Alaska Substance Abuse Prevention and Treatment System Effectiveness Study

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1 Alaska Substance Abuse Prevention and Treatment System Effectiveness Study Working Paper #2 A Brief Summary of the Evolution of Substance Abuse Treatment and Prevention Services and the Approaches to Measuring their Effectiveness Alaska Mental Health Trust Authority William Herman, Program Manager Jeff Jessee, Director Bernard Segal, PhD Brian Saylor, PhD, MPH, Director University of Alaska Anchorage 3211 Providence Drive Anchorage, Alaska This project was supported by a contract from the Alaska Mental Health Trust Authority

2 TABLE OF CONTENTS TABLE OF CONTENTS... i I. The Evolution of Substance Abuse Treatment and Prevention... 1 A. Introduction... 1 B. Paper Summary... 1 C. Alcoholism: The Nature of the Problem... 3 D. The Extent of the Problem... 3 II. Alcohol Treatment: Theory and Practice... 5 A. Early Concepts of Alcoholism: The Pre-Prohibition Period... 5 B. The Post-Prohibition Period: AA and Alcoholism as a Disease... 7 C. The "Disease Concept" of Alcoholism... 9 D. Adoption of the Disease Concept of Alcoholism E. Unitary Disease Concept Changes F. Dual Diagnosis/Comorbidity G. Multidimensional Concepts of Drinking-Related Problems H. Examples of Alternative Approaches to Substance Abuse Treatment III. Treatment Settings A. Inpatient/Residential Treatment B. Transitional Care C. Outpatient Treatment IV. Treatment Approaches A. Alcoholics Anonymous (AA) B. Other Self-Help Groups C. Patient-Treatment Matching D. Counseling or Psychotherapeutic Approaches E. Marital Counseling F. Adjunctive Treatments G. Behavioral Approaches to Alcoholism H. Aversion Techniques I. Controlled Drinking (Moderation) Theory Evolution of Substance Abuse Treatment i

3 J. Relapse Prevention V. Treatment of Drug-Related Problems A. Historical/Philosophical Perspective on Drug Treatment B. The Changing Role of the Federal Government C. Approaches to Drug Treatment VI. Measuring Treatment Success A. Effectiveness of Treatment Settings B. Measuring Drug Treatment Effectiveness C. General Findings of Treatment Effectiveness D. Research Findings on the Value of Treatment E. Concluding Remarks VII. Science-Based or Best Practice Treatment VIII. Substance Abuse Prevention A. Issues and Concerns Common to Both Alcohol and Drug Prevention B. Prevention of Alcoholism C. National Prevention Policies D. Alcohol Prevention Programs E. Prevention of Drug Abuse IX. Conclusions Evolution of Substance Abuse Treatment ii

4 I. The Evolution of Substance Abuse Treatment and Prevention A. Introduction Of our current social issues, few have as many different and competing perspectives as the issue of alcoholism and other forms of drug addiction and how we deal with them. The intent of this section is to review alcohol ism in America from the historical and current contexts of medical, psychological, and sociocultural knowledge and understanding. This purpose of this section is to provide background information about alcoholism, related disorders, and prevention of such addiction problems. The information synthesized here is intended to provide a larger context for understanding the problem of alcoholism and alcohol abuse and the impacts the conditions have on our social fabric. It also presents new thinking about the treatment and prevention of these serious problems which may influence our ability to amend current practices based on new knowledge. B. Paper Summary There is currently a serious rethinking taking place in the United States about the nature of alcoholism. Until recently, it has generally been accepted that "most alcohol-use problems are well characterized as representing one stage or another in the development of a single disease of alcoholism and] that a single-disease concept of alcoholism is the "officially correct view." This view has fostered a universal belief about alcoholism that can be summarized in the six following statements: 1. There is a unitary phenomenon that can be identified as alcoholism. 2. Alcoholics and pre-alcoholics are essentially different from non-alcoholics. 3. Alcoholics may sometimes experience a seemingly irresistible craving for alcohol or a strong psychological compulsion to drink. 4. Alcoholics gradually develop a process called "loss of control" over drinking, and possibly even an inability to stop. 5. Alcoholism is a permanent and irreversible condition. 6. Alcoholism is a progressive disease that follows an inexorable development through a distinct series of phases. The concept of a disease model, however, is being challenged by new and different approaches that offer an alternative to traditional beliefs about alcoholism. This alternate approach is reflected in the following statements: 1. Alcohol dependence summarizes a variety of syndromes defined by drinking patterns and the adverse physical, psychological, and/or social consequences Evolution of Substance Abuse Treatment 1

5 of such drinking. These syndromes, jointly denoted as alcohol dependence, are best considered as a serious health problem. 2. An individual's pattern of use of alcohol can be considered as lying on a continuum, ranging from to severely pathological. 3. Any person who uses alcohol can develop a syndrome of alcohol dependence. 4. The development of alcohol problems follows variable pattern over time and does not necessarily proceed inexorably to severe fatal stages. 5. Recovery from alcohol dependence bears no necessary relation to abstinence, although such a concurrence is frequently the case. 6. The consumption of a small amount of alcohol by an individual once labeled as "alcoholic" does not initiate either physical dependence or a physiological need for more alcohol by that individual. 7. Continued drinking of large doses of alcohol over an extended period of time is likely to initiate a process of physical dependence that will eventually be manifested as an alcohol withdrawal syndrome. 8. The population of persons with alcohol problems is multivariate. 9. Alcohol problems are typically interrelated with other life problems, especially when alcohol dependence is established. 10. An emphasis should be placed on dealing with alcohol problems in the environment in which they occur. 11. Treatment services should be designed to provide for a continuum of care throughout the lengthy process of recovery from alcohol problems. Based on these principles, alternatives to the disease concept, in the form of multidimensional theories, are being developed. These approaches reflect a synthesis of biomedical, psychological, and sociological principles or knowledge combined into a comprehensive system that takes into account that alcoholism or other types of problem drinking not only vary with respect to drinking behavior, but also with different personalities, and that there are multiple combinations of adverse consequences that require different types of treatment interventions. A multidimensional approach allows more flexibility in thinking about alcoholism, and it address better the diagnostic and treatment needs of specialized populations who manifest drinking problems. The traditional disease concept of alcoholism, for example, has not generally allowed for the specialized intervention strategies that address the needs of women, children, and older persons, among other groups needing more individualized attention, such as Alaskan Natives, American Indians, and members of other minority groups. Their drinking behavior requires that an understanding of their special problems be developed, and that any approach to alcoholism must be sensitive to differences between men and women, especially recognizing the biological differences between genders. Nor has the disease concept been particularly sensitive to cultural differences. Multidimensional theory can not only account for some of the needs of special population groups, but it may also provide a stronger theoretical base for studying cultural variations in drinking and drinking-related problems. Evolution of Substance Abuse Treatment 2

6 C. Alcoholism: The Nature of the Problem Drugs and drug-taking behavior have become well embedded in our society. The problems they create present a formidable challenge. But these problems are not new - - alcohol, tobacco, opium and other drugs have been in use since the nation was founded. The current period in our history, however, is marked by a new dimension of drug activity characterized by the widespread use, particularly among Alaskan youth and young adults, of numerous kinds of powerful mind-altering substances, many of which are dependency-producing. Never before have so many been exposed to a variety of potent drugs, both legal (licit) or illegal (illicit). The concern about drugs 1, however, has resulted in severe misconceptions about the nature and extent of the problem. Stephens (1992) described these misperceptions as follows: First, there is much misunderstanding concerning this "epidemic." One would almost believe from our mass media messages that huge segments of American society regularly abuse drugs like crack. Second, there appears to be enormous confusion among both the general public and our decision makers about what psychoactive drugs are. Most simply want to lump all types of psychoactive drugs into one category called "dope" or "drugs." The implication is "one type of problem, one type of solution." Third, there is a great deal of hypocrisy concerning drug usage. The use of addictive substances like tobacco products and alcohol is condoned -- indeed in some cases even subsidized by the state.... Fourth, Americans tend to ignore... social and cultural contexts in which drug use occurs when searching for an answer to the question, "Why do people use drugs?" Most often, drug users are believed to suffer from mental, emotional or possibly even physiological "diseases." Because of this disease state, they have difficulty coping with stress and the problems of living. They take drugs to escape and to ameliorate the anxiety and depression they feel. Finally, Americans are perplexed about how to deal with the drug problem. Some feel that a "get tough" approach is the only solution while others maintain that the ultimate solution lies in decriminalization or outright legalization of all psychoactive substances. (pp. 1-2) D. The Extent of the Problem Across the United States, over 85 percent (more than 169 million people) have consumed alcohol. Alcohol-related problems have a significant impact on the nation's health and welfare. Economic estimates of this impact indicate that alcoholism and alcohol abuse cost about $100 billion annually. Approximately 14 million Americans -- about 7 percent of the adult population -- meet the diagnostic criteria for alcohol abuse and/or alcoholism. About 40 percent of Americans report having a direct family experience with alcohol abuse or alcoholism. The misuse of alcohol is involved in approximately 30 percent of suicides, 50 percent of 1 This is intended to mean alcohol, tobacco, opium and other drugs. Evolution of Substance Abuse Treatment 3

7 homicides, 52 percent of rapes and other sexual assaults, 48 percent of robberies, 62 percent of assaults, and 49 percent of all other violent crimes. Alcohol is also a factor in 30 percent of all accidental deaths, including up to 50 percent of motor vehicle deaths. In fact, more than 100,000 Americans die each year from alcohol-related causes, which, if it were ranked independently, would make alcohol-related problems the third leading cause of death in the United States. Americans annually spend over $35 billion on alcoholic beverages, consuming over 23.5 gallons of beer and 2 gallons of distilled wine and spirits per person annually. Cigarette smoking, though tending to decline among males, is increasing among women and adolescents, particularly among female adolescents. The use of smokeless tobacco has also increased among adolescent males. The economic cost of substance abuse to health and social institutions is significant, estimated as $246 billion in 1992 (Harwood et al., 1998). Alcohol-related costs are estimated at $148 billion, while other forms of drug abuse are estimated to cost $98 billion. These costs have increased considerably since % higher for alcohol and 50% higher for drugs over and above the increase in population growth and inflation (Harwood et al., 1998). Harwood et al. (1998) also estimated that the costs of crime-related substance abuse amounted to $59.1 billion for alcohol-related crimes and $19.7 billion for drug-related crimes. These costs include reduced earnings due to incarceration, crime careers, criminal victimization and the costs of criminal justice and drug interdiction. Drug abuse was estimated to contribute to 25-30% of income-generating crime; alcohol abuse was estimated as being involved in violent crimes, especially domestic violence, sexual assaults against women and child abuse. The economic burden of these expenses falls on the non-abusing taxpaying population of our society. The U.S. government, through tax revenue, spent $57.2 billion in 1992 for alcohol-related problems, compared with $15.1 billion for private insurance, $9 billion for victims, and $66.8 billion for alcohol abusers and members of their households. Concerning drug abuse, the government spent about $45.1 billion (46.2%); private insurance spent $3.1 billion, victims, about $6.5 billion, and abusers and their families about $42.9 billion (Harwood et al., 1998). The costs imposed on the non-abusing part of society include drug- and alcohol-relate crimes and trauma, such as motor vehicle crashes, government services, and various social insurance mechanisms. The costs related to the abusers include lost legitimate earnings, encompassing lost tax revenue. Evolution of Substance Abuse Treatment 4

8 II. Alcohol Treatment: Theory and Practice Excessive consumption of alcohol can result in serious adverse consequences that must be addressed at both national and local levels. While there is universal agreement that alcohol produces a wide range of effects and consequences, there is no similar agreement on how to define "alcoholism." As George Gallup, Jr., noted: Despite the fact that alcoholism is common, not only in the US., but in many other nations, and the fact that incredible numbers of people are adversely affected by alcohol, we know relatively little about alcoholism and alcohol abuse: what alcoholism is, how to define it, how to recognize its symptoms and its impact, why some people can control their drinking and others cannot, why some alcoholics can recover, but others cannot. (cited in Diames, 1984, p.55) The lack of uniformity in defining alcoholism exists because of disparate views held by professionals in different disciplines regarding how they define alcoholism. Thus medical practitioners, the legal profession, alcohol counselors, the clergy and biomedical, behavioral and social scientists, as well as recovering alcoholics, all differ with respect to how they define alcoholism; and each definition has important implications for public policy concerning alcoholism and its treatment and prevention. With respect to treatment, for example, if alcoholism is defined as having a physiological basis, such as metabolic changes in the structure of certain brain cells, then treatment would mainly consist of a pharmacological approach that would seek to correct the physiological imbalance. In contrast, if an accepted definition of alcoholism is that it results from a lack of will power, then a moral approach would be stressed as the appropriate treatment method. Because of this lack of specificity in defining alcoholism, a very complex situation exists in which there is significant controversy over what is effective treatment for it. To understand how this situation arouse, and to be able to place it in a proper perspective, it is helpful to trace the history of some of the recent definitions of alcoholism. Part of this unit will examine some of the origins of traditional and contemporary concepts of alcoholism; it also contains a discussion of new approaches in the field. The intent is to provide a comprehensive perspective on alcoholism, and to illustrate how certain views have come to prevail. A. Early Concepts of Alcoholism: The Pre-Prohibition Period The belief that continued excessive consumption of alcohol can result in illness or in a chronic disorder dates back to early history, but the term "alcoholism" is thought to be of more recent origin. The earliest documented usage of the term is attributed to Magnus Huss, a Swedish scientist who, in 1849, described a condition resulting from the abuse of alcohol and labeled it "alkoholismus chronicus" ("chronic alcohol disease"). The belief that chronic drinking is a special disease was expressed earlier by Benjamin Rush, a prominent physician in colonial America. After having observed what happened Evolution of Substance Abuse Treatment 5

9 to people who drunk continuously, Rush, in 1814, concluded that drunkards were "addicted" to spirituous liquors and that they became addicted gradually and progressively. Rush characterized bouts of drunkenness as an inability to refrain from drinking, a condition he designated as a "disease of the will," which could only be cured by total abstinence. Rush's ideas about habitual drunkenness provided nearly all the fundamental principles on which most of today's thinking is based: 1. The cause of habitual drunkenness is alcohol; 2. The drunkard's condition is due to a loss of control over drinking - it is a compulsive activity; 3. This condition is a disease; and 4. The only cure is abstinence. Rush's beliefs concerning chronic drinking were readily adopted by the Temperance Movement in the United States. The Temperance Movement s aim was in its formative stage, was to help drunkards and prevent drunkenness. The Temperance Movement, prior to the Civil War, maintained that inebriety, intemperance, or habitual drunkenness was a disease and a natural consequence of the consumption of alcoholic beverages and believed that: Intoxicating liquors are dangerous articles; that multitudes of persons are so susceptible to the narcotic influence of alcohol that, whatever their accomplishments or station, if they drink at all they drink to drunkenness; and that the confirmed inebriate is a diseased [emphasis added] individual undergoing the tortures of a living death, manifesting symptoms characteristic of the operation of an irritant narcotic poison (Palmer, 1986, p. 21). In its early years the Temperance Movement thus directed most of its efforts toward helping drunkards to achieve sobriety. Because drunkenness was perceived as a disease resulting from addiction to alcohol, emphasis was placed on persuading people to abstain from alcohol so as to not become afflicted with the disease. The basic philosophy of the Temperance Movement changed after the Civil War, when it re-emerged as a widespread movement to invoke discipline and to create a society of predictable individuals devoted to self-improvement. Alcohol was to be combated because it contributed to crime, drunkenness, poverty and moral degeneracy. With this alteration in its philosophy, the Temperance Movement shifted away from advocating temperance to supporting prohibition. Alcohol became a symbol that represented a decline in morality brought about by drinking behavior and the lifestyles of the working class. In its quest for reform the temperance movement changed its earlier position that inebriety is a disease, now insisting that the fault always lies with the drunkard, never in the drink, and that only evilly disposed persons and fools fall victims to alcoholic excess (Palmer, 1986). The efforts of the prohibition movement ultimately culminated in national prohibition. Evolution of Substance Abuse Treatment 6

10 While prohibition, as history shows, did not eradicate drinking, it succeeded in shifting efforts away from perceiving alcoholism as an addiction or specific disease. Attention was given instead to the evil effects of alcohol and to eliminating it from American society. "Demon rum" was now the enemy. One result of this change was a weakening of the sympathetic attitude toward habitual drunkards long held by reformist movements. "The drunkard came to be viewed less and less as a victim and increasingly more as simply a pest and menace" (Levine, 1978, p. 161). What is important to understand about this period in American history is that it established attitudes about alcohol and alcoholism that continue to affect how alcoholism is defined, treated, and prevented. One of the major effects of prohibition was that it significantly distracted attention away from efforts to differentiate between different types of drinking behavior and the short- and long term effects of drinking. That is, it direct efforts away from developing an understanding of what alcoholism is and is not, and from identifying what factors might serve to maintain drinking by alcoholics and what factors differentiate alcoholics from non-alcoholics. Instead, as a result of the temperance and prohibitionist movements views, alcoholism or drunkenness was perceived as a "moral failing" rather than as an illness. The cause of the moral failure was a lack of will to overcome drunkenness, and the only way to combat this behavior was to make alcohol unavailable. The fact that the chronic or problem drinker may feel guilty after a drinking episode helped to characterize drinking as "sinful," and as socially undesirable. This "moral" approach is reflected in contemporary efforts to limit the sale of alcohol and in the desire to maintain a public appearance of abstinence. Nevertheless, when the major target of public action is focused on limiting the amount of alcohol consumed, and on changing the individual's decision to consume alcohol, drunkenness or alcoholism contains elements of a moral failing. It should be noted that beliefs expressed by those in the Temperance Movement, and by other groups that advocated the prohibition of alcohol, also influenced attitudes toward drugs in the United States, many of which continue to prevail. Around the turn of the century, and afterward, there was a dramatic increase in drug use in the United States. Morphine, later taken as heroin, and marijuana were special targets of adverse public opinion. In general, the attitudes and opinions about alcohol and other drugs espoused by the anti-alcohol movements in the first half of this century contributed directly to the division of attitudes in the 1950s through the 1970s concerning drug use in America. These beliefs also provided the basis for the strategies adopted by federal, state, and local governments concerning the use of mood-altering drugs. Thus, as White (1979) noted, the prohibitionist beliefs were integrated into the social fabric of American culture, and this integration became so complete that it has prevented the formation of national policies for the social control of mood-altering drugs. B. The Post-Prohibition Period: AA and Alcoholism as a Disease The end of prohibition rekindled interest in developing an understanding of alcoholism, one that did not specifically focus on alcohol itself as the source of addiction. After having faced 12 years of prohibition, and a longer period of temperance and prohi- Evolution of Substance Abuse Treatment 7

11 bitionist philosophy, the public was unwilling to deal with the fact that alcohol may be an inherently addicting substance. In this atmosphere the notion that alcoholism is a disease flourished, and the impetus that gave added emphasis to this notion came from a new philosophy espoused by Alcoholics Anonymous (AA), an organization founded in 1935 to assist alcoholics to obtain sobriety. AA was established on the basis of the belief that alcoholism is a disease, one that could only be dealt with by admitting "one's powerlessness over alcohol," and by accepting responsibility for this problem. This creed, advocated by Bill Wilson, the founder of AA, along with Dr. Robert (Bob) Holbrook Smith, who assisted Bill W., as he came to be known, was derived from a definition of alcoholism by Dr. Robert Silkworth, a physician whose ideas greatly influenced Bill W. Silkworth (1946) defined alcoholism as a disease, one represented by an "obsession of the mind that compels us to drink and the allergy of the body that condemns us to go mad or die" (p.1). While AA did not accept this specific definition of alcoholism, the conceptualization advanced by Silkworth provided the framework for AA's definition. The AA approach defined alcoholism as a disease resulting from long-term drinking. Because of either an inherited predisposition or a physiological response to the effects of chronic drinking, an allergic-type reaction to alcohol occurs that causes susceptibility to alcoholism. Also involved in this disease process is an obsession with alcohol and its effects, that is, a craving for alcohol to the extent that one loses control over one's drinking. Stated differently, alcoholism, as conceptualized by AA, is a disease represented by a craving for alcohol resulting from a loss of control over drinking that is attributable to an underlying physiological anomaly. The underlying physiological anomaly, or predisposition, and loss of control over drinking, are the essence of the disease model of alcoholism, leading to the premise that the only treatment for this disease is complete abstinence from alcohol. Based on this approach, Bill W. advocated that one could only start to recover from the compulsion to drink by first admitting powerlessness over alcohol, and by accepting that help is needed to abstain. AA provides the support for a conversion from drinking to sobriety, and for maintaining sobriety. The philosophy of AA was expressed in a publication entitled "Alcoholics Anonymous" (1939), which came to be known as the "Big Book." In it Bill W. developed the "Twelve Steps" to recovery that have become AA's basic principles for overcoming alcoholism. Since its inception in the mid-1930s, "AA has come to serve as a major vehicle for defining alcoholism in this country, and members of AA have become perhaps the most important lobby advocating the now generally accepted disease concept of alcoholism" (Tournier, 1979, p. 230). Peele (1989) stated that by the 1970s "AA had become the model for all treatment groups and a linchpin in the provision of services for drinking problems in the United States" (p. 24). Additionally the widespread acceptance of AA led to its being involved as an adjunct to the outpatient treatment of alcoholics, and frequently as part of inpatient programs, as well (Blumberg, 1977). Evolution of Substance Abuse Treatment 8

12 The major question that needs to be asked is: Why did the disease concept of alcoholism, championed by AA, achieve such widespread acceptance? To answer this question it is first necessary to take three things into consideration: 1. The end of prohibition gave rise to a rapid increase in various kinds of drinking problems; 2. The divisiveness generated by the Prohibitionist Movement made it essential that if problem drinking were to be addressed, it had to be accomplished in a way that made it necessary to distinguish interest in dealing with alcohol problems from interest in prohibition and temperance movements; and 3. If progress were to be made, it was essential to remove the stigma of intemperance and immorality from the drinker. With these three conditions in mind, the stage was set for a movement that could distinguish its response to drinking problems from moralistic action against alcohol. Shaw et al. (1976) noted that: The AA philosophy not only allowed this differentiation, but also managed to achieve it without blaming the individual drinker. By promoting the idea that a particular group of drinkers were unable to cope with alcohol, and by labeling their inability an illness, AA facilitated a response to drinking problems which blamed neither alcohol itself nor the drinker as a person. (p. 47) Two important results of the establishment of AA were: (a) it convinced the public to regard alcoholism as a progressive disease, and (b) it helped to establish alcoholism research as a legitimate area of inquiry in the various fields of scientific research in American universities. Thus the very research that AA helped initiate furthered an understanding of alcoholism, but much it was also directed at verifying AA's basic tenets. C. The "Disease Concept" of Alcoholism The major tenet held by AA was that alcoholism is a special disease characterized by a loss of control over drinking, which requires sobriety as the cure because of the alcoholic s underlying vulnerability to alcohol. A single drink, after stopping, is likely to lead the person back to uncontrolled drinking. Alcoholism is a lifetime condition that necessitates ongoing abstinence and a lifetime of recovery. This notion is expressed by AA members self-description of recovering as opposed to recovered (Peele, 1989). Elvin Jellinek, a proponent of the disease concept of alcoholism described different classifications or typologies representative of problem drinking. 1. Early Classification Schemes for Alcoholism One of the earliest and most important alcohol research centers was the Yale Laboratory of Applied Physiology, established at Yale University in the mid-1930s. The research that was carried out by physiologists and biochemists there led to two Evolution of Substance Abuse Treatment 9

13 significant events: (a) the founding, in 1940, of the Quarterly Journal of Studies on Alcohol to publish the extensive research findings that were generated in the research laboratory; and (b) the realization that research into the causes and nature of alcoholism required more than laboratory research alone. The latter problem was solved by changing the original research center into the "Yale Center of Alcohol Studies," dedicated to a multidisciplinary approach to alcoholism. The establishment of this multidisciplinary center, which was later to move to Rutgers University, was particularly important because it heralded a recognition within the scientific community that alcoholism is a disease that requires a comprehensive, interdisciplinary approach. The first director of the Yale center, E.M. Jellinek, was particularly influential in helping to promulgate the disease concept of alcoholism. As a result of his study of AA members who were "recovering alcoholics," Jellinek proposed several classifications of problem drinking, but singled out only one type, gamma alcoholism, to be representative of the disease of alcoholism. Jellinek's (1960) typologies follow. a. Alpha Alcoholism: Alpha alcoholism represents a purely psychological continual dependence or reliance upon the effect of alcohol to relieve bodily or emotional pain. The drinking is undisciplined in the sense that it contravenes such rules as society tacitly agrees upon - such as time, occasion, locale, amount, and effect of drinking - but does not lead to loss of control or inability to abstain. The damage caused by this species of alcoholism may be restricted to the disturbance of interpersonal relations. There may also be interference with the family budget, occasional absenteeism from work and decreased productivity, and some of the nutritional deficiencies of alcoholism, but not the disturbances due to withdrawal of alcohol. Nor are there any signs of a progressive process. b. Beta Alcoholism: This species of alcoholism is one in which such alcoholic complications as polyneuropathy, gastritis, and cirrhosis of the liver may occur without either physical or psychological dependence on alcohol. The incentive to the heavy drinking that leads to such complications may be the customs of certain social groups in conjunction with poor nutritional habits. The damage in this instance is nutritional deficiency diseases, impaired family budget, lowered productivity, as well as a curtailed life span. Withdrawal symptoms, on the other hand, do not emerge. Beta alcoholism is progressive, and may develop into gamma or delta alcoholism. c. Gamma Alcoholism: Gamma Alcoholism is that type of alcoholism in which the drinker acquires an increase in tissue tolerance to alcohol resulting in an adaptation in cell metabolism. Withdrawal symptoms and "craving" (i.e., physical dependence) and loss of control are also involved. In gamma alcoholism there is a definite progression from psychological to physical dependence and marked behavioral changes. Gamma alcoholism produces the greatest and most serious kinds of damage. The loss of control impairs interpersonal relations to the highest degree. The damage to health in general, and to financial and social standing, is also more prominent than in any other type of alcoholism. Gamma alcoholism is what alcoholic members of AA recognize as alcoholism to the exclusion of all other species. Evolution of Substance Abuse Treatment 10

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