From one beer with friends to alcohol dependence: a synthesis about our knowledge of this path

Abstracts

Artigo de revisão sobre os estudos prospectivos a respeito da história natural do alcoolismo, com ênfase na contribuição de Vaillant, que discorre sobre o impacto de seus achados na evolução dos conceitos de uso nocivo e dependência, bem como suas principais implicações terapêuticas. É salientado o fato de as taxas de abstinência não terem aumentado no tratamento de dependentes graves nos últimos 25 anos.

Bebidas alcóolicas; Estudos prospectivos; Formação de conceitos; Eficácia de tratamento

From one beer with friends to alcohol dependence: a synthesis about our knowledge of this path

Sérgio de Paula Ramos; Arnaldo Broll Woitowitz

Unidade de Dependência Química do Hospital Mãe de Deus de Porto Alegre

^{Correspondence}

ABSTRACT

Review paper about prospective studies concerning the natural history of alcoholism. Emphasizing Vaillant and the impact of his contribution to the evolution of the concepts of harmful use and dependence, as well as its most important therapeutic implications. The fact that the abstinence rates, in the treatment of a severe dependence, almost remaining the same in the last twenty-five years is highlighted.

Keywords: Alcoholism. Prospective studies. Concept formation. Treatment efficiency.

Introduction

Considering alcohol abstinence as the only parameter to assess the efficacy of the treatment for alcoholics, the conclusion is that they have not improved in the last 25 years. In fact, abstinence rates, in well-controlled 1-year follow-ups, remain below 20%.^1,2 This modest rate of success rate justifies per se the continued effort to better understand alcohol dependence syndrome and its natural history, as well as the etiology of these disorders.

In the Western world the fact is that nearly 90% of the adult population consume some type of alcoholic beverage. It is also a fact that 10% of drinkers will present harmful use of alcohol and other 10% will become dependent, what amounts to say that 1 among 5 drinkers will have health problems due to alcohol intake.³ Etiological studies try to discern in what these drinkers differ from the others, as, while those who have only pleasure from alcoholic beverages - which may also provide a certain protecting effect for innumerable clinical affections - these drinkers become, with time, bearers of one of the most consuming diseases, considered their own and their families' health.

Nevertheless, while etiological studies do not provide therapeutical tools to enhance our efficacy, the exam of some people's trajectory, from moderate drinking up to alcohol dependence, may accomplish this role. Thus, the objective of the current review is to synthesize the current knowledge about the natural history which sometimes leads moderate drinkers towards alcohol dependence, as well as the main therapeutical implications. Jellinek, Cahalan, Edwards, Miller, Babor, but especially Vaillant, author of three of the most consistent studies about the subject, will be emphasized.

Alcoholism: evolution of the concept

Although Magno Huss was the first to define, in the 19^th century, alcoholism as a disease, and Alcoholics Anonymous have guided, since 1935, all his work by this same concept, the concept of alcoholism-disease has been popularized in contemporaneous science only with Jellinek.⁴ According to him, a person has or does not have alcoholism, as in any all-or-nothing situation. Black or white, having or not having. And for their bearers the only way out to treat their 'progressive and fatal disease⁴ would be complete alcohol abstinence. Therefore, according to this view, all patients who do not achieve sustained abstinence are cases of therapeutical failure. It may be highlighted that those who have developed this conceptual model or are identified with it, were, mostly, therapists who, as such, have worked with clinical populations.

However, community studies by sociologists and epidemiologists have provided other relevant contributions. Concepts such as heavy drinker, abusive drinker, and problem drinker appeared.⁵ These authors have highlighted a subgroup of alcohol users who had not alcoholism disease, but who, despite this, should not be less worried, as they were responsible for traffic and work accidents, domestic and public physical aggressions, besides having a series of clinical affections which placed them in the position of users of health services.

Up to now, therefore, four diagnostic categories started to be outlined: abstemic subjects, drinkers without problems (the so-called social drinkers), drinkers with problems and alcoholic subjects. This view was supported by Vaillant's work,⁶ as this author was capable of evidencing in his prospective studies (started with adolescents, who have been followed up for 60 years) that not all drinking problems are progressive and that alcoholism is not always a fatal disease. Moreover, that some problem drinkers succeed in returning to a pattern of ingestion without problems, and the same may occur with severe alcoholics, although this has been more an exception than a rule in his findings.

Anyway, the prospective study by Vaillant,⁶ among other merits, has succeeded to call the attention for the complexity of the theme.

In 1976, Edwards & Gross⁷ defined alcohol dependence syndrome widening the perception of alcoholism, from a unitary picture deserving a uniform therapeutical conduct, towards a multifaceted, poly-determined syndrome, which comprises a comprehensive spectrum of therapeutical proposals. This view remains updated and it has been the source of both the ICD-10 and the DSM-IV. In these classifications the four categories above mentioned are contemplated, except for the fact that problem drinkers started being called harmful ones and alcoholics, bearers of dependence syndrome.

Evolution

In the Western world, the beginning of systematic consumption of alcoholic beverages by a determined person is subordinated to cultural patterns. Therefore, while in winegrowing cultures children are introduced to wine at home by their parents and grandparents, in Anglo-Saxon cultures this beginning is inserted, on adolescence, in the context of initiation rituals to adulthood. Vaillant⁶ has demonstrated that ethnic groups who tolerate adult drunkenness, but censure the learning of safe practices of alcohol consumption by children and adolescents, would be more subjected to the development of future alcoholics.

In the last two decades different Brazilian authors have been highlighting the rising precocity of alcohol consumption by adolescents.^{8 11 43} Although it is early to reach a conclusion about a possible increase in alcoholism rates, it suffices to see the increase in the rate of alcohol-related traffic accidents, especially involving people under 30 years of age, to understand the toll that Brazil is paying due to this liberalization of habits. However, it may not be forgotten that most of youngsters who start consuming alcohol do not have any kind of problem. The probability of occurring these problems would be increased, according to what was demonstrated by Vaillant,⁶ due to the existence of alcoholic relatives. The higher the number of alcoholic relatives, the higher the chances of alcohol abuse.

On the other hand, Vaillant was capable of evidencing that, before having these problems, problem drinkers had a higher prevalence of anti-social personality disorder, but not dependent personality disorder.

Once a harmful alcohol consumption pattern develops, it may follow different paths. Vaillant⁶ has demonstrated that these drinkers may, for decades, not develop dependence, as well as return to an ingestion pattern without problems (p.309). The therapeutical consequence of this finding, which will be examined below, is that, for this diagnostic category, the proposal of life abstinence, as the sole alternative, may be counter-producing.

The evolution from harmful drinking towards dependence syndrome is a process which may last from few months up to 30 years. Subjects with anti-social personality disorder, who use alcohol to defy social principles, tend to have a faster development towards dependence.

Once alcoholism is installed the return of consumption to a pattern of ingestion without problems, although having been described by different authors,^{6 12 13} seems to be an absolute exception which fades away as the severity spectrum of dependence increases.⁶

Therapeutical principles

The question is what has proposed and proposes science for these patients?

In the '80s, Hingson et al,¹⁴ studying a sample of people who acknowledged having problems with their alcohol habits, were already capable of demonstrating that one year afterwards only nearly half of them had sought some kind of attention. Of these, nearly half had been referred by a physician and of those in this situation, around half were investigated regarding this topic. Almost half of patients investigated were prescribed a specific conduct which half decided to follow. Finally, among those who received a specific treatment for their alcohol problem, one third had a chance to become abstinent. That is, only 1% of patients who acknowledged problems with their alcohol habits have sought help, were well-assessed, diagnosed, motivated for the treatment and reached abstinence. Considering that patients with problem alcohol intake most frequently do not acknowledge their dependence, we must conclude that this 1% is overestimated. This finding was confirmed by Ramos et al.,¹⁵ who have not found any specific treatment for alcoholism prescribed in the sample of hospitalized patients in the studied school-hospital.

Such a reality points to the need of new researches and to the optimization of the therapeutical efforts, as the low therapeutical response, which will be described below, is certainly one of the sources of the lack of motivation both for physicians to improve their diagnostic capability and for patients to seek treatment. In our milieu, since the '70s, researchers from different places have highlighted the difficulty of physicians to diagnose alcoholism. Therefore, Masur & Zwicker,¹⁶ Pechansky et al.,¹⁷ Kerr-Corrêa & Silva,¹⁸ Kerr-Corrêa et al.,¹⁹ Rosa et al²⁰ and, more recently, Ramos et al.¹⁵ have demonstrated the low capability of physicians to diagnose this disease. In these studies, performed in different Brazilian school-hospitals, with hospitalized patients, the diagnosis of alcoholism was given for less than 20% of the cases, an incapability which has remained constant along the almost 25 years which have passed between the first and the last of the mentioned studies.

This occurrence seems to be related to the contents taught in the medical schools. Masur & Zwicker¹⁶ demonstrated that the conceptions of medical students on alcoholism have almost not changed during their 6 college years. This lack of medical training for the diagnosis of alcoholism, which results in a low specific attention to the problem, is a severe fact, as Hampke et al.²¹ demonstrated that these patients, when duly managed, increase 3 to 5 times their demand for specialized treatment. This fact, somehow, started with the appearance of Alcoholic Anonymous in 1935, which was hailed as a valuable alternative, having its main concepts incorporated by Jellinek,⁴ in his famous The Disease Concept of Alcoholism, in which, while introducing the concept of alcoholic disease, he breaks with the notion of alcoholism-symptom, starting a new phase.

Accordingly with the work of Alcoholic Anonymous and with the notion of alcoholism-disease, Johnson²² proposes his therapeutic technique which intends to provide patients with a 'reality bath', by means of confrontation groups, introduced in Brazil by Ramos et al.,²³ and known up to now as the Minnesota model.

The fact of having the specific goal of abstinence facilitated the development of a whole methodology to assess the therapeutical efficacy, what arose an enthusiastic discussion about theoretical referentials and therapeutical goals.

An example of this was the quarrel raised by Sobell & Sobell,¹³ mainly with the members of Alcoholic Anonymous and therapists identified with them, when they demonstrated that alcoholics treated for controlled drinking evolved better than those treated for abstinence.

By the way, up to a determined point, this evidence had already been demonstrated by Davies.¹²

How may this finding be explained?

Edwards & Gross,⁷ while proposing the concept of alcohol dependence syndrome, decisively contributed for the debate by proposing that alcoholism was not a unique condition, deserving a universal treatment, but rather a syndrome, capable of hosting several conditions. Accordingly, Orford & Edwards¹ demonstrated that a brief therapeutical intervention, such as simple counseling, could be as much efficient as psychotherapy conducted during one year by specialists on alcoholism. These authors found that at the end of one year, 1/3 of patients had mild alcohol problems or even no problems, but less than 20% were totally abstinent.

With these last findings, the doors opened for the following perceptions: 1) alcoholism could no more be understood as a unique condition that patients had or had not, 2) due to the multiple possibilities, some patients could benefit from treatments not centered on alcohol abstinence, 3) sophisticated, expensive and extensive therapeutical techniques did not necessarily produce better results, 4) duly motivated, some patients succeeded to recover from alcoholism with simple counseling.

Gradually, the psychoanalytic view of patients victimized by their inconscient conflicts and needing an extensive psychotherapy gave room to another vision, that of patients capable of helping themselves by means of cognition, if adequately oriented.

Simpler and less invasive therapeutical techniques were proposed. Patients started being recognized as subjects able to abstain and they received the task of just not relapsing. Summing up, this is the proposal of the book 'Relapse prevention.²⁴ This technique is intended to build a therapeutical project with patients, by setting shared objectives, aiming to increase their self-efficacy to deal with the different situations which motivate the consumption of drugs.

The central issue became the patients' motivation to comply with the prescribed treatments and to be wiling to make changes in their lives. In the '80s, Miller²⁵ and Prochaska & DiClementi²⁶ were the most concerned authors regarding these issues. Miller²⁵ proposed techniques to help patients to be motivated for change. This author was in the board of the Hazelden Foundation, the temple of the confrontation therapy proposed by Johnson^2,2 and started to perceive how much more useful was the posture of being on the patients' side rather than the previous one, of actually being placed in the opposite side of patients, aiming at, almost militarily, destroying the dependent subjects' ego defenses. Although both in the US and in Brazil the Minnesota model is still popular, it was born then the 'Motivational Interview'.

Contemporaneously to Miller's efforts, Prochasca & DiClementi²⁶ started to study what they called 'stages of change', seeing them as a process in which there are specific motivational aspects on each of the stages proposed.

In Table 1, Miller²⁵ sums up which would be the therapist's tasks at each of these stages.

Both Miller's and Prochaska & DiClementi's proposals have benefited from Beck's contribution,²⁷ a former psychoanalyst who, at the beginning of the '60s, while studying depressive patients, launched the foundations of his 'Cognitive Therapy', later adapted by him for patients with psychoactive substance use disorders.

This author's daughter sums up the principles of cognitive therapy in the following decalogue:²⁸ 1) It is based in a formulation about the continuous development of patients and of their cognitive problems, 2) It requires a safe therapeutical alliance, 3) It emphasizes active collaboration and participation, 4) It is goal-oriented and problem-focused, 5) It initially emphasizes the present, 6) It is educational, aiming to teach patients to be their own therapists and emphasizes relapse prevention, 7) it is time-limited, 8) Its sessions are structured, 9) It teaches patients to identify, assess and respond to their dysfunctional thoughts and beliefs, 10) It uses a variety of techniques to change thoughts, mood and behaviors.

With the decisive contributions of Miller, Prochaska, DiClementi and Beck, in the '90s, the main therapeutical proposals for harmful drinkers and alcohol-dependent subjects were settled and the efforts were directed towards increasingly specific indications, aimed to optimize the results.

With this objective the studies on matching have appeared.^29-31 However, the most famous of them was the 'Project Match', due to its comprehension and cost.³²

The main issues examined by this set of studies are 1) For which patients abstinence should be indicated? And for which, controlled drinking? 2) More extensive treatments versus brief interventions, 3) For which kind of therapist each type patient should be indicated?

Unfortunately, the answers for these questions are still open, as there are currently only three consistent facts: 1) any treatment is better than none,³² 2) less severe patients benefit from brief interventions,³³ not necessarily aimed at abstinence,³⁴ and 3) the therapists' own characteristics, such as sympathy, influence more the results obtained in a certain treatment than the school to which therapists are linked.³⁵

Therapeutical efficacy

The question to be faced up here is how much do patients recover.

Studies on therapeutical efficacy, especially of treatment for alcoholics, date from the '70s. One of the most known from this initial period is the already mentioned study by Orford & Edwards,¹ who found 20% of abstemic subjects in a one-year follow-up. Curiously, 18 years afterwards, Paille et al.,² for a same time period, found a rate of 19,3%, and recently Moos & Moos³⁶ found 29,5% of abstinence among outpatients, treated for up to 8 weeks. That is, in 26 years, the so-called law of the third in the treatment of alcoholics - of unknown authorship - has not been overcome, According to this law, 1/3 of patients recover, 1/3 do not have significant alterations and 1/3 keep worsening.

In Brazil, however, the pioneer studies to assess the therapeutical efficacy were conducted under the leadership of Dr. Arthur Guerra de Andrade.^37-40 Considering the severity of the studied samples, it may be concluded that these studies have shown results similar to those of the international literature. That is, the abstinence rate in 6-month follow-up ranged from 12³⁹ to 25%.⁴⁰

Interestingly, Bernik et al.⁴⁰ reported 50% of dropouts in outpatients, and 13 years afterwards Marques⁴¹ found 47%.

Consensus and challenges

Based on the whole evidence herein reviewed, the Brazilian consensus for the treatment of ‘Psychoactive Substances Users’⁴² recommends as psychotherapic techniques for harmful drinkers and alcohol-dependent subjects, motivational interviews, brief intervention, relapse prevention and cognitive-behavioral therapy. It may be highlighted, however, according to what was exposed in the previous topic, that 50 to 60% of patients do not benefit from these procedures, therefore delimitating an extensive field open to research.

Conclusion

In the last decades, due to prospective studies, particularly by Vaillant, it has been possible to reach a conceptual progress about the different types of problems in the relationship drinker-alcohol. Due to this progress, new proposals of briefer and cheaper therapeutical interventions were done and different matching criteria have been suggested. However, up to now the therapeutical results were not capable to rise significantly abstinence rates in severe alcohol-dependent subjects. This finding should motivate further studies and sequential therapies, which should start emphasizing the motivation for abstinence and proceed considering patients' individualities, both conscious and unconscious.

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Este artigo é produto da tese de doutorado intitulada "A PSICANÁLISE E OS TRANSTORNOS POR USO DE SUBSTÂNCIAS PSICOATIVAS", defendida, pelo primeiro autor, na UNIFESP, em 2003.

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Publication Dates

• Publication in this collection
  04 Jan 2005
• Date of issue
  May 2004