Handbook of Clinical Alcoholism Treatment

The editors and chapter authors of the Handbook of Clinical Alcoholism Treatment set out to provide a comprehensive, easily accessible review addressing crucial issues in the understanding of the disease of alcoholism. They have accomplished this with extraordinary attention to detail in what has morphed into a mini-textbook rather than a cursory review or handbook. For primary care providers and addiction specialists, this resource provides extensive epidemiological, neurobiological, psychological, and sociocultural knowledge relevant to the understanding and successful treatment of patients suffering from alcoholism. Alcoholism is defined as a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Often progressive and fatal, it is characterized by periodic or continuous impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions of thinking, most notably denial. The multifaceted etiology and natural course of alcoholism mandate a broad-based understanding and multidisciplinary approaches to assessment and treatment.

In the first two of five sections, the handbook addresses the fundamentals of alcoholism and diagnostic tools, respectively. Appropriate emphasis is placed on psychological foundations, including the important principles of social learning theory as well as the “brain disease” model of neurotransmitter-influenced reward pathways of reinforcement. Most notable is an excellent system-by-system review of the medical consequences of alcoholism with special emphasis placed on the brain and neuroimaging. Diagnostic criteria and laboratory markers are discussed and listed for easy access by the clinician. Overreliance on exclusively descriptive psychiatric diagnostic criteria and patient self-reports makes the psychiatric diagnosis of alcohol abuse or dependence challenging (1).

Research-driven advances in understanding many biological elements of alcoholism have provided the foundation for possible therapeutic medications (2). Sections three and four of this book focus primarily on specific psychotherapeutic and pharmacological modes of treatment and the variety of settings where these interventions can effectively occur (3). The authors and editors have provided a thorough and remarkably up-to-date review of these agents. However, it is not part of the dialogue to wonder why naltrexone is not effective as a treatment for alcohol dependence outside of research trials. Whether acamprosate or other treatments will be successful or will suffer a similar fate is an important question. The Handbook does not conclude what is acceptable research or provide clinical models. With others (4), one of us (M.S.G) has proposed 5-year outcomes with urine test confirmation to evaluate the role of different and often competing treatments in alcoholism.

The discussion of successful traditional psychotherapeutic approaches, including cognitive behavior therapy, motivational enhancement, and 12-step programs alone or in combination is likely more important to the clinician. The chapter authors appropriately acknowledge the importance of treatment/patient location and provide excellent sections on emergency management and primary health care settings as well as on the role of employee assistance programs and the criminal justice system. The increased awareness and understanding of the importance of identifying problem drinking combined with knowledge of treatment types, options, and locations will provide clinicians the tools to match patients to treatment properly for effective intervention and recovery.

Finally, section five provides an excellent and interesting overview of special topics, including fetal alcohol syndrome, dual diagnosis considerations, and issues specific to women, the elderly, and HIV-infected populations.

Notably missing from this fine text is a thorough description and discussion of the 12 steps of Alcoholics Anonymous (AA), their history, how they work, and what patients/clinicians can expect (5, 6). Al Anon, Alateen, and other 12-step meetings have helped loved ones understand the disease of alcoholism and obtain loved ones the treatment that they need. By leaving AA to the Big Book (7), this handbook does little to counter the argument made by addictions professionals that psychiatrists are adverse to the goals and treatment model that so many patients and family members choose. We have found that the greater our understanding of 12-step recovery, meeting types, and myths regarding AA, the more effectively we can manage resistance to this essential component of recovery from problem drinking. Psychiatrists are interested in how self-help works; AA, getting a sponsor, etc., should be a part of every handbook.

Drinkers smoke and smokers drink (8, 9). Identifying and treating smoking, the number-one cause of death among alcoholics, deserves attention (10). Alcohol abusers and alcohol-dependent people often have other substance abuse disorders. Comorbid psychiatric and addiction disorders are the rule rather than the exception (11). Drug testing should be a part of every evaluation of an alcohol abuser or person with any substance abuse disorder. Many patients find it easier to admit to alcohol use than to cocaine or heroin abuse. Denial, minimizing, and outright lying are a part of the disease of alcoholism. Alcohol intoxication diagnoses are made more often by law enforcement agents using roadside sobriety and breath testing or emergency room personnel using these tests than psychiatrists who only ask the patient. History taking from the patient may be the best example of a clinical oxymoron. Interviews with family members, friends, employers, and others as well as comprehensive testing are essential to avoid either misdiagnosis or partial treatment of disease. The obvious limitations of DSM and psychiatric approaches to diagnosis should be considered alongside the strengths and limitations of drug testing.

Finally, the text should consider an expert’s role in identifying and treating alcoholic colleagues as well as studying and improving treatment. What standards should we follow to evaluate new treatments? Outcome measures such as return to work, psychiatric progress, and drug-free outcomes as demonstrated by 5 years of randomized and supervised testing, the mainstay of physician treatment program evaluations, should be part of all treatment evaluation (4).

In summary, the Handbook of Clinical Alcoholism Treatment is a thorough, well-written, and easy to read resource on a remarkably broad variety of topics within the field of alcoholism. It is a multiauthor or multiexpert text but reads almost as if it were written by the editors. The chapter authors and editors have done a remarkable job in producing a current, comprehensive, extraordinarily informative text for promoting effective intervention and treatment of patients suffering from alcoholism.