Structured Preparation before Alcohol Detoxification; A Shift from the Current Treatment Paradigm

iHEAR Partnership, 1 Prince Regent Road, UK

*Corresponding Author:

Christos Kouimtsidis
Consultant Psychiatrist, iHEAR Partnership
1 Prince Regent Road, UK
Tel: 02085381150
Fax: 02085381164
E-mail: drckouimtsidis@hotmail.com

Received date: April 27, 2017; Accepted date: May 10, 2017; Published date: May 17, 2017

Citation: Kouimtsidis C (2017) Structured Preparation before Alcohol Detoxification; A Shift from the Current Treatment Paradigm. J Addict Res Ther 8:326. doi:10.4172/2155-6105.1000326

Copyright: © 2017 Kouimtsidis C. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Addiction Research & Therapy

Abstract

The current treatment paradigm for alcohol dependence of planned medically assisted detoxification and aftercare has two main limitations; (i) only a percentage of people are engaged and exposed to aftercare, which is considered to be the effective treatment component; and (ii) does not take into account the accumulating evidence of the adverse effect of repeated medically assisted detoxifications. The proposed new treatment paradigm of Structured Preparation before Alcohol Detoxification (SPADe) is based on the most recent cognitive theories of addiction and aims to reverse the automatized decision making process, support lifestyle changes and conscious decision making, while amount of alcohol and pattern of drinking are kept stable, before proceeding to medically assisted detoxification. The current paper comments on the Abstinence Preparation Group, which is one of those interventions developed and evaluated following the SPADe paradigm.

Keywords

Alcohol dependence; Treatment; Structured preparation

Introduction

Current treatment paradigm for alcohol dependence and associated challenges

For several decades medically assisted withdrawal (detoxification) from alcohol was considered the first step and the main treatment component for alcohol dependence. It was considered that professionals should take every given opportunity to detoxify people dependent on alcohol, with the belief that the experience of sobriety, even for a short period of time, will have a beneficial, accumulating effect over years. Current NICE guidelines though advise against rushed detoxifications from alcohol [1]. NICE advise that detoxification (for those who are dependent) should be planned and should be part of a structured treatment package, which should put emphasis on aftercare treatment for short term relapse prevention and longer term support through mutual aid groups. They also support the use of pharmacological treatment.

From a diverse range of aftercare interventions, Relapse Prevention based on Cognitive Behaviour Therapy (CBT) is most supported by evidence [2]. These interventions put emphasis on regaining control over the decision making process involved in drinking [3,4]. Key components include identifying high risk situations, reduce positive expectancies from drinking, develop negative expectancies from drinking, develop self-efficacy and coping skills and finally develop overall lifestyle changes compatible with an abstinent way of living. However there is one major barrier compromising the effectiveness of those aftercare interventions. Empirical evidence suggests that the majority of people seeking treatment for alcohol dependence do not appreciate the need for post detoxification treatment and support and more than 40% of those completing detoxification won’t attend any aftercare intervention (short term or long term), which dictates the need to maximise our efforts to engage people in aftercare [5].

Furthermore there is accumulating evidence to suggest that repeated detoxification attempts might have negative impact on cognitive functioning. People with alcohol dependence who experience more detoxifications, show inability to perform a task that captures two of the basic features of addictive behaviour-cue-induced motivation to seek a reward, and failure to inhibit such motivation when reward seeking is inappropriate [6,7]. Under emotional challenge, these individuals show inability in conflict resolution and increased sensitivity to stress, both of which may contribute to relapse [8,9]. Additionally, there is evidence to suggest that multiple detoxification attempts can exacerbate craving, impacting on subsequent attempts at achieving abstinence such that repeated attempts may be less likely to result in positive outcomes [10]. Therefore it seems crucial not only to maximise participation in aftercare to reduce the risk of relapse but reduce the number of detoxification attempts individuals have.

The theory behind structured preparation before alcohol detoxification (SPADe)

To that effect there is some evidence to suggest that preparation before alcohol detoxification specifically may result in improved outcomes [5,11], although this is as yet lacking in formal Randomised Control Trial (RCT) evidence. There is good theoretical base to adopt this type of approach. Cognitive theories and models for addiction consider substance use as a decision making process, involving cognitive elements which are or can be conscious and therefore modifiable. Addiction is the result of biases that affect conscious functions such as beliefs, attention and memories as well as unconscious processes in information recall from memory [12]. Addictive use of a substance is regulated by automatic cognitive processes, while craving represents the activation of non-automatic processes. As addiction develops the expectancy-based control system of behaviour becomes unconscious and therefore behaviour is influenced less by conscious expectancies involving controlled processes and more by unconscious expectancies involving automatic processes [13]. It is hypothesised that representations of the behaviour are “linked” in long-term or semantic memory with propositions about outcome (e.g. relaxing, risk, etc.). Such links may be created by direct experience but are not likely to be solely determined by this and may be formed by abstraction of information from the environment. These ‘semantic’ links become strengthened and more tightly connected with repetition of behaviour. Over time, activation of one part of the “network” (e.g. alcohol-representations) automatically triggers propositional links in other parts (e.g. relaxation concepts) and vice versa [13].

The SPADe Approach

SPADe approach aims to reverse the decision making process, while the amount of drinking is kept stable and therefore activation of these “semantic links” are prohibited. The main components and emphasis in this approach is to maintain a stable amount and pattern of drinking “as if alcohol was medication”. While this is achieved the person starts introducing or expanding on existing daily activities and structure in his/her life and establishing those lifestyle changes necessary to enter a new life without drinking. In this way the person is regaining partial control over his/her drinking, being able to make a rational choice about when and how much he/she drinks and in results increasing his/her self-efficacy. SPADe treatment paradigm follows the biological principle of homeostasis and gradual change in order to regain control over drinking as the first step towards lifelong sustainable abstinence. The intervention could be offered in individual sessions over a period of 6-12 weeks or in open rolling groups such as the Preparation for Alcohol Detox [5] and the Abstinence Preparation Group (APG) [14]. The APG consists of six weekly hourly sessions, facilitated by two people and has the structure of a group CBT intervention (three parts).

References

1. National Institute for Health and Clinical Excellence (2011) Alcohol use disorders: Guidelines on diagnosis, assessment and management of harmful drinking and alcohol dependence. The British Psychological Society and the Royal College of Psychiatrists.
2. Raistrick D, Heather N, Godfrey C (2006) Review of the effectiveness of treatment for alcohol problems. National treatment agency for substance misuse. London: Department of Health.
3. Marlatt AG, Donovan DM (2005) Relapse prevention: Maintenance strategies in the treatment of addictive behaviours. New York: The Guildford Press.
4. Monti PM, Abrams DB, Kadden RM, Cooney NL (1989) Treating alcohol dependence: A coping skills training guide. Guilford press, London.
5. Kouimtsidis C, Drabble K, Ford L (2012) Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. DEPP 19: 81-83.
6. Duka T, Gentry J, Malcolm R, Ripley TL, Borlikova G, et al. (2004) Consequences of multiple withdrawals from alcohol. Alcohol Clin Exp Res 28: 233-246.
7. Loeber S, Duka T, Welzel H, Nakovics H, Heinz A, et al. (2009) Impairment of cognitive abilities and decision making after chronic use of alcohol: The impact of multiple detoxifications. Alcohol and Alcohol 44: 372-381.
8. Loeber S, Duka T, M�¡rquez HW, Nakovics H, Heinz A, et al. (2010) Effects of repeated withdrawal from alcohol on recovery of cognitive impairment under abstinence and rate of relapse. Alcohol and Alcohol 45: 541-547.
9. Duka T, Trick L, Nikolaou K, Gray MA, Kempton MJ, et al. (2011) Unique brain areas associated with abstinence control are damaged in multiply detoxified alcoholics. Biol Psychiatry 70: 545-552.
10. Duka T, Townshend JM, Collier K, Stephens DN (2002) Kindling of withdrawal: A study of craving and anxiety after multiple detoxifications in alcoholic inpatients. Alcohol Clin Exp Res 26: 785-795.
11. Kouimtsidis C, Ford L (2011) A staged programme approach for alcohol dependence: Cognitive behaviour therapy groups for detoxification preparation and aftercare; preliminary findings. Short report DEPP19: 81-83.
12. McCusker CG (2001) Cognitive biases and addiction: An evolution in theory and method. Addiction 96: 47-56.
13. Ryan F (2002) Detected, selected, and sometimes neglected: Cognitive processing of cues in addiction. Exp Clin Psychopharmacol 10: 67-76.
14. Kouimtsidis C, Charge KJ, Moch J, Stahl D (2016) Abstinence preparation group intervention for dependent alcohol users. How does it work? Results of a process study. J Subst Use.