address these multiple needs of
Clinicians who use the MET approach are trained to express
empathy with patients, identify discrepancies in the patient’s
faulty thought processes, and support the patient’s selfefficacy. They are taught how to avoid arguments and how
to handle resistance productively.
The disease model of alcoholism also views the addictive
behavior as a symptom of an underlying spiritual crisis. To
recover from alcoholism, the individual must address the
larger issues of spirituality and character development.9, 10
Therapeutic change is hypothesized to occur through
acceptance and adherence to the 12 steps of Alcoholics
Anonymous and its methodology of education, therapy, and
fellowship.11 Education provides the basic information
concerning the disease process and strategy for recovery.
Therapy addresses the emotional impediments to change,
and facilitates the development of skills and attitudes to
sustain recovery. Fellowship establishes the interpersonal
supports necessary for long-term recovery, and develops the
sense of connection and spirituality integral to the
Even though MET is a brief treatment, it was shown to be
just as effective as the longer therapies tested in Project
MATCH. More than three published, methodologically
sound MET studies produced positive outcomes,offering
strong evidence of MET’s effectiveness.6
The process of treatment initially focuses on recognition and
acceptance of the disease of alcoholism, followed by the
development of skills to build a sense of self-efficacy.
Patients are taught useful skills to change their thought
patterns and behaviors concerning alcohol. In addition,
Based on the principles of motivational psychology, MET
posits that the responsibility and ability to change is found
within the person.7 Instead of trying to cajole, confront, or
convince alcoholics to change their self-defeating behaviors,
MET uses motivational strategies to promote a desire to
change. MET is designed to increase the motivation for
change for individuals who may not even be aware that they
have a problem with alcohol.
patients are introduced to the concept of a Higher Power as
a positive resource and connection.11 More advanced phases
of treatment include learning how to take interpersonal risks
that confront earlier dysfunctional ways of dealing with
people and situations leading to alcohol use. Patients also
complete a self-inventory of their prior behaviors under the
influence of alcohol and learn how to release themselves
from the wrongs they might have done.11
Because the disease model of treatment is so strongly linked
to 12-step recovery, it is not surprising that a major
component of treatment is the introduction of Alcoholics
Anonymous (AA) during treatment and motivation to
attend AA as part of aftercare following discharge.
Treatment programs are responsible for introducing almost
35 percent of the members of AA to the organization.12
The disease model of treatment has not been extensively
studied for effectiveness, probably because of its clinical, not
academic, origins. One study compared employed alcoholics
who were randomly assigned either to (1) participate in
three weeks of inpatient treatment followed by one year
attendance at AA meetings, (2) attend AA meetings only,
or (3) choose between the two programs.13 The patients
were followed for two years. The researchers found that
patients who completed inpatient treatment and followed it
with AA involvement had the lowest rates of relapse of the
three groups. These results suggest that integration of AA
with an inpatient disease model treatment program is more
effective in preventing relapse than referral to AA alone.
Twelve-Step Facilitation (TSF)2 has been developed by the
scientific community as a means of comparing the disease
model to other treatment approaches. Similar to the disease
model, TSF is based on the concept that alcoholism is a
medical and spiritual disease. The treatment systematically
introduces patients to AA and motivates them to become
involved in AA meetings and activities. Project MATCH
randomly assigned patients to receive cognitive behavioral
therapy, motivational enhancement therapy, or TSF in
outpatient settings. The TSF groups were patients who
either had completed an inpatient course of treatment
(aftercare sample) or would receive their initial treatment as
part of the project (outpatient sample). The study found
that the aftercare sample generally was more successful at
maintaining abstinence. Individuals in the outpatient group
who were randomized to TSF generally had better
abstinence rates following treatment.14 These results suggest
that the disease model of treatment combined with AA
involvement is effective for naïve outpatients as well as for
outpatients who have completed an inpatient episode of
Percent of alcohol dependent
patients reporting prior AA
involvement at admission
completed. AA views recovery from addiction as a lifelong
process, and involvement in AA is a lifetime commitment
to recovery.
Alcoholics Anonymous
Although formal treatment begins the recovery process, selfhelp programs based on 12-step principles, continue the
lifetime process of maintaining recovery. Alcoholics
Anonymous (AA), started with a few members in 1935 and
dramatically increased membership in the next 50 years to
over 1.7 million members in 94,000 AA groups worldwide.9
Other programs based on the same philosophy as AA soon
began to develop to deal with more diverse issues of
addiction, such as Al-Anon, a support group for family
members of addicts and alcoholics.
Figure 11. Prior AA Involvement of
Caron Foundation Patients
19 or
60 or
Age Group in Years
Source: on
It has been difficult to scientifically study the effectiveness of
AA because it is a voluntary organization. However, a
number of naturalistic studies suggest that it is an effective
means of maintaining abstinence. AA has been conducting
triennial anonymous scientific surveys of its members since
1968. According to a survey completed in 1998, the average
length of sobriety for its members is more than seven years
with almost half of the members sober for more than five
years.12 A recent scientific investigation of AA found that
individuals who participated in AA four months or longer
had better eight-year alcohol-related outcomes than did
individuals who did not become involved in AA.17 In
addition, two large-scale analyses of many research studies
on AA found that participation in AA is related to
improved psychosocial functioning and decreased drinking.18
AA differs from formal treatment, even disease model
treatment, in a number of important ways. AA is based in
community involvement, rather than individual treatment,
and participation in the fellowship meetings and sponsorship
are essential components of AA. The community approach
of AA appears to be very helpful to individuals who have
destructive social networks that support their drinking,
because AA introduces them to new constructive social
networks of people who support each other’s sobriety.15
Individuals with heavy alcohol use and psychiatric problems
have been found to benefit from AA involvement, possibly
because the 12-step social network provides external
supports to compensate for poor internal resources.16 AA
also appears helpful to individuals who have suffered
cognitive impairment because it allows participants to
incorporate new information gradually.5
Also, AA participation does not appear to be influenced by
employment status, education, or race.19 Although AA
began mainly as a white, middle-aged male-dominated
program, the most recent membership survey revealed a
much more diverse membership. The percentage of female
members rose to 34 percent in 1998 from 22 percent in
1968, and members age 30 years or younger currently
comprise 9 percent of the membership.12 Both male and
female alcoholic patients at the Caron Foundation have
reported similar rates of AA involvement.20 However, as
shown in Figure 11, adolescents in treatment for alcoholism
report much lower levels of AA involvement than adult
patients, and middle-aged patients report the highest levels
of AA involvement prior to treatment.
Formal treatment programs utilize professionals to help
people with addictions, whereas the “experts” in 12-step
programs are its members. Twelve-step groups are not lead
by professional therapists or counselors; they are lead by the
people who come for help. Addiction treatment also is
finite. Patients are expected to learn the new behaviors in
treatment and to continue using them when treatment is
Active participation in AA involves much more
engagement than simply attending meetings. AA members
who engage in AA-related activities, such as reading AA
materials and becoming a sponsor, are more likely to have
longer-term recovery rates than members who passively
attend meetings.21 Involvement in AA following addiction
treatment is related to increased positive ways of coping,
high commitment to continued abstinence, and an
increased sense of self-efficacy.22 However, a major
impediment to the effectiveness of 12-step programs is the
high dropout rate. It has been estimated that 50 percent of
AA members drop out within the first three months and
that only 20 percent of alcoholics referred to AA regularly
attend meetings.9
maintenance medications. Three medications approved by
the Federal Drug Administration (FDA) that represent
major advances in pharmacological treatment will be
presented, followed by a discussion of possible reasons why
we have not yet discovered the “magic pill.”
Disulfiram (AntabuseTM) was developed in the 1940s and
for 50 years was the only FDA-approved medication for
alcohol maintenance. Dilsufiram inhibits aldehyde
dehydrogenase, an enzyme that metabolizes alcohol.3 If a
person consumes alcohol while using disurfiram, the
medication produces unpleasant symptoms, such as
headache, nausea, vomiting, flushing, anxiety, vertigo, and
confusion. The theory behind the development and use of
disulfiram is that it will deter people from alcohol use
because they realize that the alcohol-disulfiram reaction will
make them physically ill.
In order to determine why people do not become actively
involved or drop out from AA, researchers have examined
the attributes of individuals who successfully use the
program and those who drop out. Self-identification as an
alcoholic appears important for successful 12-step program
affiliation. A study of AA affiliation following discharge
from treatment found that individuals who remained
involved in AA were more accepting of all aspects of the
program than were individuals who rejected the program or
who thought their drinking was not very serious.23
There have been relatively few controlled clinical trials of
disulfiram. The results of these studies show modest support
that disulfiram reduces the frequency of alcohol use, but
does not increase abstinence.24 There is little evidence that
disulfiram works better than a placebo.3 The positive effects
of disulfiram are due to fears about negative reactions with
alcohol, not the effects of any active ingredients of the
Thus, it appears that AA is as effective as a person wants it
to be! Active long-term involvement in AA is strongly
related to recovery and improved psychosocial functioning.
Involvement, however, is more demanding than simple
cessation of alcohol use and requires a greater level of
participation than mere attendance at meetings. The
research on AA strongly indicates that its effectiveness is
intertwined with acceptance of the philosophy, spirituality,
and personal growth inherent in the 12-step approach.
Thus, individuals who adhere to their prescribed use of
disulfiram (or a placebo that they believe is disulfiram) tend
to avoid alcohol use. However, because alcoholism is a
disease characterized by ambivalence, denial, and relapse,
individuals who find excuses not to take disulfiram are more
likely to return to alcohol use. Disulfiram is more effective
when another person observes the patient correctly taking
the prescribed dose, when incentives are offered for
compliance, and when patients receive reminders about
taking their medication.4, 25
Medications for Alcoholism
As research discovers the ways in which alcohol affects the
brain, medications are emerging as important treatment
tools for alcoholism. The focus of pharmacological treatment
for alcoholism is to assist recovery by modifying activity of
the brain that is negatively affected by alcohol.
Although there has been much progress in medications that
ease the detoxification process, this section focuses only on
In 1994, 50 years after the appearance of disulfiram,
naltrexone hydrochloride (ReViaTM) was approved by the
FDA for the treatment of alcoholism. Unlike disulfiram,
which creates aversive effects, naltrexone reduces the
pleasurable aspects of alcohol by blocking the narcotic
effects on the brain’s opiate receptor sites. The idea
underlying this treatment is that people will not continue to
drink if they do not experience the positive “rewards” of
Limitations of Pharmacotherapy
Naltrexone has been found to be effective in preventing
alcohol relapse for alcohol-dependent individuals.26, 27 A
report that analyzed a large number of randomized
controlled studies of naltrexone concluded that alcoholdependent individuals assigned to naltrexone experienced
lower relapse rates and alcohol consumption compared with
individuals treated with placebo.28 Clinical trials have found
naltrexone to be especially beneficial to alcohol-dependent
individuals who experience high levels of cravings and who
have a family history of alcohol problems.26, 29, 30, 31
Despite over 50 years of research, only three medications
have been approved for the treatment of alcoholism. There
is no “magic pill” to treat alcoholism because not all patients
respond well to medications. An effective medication needs
to target an individual’s biology, but more research is needed
to identify genetic traits that shape response to alcohol.35
Although molecular genetics research is in the process of
identifying specific genes responsible for alcohol-related
behaviors, research is still in its early stages. The usefulness
of current pharmacotherapy for alcoholism remains limited
due to a number of factors.
abuse other drugs. Also, not all patients respond well to
acamprosate and more research is needed to identify the
specific alcoholic subgroups for whom it can be useful.25
Naltrexone appears to reduce a person’s emotional response
to alcohol; patients have reported that naltrexone reduces
the alcohol “high” that they experience.24 This lowered
emotional reaction might dissuade people who have one
drink from progressing to heavy alcohol consumption.
Naltrexone use alone does not guarantee abstinence. Similar
to disulfiram, compliance with naltrexone is low except
among highly motivated individuals, such as probationers32
and health care professionals, who can suffer severe negative
consequences if they relapse.33
None of the medications developed thus far have been
shown to eliminate alcohol use completely. At best,
medications assist people in their journey to recovery by
helping to deter alcohol use through adverse consequences
(disulfiram) or through a decrease in the pleasurable rewards
of alcohol (naltrexone and acamprosate). Even in the most
rigorous clinical trials, none of these medications were
completely effective in producing abstinence. Instead, the
effectiveness of the medications has been shown through
longer periods of abstinence and lower levels of alcohol use
compared to placebo.
free of side effects, and toleration of unpleasant side effects
may be problematic for some individuals.37 The ambivalence
of addiction also may lead some alcoholics to question the
continuation of a medication that causes adverse effects or
that reduces the pleasurable consequences of drinking.
Although behavioral interventions to increase compliance
have been developed, we do not know if patients are told
about them or use the interventions consistently.
Clinical trials of medications also generally restrict
participation to alcoholics who do not have other cooccurring medical or psychiatric conditions or who do not
also abuse other drugs despite the reality that many
alcoholics do have co-occurring conditions and do abuse
other drugs.25 When these medications are approved and
introduced into clinical practice, health care providers are
uncertain about their potential effectiveness with these “real
world” patients.
Acamprosate (CampralTM) was approved by the FDA for
alcohol treatment in 2004. Acamprosate appears to block
the glutamate receptor in the brain and, thereby, decrease
the intensity of a person’s craving for alcohol.34 It is well
tolerated and has few side effects.34
Research studies involving more than 3,000 patients
indicate that acamprosate is effective in the treatment of
alcoholism.25 The research literature has found that patients
on acamprosate generally have higher rates of abstinence
and longer periods of abstinence than patients on placebo.35
Acamprosate has been shown to benefit patients, regardless
of gender, age, or liver function status.36 It appears to be
effective for use with alcoholics who have stopped drinking,
but may not work with active alcoholics or patients who
Patients also do not always comply with medication
regimens. As we have seen, compliance is a major
impediment to the effectiveness of disulfiram and
naltrexone.25 People do not comply with their prescriptions
for a wide variety of reasons. No medication is completely
When the Caron Foundation prepared itself to introduce
naltrexone to the clinical population, we surveyed staff
attitudes and knowledge prior to and following training.
Consistent with prior research,39 we found that medical staff
and staff with higher academic degrees appeared to hold
more positive attitudes and knowledge regarding naltrexone
than other staff prior to the training.39, 40 As shown in Figure
12, all staff increased their knowledge and positive attitudes
toward the medication following training, resulting in no
significant differences among staff.
Thus, medications are a useful treatment in a
multidisciplinary approach. To achieve maximum
effectiveness, they should be used in conjunction with a
behavioral strategy.
Clinical medication trials generally have a multidisciplinary
approach, combining medication or placebo with a tested
behavioral strategy. Results of these studies tend to focus
primarily on the effects of medication without consideration
of the role of the behavioral treatment in effectiveness—
although the type and intensity of behavioral treatment has
been shown to impact medication trials.25 It is not known
how well patients in real-world settings follow through on
the recommendation to engage in behavioral treatment in
conjunction with medications or if they use effective
behavioral treatments at all.
Figure 12. Caron Foundation Clinical Staff
Attitudes Before and After Naltrexone Training
Use with 12-step
Treatment is effective when it increases abstinence from
alcohol, decreases alcohol-related problems, and helps to
restore the patient’s ability to function in major life areas.
We are now able to identify various elements that predict
which patients are more likely to achieve and maintain
abstinence. As more predictors of recovery are identified and
strategies to improve them are incorporated into treatment
programs, recovery rates for alcoholism also might increase.
Use at Caron
Prevents relapse
Not addictive
Treatment Effectiveness
counselors positively impacted naltrexone use. Another
survey of the attitudes of clinicians regarding addiction
treatment, found that physicians and psychiatrists, providers
with more years of experience in the field, and providers
with more advanced degrees showed the highest support for
use of medications.39
Source: on
Recovery Rates
Medications also have not been well accepted by the
alcohol treatment field. For example, an ongoing survey of a
national sample of 400 private substance abuse treatment
programs found that naltrexone was used in less than half of
the sample.38 Interestingly, the research team found that the
composition of professionals involved in the treatment
programs was key to the adoption of naltrexone: older, more
established programs whose administrators were considered
to be opinion leaders were more likely to adopt the use of
naltrexone; and programs with higher proportions of degreed
Relapse rates for alcoholism and other addictive diseases do
not differ significantly from other chronic diseases, such as
diabetes, hypertension, and asthma.41 Following alcohol
treatment, as many as 70 percent of employed patients with
family support, and up to 50 percent of less stable
unemployed patients, have reported extended periods of
abstinence of one year or more.4 In a current study on the
relationship of spirituality to recovery from alcoholism
sponsored by the National Institute on Alcoholism and
Alcohol Abuse (NIAAA) in which the Caron Foundation
is a participating site, 240 adult alcoholic patients agreed to
be contacted regarding their alcohol use after three months
following admission to an inpatient treatment program.42
Eighty percent of the contacted patients (57 percent of the
complete sample) reported complete abstinence since
discharge. In addition, the number of days a month patients
consumed alcohol decreased from an average of 20 days a
month prior to treatment to an average of less than two days
a month prior to the follow-up evaluation.43
well-being also tend to have a higher prognosis for
abstinence than alcoholics who suffer from psychiatric
Self-efficacy is a term used to describe a person’s confidence
in refusing alcohol. Numerous studies have related selfefficacy to abstinence. Although self-efficacy tends to
increase with the maintenance of abstinence over time,
prospective research studies have found that levels of selfefficacy attained during treatment also predict future
abstinence rates.50
Studies of eight- to 20-year follow-up contacts of treated
alcoholics have found that abstinence or nonproblem
drinking rates range from 21 to 83 percent.44 Relapse to
alcohol use decreases with time for alcoholics who maintain
extended periods of abstinence. For example, Vallient’s longterm study of college-educated and lower-income men found
that only 7 percent of the men who had six years of
abstinence eventually relapsed to drinking.45
As we have seen, craving for alcohol occurs for some
alcoholics during withdrawal. Craving is an emotional state
in which a person experiences a strong desire or motivation
for alcohol.51 Although the previous week’s reported alcohol
cravings more strongly predicts the subsequent week’s
alcohol use than does prior drinking, many alcoholdependent individuals do not experience cravings.
These factors may be interconnected for some alcoholics.
For example, a recent study found that alcoholic-research
participants who were abstinent from alcohol for one year
following treatment tended to have higher rates of selfefficacy and psychiatric functioning than participants who
relapsed to alcohol use.49 Another study of alcoholics
admitted to outpatient treatment found that the participants
who strongly craved alcohol were more likely to have higher
rates of depression than participants who had low cravings.52
A growing body of research strongly indicates that treatment
for drug and alcohol addiction often is accompanied by
decreases in other problems. For example, following
treatment for substance dependence, addicted persons are
more likely to be employed and earning higher incomes
than before treatment. A recent treatment-outcomes study
found that 18 months following treatment the patients
increased their work income and deceased income from
crime or public assistance.46 Also, the current NIAAA
funded study in which the Caron Foundation is participating
found that patients significantly decreased depressive
symptoms during treatment.47
NIAAA-sponsored research conducted at the Caron
Foundation and another residential treatment program also
found a relationship among cravings for alcohol, self-efficacy
in refusing alcohol, levels of spirituality, and depression.42
Initial results from the study indicate that craving for
alcohol prior to discharge from the residential treatment
program predicted relapse to alcohol use prior to the threemonth follow-up evaluation. Almost 40 percent of patients
actively desired alcohol during treatment. Patients who
actively craved alcohol throughout treatment could be
predicted by their admission ratings on depression, selfefficacy and spirituality. Specifically, the active cravers
entered treatment with higher rates of depression, lower
senses of self-efficacy, and lower levels of spirituality than
the noncravers.
Predictors of Recovery
A number of factors related to the individual and to the
treatment program appear to be related to recovery.
Alcoholics who have higher levels of psychiatric
functioning, increased confidence in one’s ability to refuse
alcohol, and lower cravings for alcohol appear more likely to
maintain abstinence over extended periods of time.
Psychiatric functioning is a measurement of a person’s
emotional well-being. As described earlier, poor psychiatric
functioning is strongly related to the development of alcohol
dependence.48 Alcoholics with higher levels of psychiatric
psychiatric medications, and target mood disorder symptoms
It is intriguing that spirituality could play a role in recovery
from alcoholism. Spirituality differs from religious
observance in that spirituality is defined by a belief in a
higher power and/or a connection with a larger sense of
being rather than adherence to a set of proscribed rituals or
behaviors. In a separate analysis, Sterling found that patients
who reported no alcohol use in the month prior to the
follow-up evaluation had higher levels of spirituality than
participants who consumed any alcohol, although both
groups had comparatively low levels of spirituality at
admission to treatment.47
Matching patients to necessary services might increase their
success in maintaining abstinence. Preliminary results by
Sterling suggest that alcoholic patients who have high
spirituality needs and who receive treatment in a program
that addresses spirituality complete treatment with higher
confidence in their ability to refuse alcohol than do similar
patients who attend a program that does not address
Likewise, patients who continue to crave alcohol while
abstinent also appear to have special treatment needs.
Although these patients improve psychosocial functioning
during treatment, they tend to complete treatment with
significantly higher depressive symptoms and lower ability to
refuse alcohol than do patients who do not crave alcohol.42
Programs that proactively address craving with cravingreduction medications, such as acamprosate and naltrexone,
provide psychiatric interventions, and teach relapse
prevention skills, might be able to increase recovery rates for
these high cravers of alcohol.
Treatment factors also predict recovery. Longer durations of
treatment tend to appear more effective than shorter
durations of care. The National Institute of Drug Abuse
recommends more than 90 days of care in residential or
outpatient facilities to increase treatment effectiveness.53 In
addition, patients who adhere to their course of treatment
by attending counseling sessions, using medications as
prescribed, adhering to continuing care recommendations,
and following the advise of their care providers concerning
lifestyle changes also tend to have better outcomes.
Positive changes in psychosocial functioning can and do
occur during treatment. For example, in general, patients
who participated in the NIAAA-sponsored research project
at the Caron Foundation and another facility showed
significant increases in self-efficacy and decreases in
depressive symptoms from admission to discharge.47 Even
spirituality showed significantly positive increases through
the use of multiple measurements in this research.
The first step to recovery is recognition by the individual
that he or she has a problem with alcohol. Some warning
signs of alcohol abuse or dependence are:
• Frequent and/or excessive alcohol consumption
• Embarrassing or problematic behavior while under the
influence of alcohol
• No memory of events that occurred while drinking
• Starting the day with a drink
• Family, coworkers, and/or friends express concern about
drinking habits
• Excuses and reasons to continue drinking despite
alcohol-related problems
It is important for treatment programs to focus on specific
areas of functioning that need to be enhanced in order to
increase recovery rates for patients. Programs that focus on
the patient’s psychiatric needs in addition to addictiontreatment needs are often able to decrease disabling
psychiatric symptoms that persist despite abstinence from
alcohol. Clinical trials now support the judicious use of
antidepressants for depressive symptoms.54 Behavioral
therapies also have been developed to increase treatment
engagement and retention, improve compliance with
Alcoholism in a complex disease and manifests itself
differently in different people. Don’t expect to develop all of
the warning signs and symptoms of alcohol abuse or
dependency. Individuals concerned about their alcohol use
should seek help at the first warning signs!
variety of pharmacological and behavioral treatments are
effective in promoting long-term abstinence and recovery.
The chronic nature of alcoholism increases risk for relapse.
However, a speedy renewed commitment to recovery
following a slip or relapse is an important step toward longterm recovery. Compared to other chronic diseases, rates of
recovery from alcoholism are good and will increase as we
learn more about the disease and how to treat it.
Many people are able to change their abusive use of alcohol
on their own. However, those who develop alcohol
dependence often need the assistance of professionals and a
supportive network. Alcoholism affects many areas of a
person’s life and long-term recovery often requires significant
lifestyle changes.
Reputable treatment programs can begin the path to
recovery. These programs provide comprehensive
assessments and individualized treatment plans that match
patient needs with specialized services. Superior treatment
programs offer a wide array of services to address medical,
psychiatric, social, and spiritual needs. They intervene to
increase motivation, teach crucial drink-refusal and relapseprevention skills, and provide a strong social support
network. In addition, many treatment programs offer
specialized programs that teach family members how to
support recovery.
Patients should not be surprised when their treatment is
expected to continue past the initial detoxification,
outpatient or inpatient episode. Remember, alcoholism is a
chronic disease and should not be treated as an acute illness.
To strengthen one’s commitment to maintain the multiple
psychosocial lifestyle changes necessary for recovery,
treatment programs recommend intensive continuing care
plans. These plans can include a longer duration of care in a
halfway house, an extended care program, or continued
outpatient treatment. Continuing care also involves a
commitment to maintain positive changes in psychosocial
functioning. Many patients leave treatment with referrals for
continued medical or psychiatric treatment and plans for
employment and education. A plan for active participation
in a peer-help group, such as Alcoholics Anonymous, also
an integral part of a continued care plan. These
organizations provide support and guidance along the road
to recovery.
In summary, alcoholism is a disease—not a moral failing.
Like many other diseases, it occurs through a combination of
inherited and environmental conditions. Although
untreated alcoholism can result in severe consequences
including early death, the prognosis is encouraging. A
Alcohol Treatment at the
Caron Foundation
David Rosenker
Executive Vice President of Treatment Services
Caron Foundation
Alcohol is the most widely abused substance in combine individual and group therapy,
therapeutic activities, daily lectures, and
the United States. At the Caron Foundation,
continuing care planning for each resident
many of our patients, adolescents or adults,
during his or her stay at Caron. An appropriate
have experienced significant problems
referral to an individual’s next level of care is
associated with alcohol use.
made following residential treatment, and
Caron staff routinely follow up with former
Alcoholism, which affects one in every three
patients, keep in touch with them, and track
American families, is more than a drug or
their progress.
alcohol problem that’s out of control. It’s a
medically diagnosable disease that is chronic,
Alcoholism is frequently difficult to identify,
progressive, and potentially fatal. The good
not only in its early stage, but also when there
news is, as many other diseases, alcoholism can
be successfully treated. Our national reputation are other co-occurring disorders. Caron
Foundation’s Residential Assessment Program
for quality care is based on our in-depth
offers an excellent opportunity to intervene on
knowledge and experience in successfully
a suspected addiction in the early stages.
treating alcoholism. Through daily lectures by
Typically encompassing four to five days, the
our professional staff, group sharing, individual
residential program provides the critical
counseling, films, selective reading, back-tomeasurements necessary to determine just how
work conferences, family sessions, and personal
alcoholism is impacting an individual’s life.
attention, each and every person in our care is
The program examines psychiatric,
given the tools to help form a solid foundation
psychological, and medical dynamics affecting
for recovery.
the patient. A multidisciplinary team
coordinates the assessment process that
Residential programs at Caron offer complete
includes the patient’s family, employer, and
gender-specific, affordable alcoholism
referral source, which are integral parts of the
treatment services. Continuing Caron’s
assessment process.
tradition of comprehensive recovery services
has made Caron a model for treatment centers
In addition to taking part in the assessment
worldwide. The Caron treatment program is
portion of the program, residents also
based on the 12-Step philosophy and its
participate in education via patient lectures,
timeless principles of hope, healing, and
group sessions, and community meetings.
recovery. At Caron, we treat the whole
Upon completion of the assessment and
individual—medically, spiritually, and
education phases, the patient, family, and
physically. A team of seasoned professionals
referral source are brought together for a post
provides multidisciplinary services.
assessment/feedback meeting. Diagnostic
Individualized treatment plans for patients
profile and a psychosocial history, determines
whether the relapse program is appropriate for
the patient. Caron’s innovative programs give
patients in relapse a place where they can
overcome feelings of failure, identify with
others in a similar situation, and find hope.
Caron’s staff utilizes a blend of therapeutic
approaches to meet each patient’s individual
needs. With a wealth of experience, Caron’s
staff brings a totally innovative approach to
relapse treatment.
findings, impressions, and recommendations
for an indicated level of treatment
intervention, if applicable, are offered at this
Caron’s Residential Assessment Program
provides individuals, families, and referrals a
safe and caring environment where the
predictable social wreckage and loss associated
with the later stages of alcoholism can be
prudently managed. For most people
experiencing withdrawal from alcohol, the
safest place to begin the recovery process is in a
setting with medical supervision. At Caron, we
provide complete medical evaluation and
detoxification. A team comprised of
physicians, nurses, and counselors meets daily
to review each patient’s progress. The team
then makes specific recommendations to help
direct recovery and to determine appropriate
continuing care.
Renaissance Institute, a Caron Foundation
recovery center, located in Boca Raton,
Florida, is an extended care facility that serves
Caron patients who require long-term,
continuing care. Based on a family-centered
treatment philosophy, this facility provides
specialized care for alcohol-dependent
individuals who have completed a primary
residential program, but would benefit from a
transitional therapeutic environment.
Renaissance Institute gives newly recovering
patients the time and place to restore their
self-identity and self-worth, while learning to
accept responsibility for their personal affairs
and well-being.
To aid in individual treatment planning, a
psychological assessment is conducted at the
onset of treatment. This allows the treatment
staff to understand the individual psychological
factors that should be considered when
treating a resident’s alcoholism. In addition to
psychological testing and evaluation,
individual psychological intervention is
provided when appropriate. Psychologists also
offer gender-specific psychotherapy groups and
groups for recovering professionals. Psychiatric
evaluation is also available in instances where
medication management is necessary. A
multidisciplinary treatment team approach
provides psychological services with a focus on
recovery from drug and alcohol dependency.
The Caron Foundation strongly believes that
in order for alcoholics to obtain the best results
of their recovery, it is critical that they stay
connected to Caron and the recovery process
itself for a miimum of one year. To help this
happen Caron Foundation has developed
Recovery Care Management to engage
patients in Recovery For Life. The Recovery
Care Management program offers individuals
and families ready access to a care manager
who provides them with consultation,
direction, and intervention when necessary.
The care manager brings the chaos of
alcoholism and early recovery into a focused
aftercare plan, with the ultimate goal of
offering a greater chance of long-term sobriety.
All recovery care patients enter into a
customized program of care that fits their
aftercare plans, living environment, and
unique lifestyles.
Because alcoholism is a chronic disease, the
potential for relapse exists. Many people find
themselves in active relapse even though they
received excellent treatment or experienced
successful periods of sobriety. Caron offers
specific residential programs to help patients
explore their relapse issues and develop
strategies to address relapse patterns. An initial
comprehensive assessment, including a relapse
Section I: What Is Alcohol?
Substance Abuse and Mental Health Services
Administration (2004)
Caron Foundation (2004)
Moak, D.H., and R.F. Anton (1999)
Tabakoff, B., and P.L. Hoffman (2004)
Schuckit, M.A., and S. Tapert (2004)
Keller, M., and J. Doria (1991)
Grant, B.F., and D.A. Dawson (1999)
McLellan, A.T., et al. (2000)
Leshner, A.I. (1997)
Jellinek, E.M. (1960)
American Psychiatric Association. (1980)
Finney, J.W., R.H. Moos, and C. Timko (1999)
Vaillant, G.E., and H. Hiller-Sturmhofel (1996)
Section II: The Costs of Alcohol Abuse
Chen, C.M., Y. Hsiao-ye, and M.C. Dufour (2003)
Schuckit, M.A., and S. Tapert (2004)
Harwood, H., D. Fountain, and G. Livermore (1998)
Centers for Disease Control and Prevention (2004)
Caron Foundation (2004)
National Institute on Alcohol Abuse and Alcoholism:
Alcohol and tobacco (1998)
Young-Hee, Y., et al. (2003)
Moak, D.H., and R.F. Anton (1999)
Grant, B.F., Hasin, D.S., et al. (2004)
Bates, M.E., S.C. Bowden, and D. Barry, (2002)
National Institute on Alcohol Abuse and Alcoholism.
Cognitive impairment and recovery from alcoholism.
National Institute on Alcohol Abuse and Alcoholism.
Imaging and alcoholism: A window on the brain.
National Institute on Alcohol Abuse and Alcoholism.
Fetal alcohol exposure and the brain. (2000)
Substance Abuse and Mental Health Services
Administration (2004)
U.S. Department of Transportation, National
Highway Safety Administration. National survey of
drinking and driving attitudes and behaviors, 2001.
Centers for Disease Control and Prevention. (2002)
National Institute on Alcohol Abuse and Alcoholism.
Underage drinking: A major public health challenge.
Grunbaum, J., et al. (2004)
Hsiao-ye, Y., G.D. Williams, and M.C. Dufour (2003)
Roberts, S., and L.F. Fallon (2001)
MacDonald, S., S. Wells, and T.C. Wild (1999)
Oggins, J., J. Guydish, and K. Delucchi (2001)
National Institute on Alcohol Abuse and Alcoholism.
Economic perspectives in alcoholism research (2001)
Steinglass, P., and S. Kutch (2004)
U.S. Department of Health and Human Services and
SAMHSA’s National Clearinghouse for Alcohol and
Drug Information. Domestic violence and alcohol and
other drugs (1995)
Mackey, R. (1996)
Ellis, D.A., R.A.Zucker, and H.E. Fitzgerald (1997)
National Institute on Alcohol Abuse and Alcoholism.
Children of alcoholics: Are they different? (2000,
October update)
Sher, K.J. (1997)
Sterling, R. (2004)
Section III: Risk Factors for Alcoholism
National Institute on Alcohol Abuse and Alcoholism.
The genetics of alcoholism (2003)
Hesselbrock, M.N., V.M. Hesselbrock, and E.E.
Epstein (1999)
McGue, M., and W. Slutske (1996)
National Institute on Alcohol Abuse and Alcoholism.
Neuroscience targets research and therapeutic targets
Rose, R.J. (1998)
Cloninger, C.R. (2004)
Johnston, L.D., et al. (2004)
Wright, D. (2004)
Ellis, D.A., R.A. Zucker, and H.E. Fitzgerald (1997)
Babor, T.F., et al. (1992)
Del Boca, F.K., and M.N. Hesselbrock (1996)
Kessler, R.C. (2004)
Li, T.K., B.G. Hewitt, and B.F. Grant (2004)
Schuckit, M.A., and S. Tapert (2004)
Vaillant, G.E., and H. Hiller-Sturmhofel (1996)
Gomberg, E.S.L. (1996)
Substance Abuse and Mental Health Services
Administration (2004)
Grant, B.F., F.S. Stinson, et al. (2004)
Levin, F.R., and G. Hennessy (2004)
Caron Foundation (2004)
Blume, S.B., and M.L. Zilberman (2004)
Notes (cont’d)
National Institute on Alcohol Abuse and Alcoholism.
Are women more vulnerable to alcohol’s effects?
Emanuele, M.A., F. Wezeman, and N.V. Eanuele
National Institute on Alcohol Abuse and Alcoholism.
Alcohol—An important women’s health issue (2004)
Chung, N., et al. (2002)
National Institute on Alcohol Abuse and Alcoholism.
The genetics of alcoholism (2003)
Grant, B.F., and D.A. Dawson (1997)
Chassin, L., S.C. Pitts, and J. Prost (2002)
Grunbaum, J., et al. (2004)
Faden, V.B., and M.P. Fay (2004)
O’Malley, P.M., L.D. Johnston, and J.G. Bachman
National Institute on Alcohol Abuse and Alcoholism.
Alcohol and aging (1998)
Gomberg, E.S.L. (2004)
Sterling, R. (2004)
Gordon, S.M., and C. Siatkowski (2003)
Section IV: Treatment and Recovery
Substance Abuse and Mental Health Services
Administration (2004)
Fuller, R.K. (1999)
Barber, W.S., and C.P. O’Brien (1999)
Schuckit, M.A., and S. Tapert (2004)
Bates, M.E., S.C. Bowden, and D. Barry (2002)
Hester, R.K., and D.D. Squires (2004)
Miller, W.R., et al. (1999)
Miller, W.R., and S. Rollnick (2002)
Chappel, J.H., and R.L. DuPont (1999)
Miller, W.R., and E. Kurtz (1994)
Sheehan, T., and P. Owen (1999)
1998 membership survey: A snapshot of A.A.
membership (1999)
Walsh, D.C., et al. (1992)
Project MATCH Research Group (1998)
Longabaugh, R., et al. (1998)
Morganstern, J., C.W. Kahler, and E. Epstein (1998)
Moos, R.H., and B.S. Moos (2004)
Tonigan, J.S., Toscova, R., and Miller, W. (1996)
Tonigan, J.S., G.J.Connors, and W. Miller (1998)
Caron Foundation (2004)
Montgomery, H.A., W.R. Miller, and J.S. Tonigan
Morganstern, J., et al. (1997)
Caldwell, P.E., and H.S. Cutter (1998)
Garbutt, J.C., et al. (1999)
Kranzler, H.R. (2000)
O’Malley, S.S. (1995)
Volpicelli, J.R., A.I. Alterman, et al. (1992)
Streeton, C., and G. Whelan (2001)
Jaffe, A.J., et al. (1996)
Volpicelli, J.R., K.L. Clay, et al. (1995)
Monterosso, et al. (2001)
Cornish, J.W., (1997)
Roth, A., I. Hogan, and C. Farren (1997)
Allen, J.P., and R.Z. Litten (1999)
National Institute on Alcohol Abuse and Alcoholism.
Neuroscience targets research and therapeutic targets.
Mason, B., et al. (2004)
National Institute on Alcohol Abuse and Alcoholism.
New advances in alcoholism treatment. (2000)
Roman, P.M., and J.A. Johnson (2002)
Forman, R.F., G. Bovasso, and G. Woody (2001)
Gordon, S.M., and J. Troncale (2004)
McLellan, A.T., et al. (2000)
Gordon, S.M., et al. (2004)
Sterling, R. (2004)
Finney, J.W., R.H. Moos, and C. Timko (1999)
Vaillant, G.E., and H. Hiller-Sturmhofel (1996)
Oggins, J., J. Guydish, and K. Delucchi (2001)
Sterling, R., S. Weinstein, et al. (2004)
Grant, B.F., F.S. Stinson, et al. (2004)
Maisto, S.A., et al. (2002)
Greenfield, S.F., et al. (2000)
Flannery, B.A., et al. (2001)
Westerberg, V.S. (2000)
National Institute on Drug Abuse (1999)
Pettinati, H.M. (2004)
Carroll, K.M. (2004)
Sterling, R., P. Hill, et al. (2004)
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About the Author
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Susan Merle Gordon, Ph.D. is the Director of Research at the Caron Foundation
and also has a private practice in Bryn Mawr, PA. Dr. Gordon has more than nine
years experience in counseling and psychological evaluation of chemical addiction
and mental health issues and has worked extensively with women and
adolescents. She holds a doctorate in philosophy, a master’s degree in Psychological
Services from the University of Pennsylvania and a Psychology licensure from the
Commonwealth of Pennsylvania. Dr. Gordon is a member of the American
Psychological Association, the Pennsylvania Psychological Association
and the APA Division 50 Addictive Behaviors Association.
Galen Hall Road
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