Thursday, October 1, 2015

How Many Kinds of Alcohol Dependence Are There?

 

This is  a very useful study that takes advantage of a superior statistical protocol that winkles out natural associations.  We do not have to rely on inspired guessing.  Better yet the data base is huge and this allows minority associations to show up as well and not be discarded.

Better yet the data conforms to empirical observation as well.  Cocaine dependence does last around five years and nicotine takes about twenty years to cause sufficient damage that the victim becomes engaged.

This will be helpful in planning better treatment protocols as well.


How Many Kinds of Alcohol Dependence Are There?
http://www.rehabs.com/pro-talk-articles/how-many-kinds-of-alcohol-dependence-are-there/


The myth that “all alcoholics are alike and all need the same treatment” is exactly that: a myth. Data from NESARC shows that there are many kinds of alcohol dependence and suggests that there should be many different kinds of treatment as well.


The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave One was the largest study of alcohol and drug use that had ever been conducted in the US; data from NESARC Wave One is still being analyzed today, even though in the interim two follow-up studies have been conducted, NESARC Wave Two and NESARC Wave Three. NESARC Wave One collected data from 43,093 individuals, 1,484 of whom met DSM-IV criteria for alcohol dependence. Wave Two was a follow-up study conducted three years later to investigate changes in status including recovery outcomes. Of the original 43,093 individuals, 34,653 were interviewed at the Wave Two follow-up.


Of the original 1,484 alcohol dependent subjects, 1,172 were available for the Wave Two follow-up interview. Wave Three is brand new and won’t be discussed here as its data are only now beginning to be analyzed.


NESARC helped to dispel many myths about alcohol and drug dependence, such as the notion that substance dependence was a chronic, progressive disease which could only end in death unless treated with the 12 steps of AA.  

 NESARC debunked this myth with data which showed that the lifetime recovery rates for nicotine, alcohol, cannabis, and cocaine dependency were, respectively, 83.7%, 90.6%, 97.2%, and 99.2%. 

Likewise, the half lives of nicotine, alcohol, cannabis, and cocaine dependency were, respectively, 26, 14, 6, and 5 years after dependence onset. Most who recovered from substance dependence received no treatment at all and never attended AA; at least half who recovered did so by controlling their substance use rather than quitting completely.

Another myth which was dispelled by the NESARC research was the idea that “all alcoholics are alike.” Moss, Chen, and Yi published a paper in 2007 which analyzed the data from NESARC Wave One and found that there were five distinct subtypes of alcohol dependence; they named these subtypes Young Adult, Functional, Intermediate Familial, Young Antisocial, and Chronic Severe.  

Figure 1 shows the percentage of people with alcohol dependence who fall into each of these subtypes. Moss, Chen, and Yi also published a paper in 2010 which analyzed the 3 year follow-up data from NESARC Wave Two for the alcohol dependent subjects and discussed their treatment and recovery status.


Moss, Chen, and Yi obtained the five subtype model of alcohol dependence by using a statistical modeling method called Latent Class Analysis. This type of analysis is a great improvement over earlier classifications such as Jellinek’s which were based almost exclusively on assumptions and preconceived notions of clinicians about the subject population. Another great advantage of Moss et al.’s classification system over earlier ones is the fact that it sampled the general population and avoided the biases inherent in clinical samples.


Some of the most important factors involved in the development of this five subtype model of alcohol dependence include age of onset of alcohol dependence, illustrated in Figure 2, comorbid antisocial personality disorder (ASPD), illustrated in Figure 3, and the percentage of relatives with alcohol dependence, also illustrated in Figure 3. Figure 3 also gives information on what percentage of each subtype have ever received any form of alcoholism treatment in their lifetimes. According to NESARC, the following categories constituted alcoholism treatment:
  • Alcoholics⁄Narcotics⁄Cocaine Anonymous, or 12-step meeting
  • Family services or other social service agency
  • Alcohol⁄drug detoxification ward⁄clinic
  • Inpatient ward of psychiatric⁄general hospital or community mental
  • Outpatient clinic, including outreach and day⁄partial patient programs
  • Alcohol⁄drug rehabilitation program
  • Emergency room because of drinking
  • Halfway house⁄therapeutic community
  • Crisis center because of drinking
  • Employee assistance program (EAP)
  • Clergyman, priest, or rabbi
  • Private physician, psychiatrist, psychologist, social worker, or any other professional
  • Any other agency or professional

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The important characteristics which define each subtype are as follows:

  • Young Adult: This subtype has a relatively young age of onset of alcohol dependence (AD) (19.6 years old), very low prevalence of antisocial personality disorder (ASPD) 

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  • Functional: This subtype has the oldest age of onset of alcohol dependence (AD) (37 years old), very low prevalence of antisocial personality disorder (ASPD) 

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  • Intermediate Familial: This subtype tends to have medial values on all essential traits. There is a somewhat late age of onset of alcohol dependence (AD) (32 years old), a medial prevalence of antisocial personality disorder (ASPD) (12.5%), and a medial percentage of first or second degree relatives with alcohol dependence (47%). This medial subtype is neither very like nor very unlike the other four subtypes.
  • Young Antisocial: This subtype has a the youngest age of onset of alcohol dependence (AD) (18.4 years old), the highest prevalence of antisocial personality disorder (ASPD) (54%), and a high percentage of first or second degree relatives with alcohol dependence (52.50%). This subtype is very similar to the Chronic Severe subtype in all respects except for the early age of onset of alcohol dependence (AD).
  • Chronic Severe: This subtype has a relatively late age of onset of alcohol dependence (AD) (29 years old), a high prevalence of antisocial personality disorder (ASPD) (47%), and the highest percentage of first or second degree relatives with alcohol dependence (77%). This subtype is very similar to the Young Antisocial subtype in all respects except for the late age of onset of alcohol dependence (AD).
Next let’s look at some of the follow-up data. In Figure 4 we look at the data from NESARC Wave Two, the follow-up study which took place three years after NESARC Wave One, to see how many of the alcohol dependent subjects from Wave One still have alcohol dependence three years later and how many have either recovered or now only meet criteria for alcohol abuse instead of alcohol dependence.
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Figure 4 also shows what percentage of subjects received alcoholism treatment in the year prior to the Wave Two interviews. Note that this is different from the treatment data found in Figure 3, which shows what percentage of subjects ever received any alcoholism treatment in their lifetimes.

It’s of great interest to note that the first two subtypes, Young Adult and Functional, have the highest rates of recovery and the lowest rates of treatment utilization. These two subtypes also have the lowest rates of comorbid antisocial personality disorder (ASPD).

By way of contrast, the last two subtypes, Young Antisocial and Chronic Severe, have the poorest rates of recovery and the highest rates of treatment utilization. These two subtypes also have the highest rates of comorbid antisocial personality disorder (ASPD). This suggests that the rates of self-recovery, i. e. recovery without treatment or so-called spontaneous remission, are highest among these first two subtypes.

It would be interesting if we knew which individuals were coerced into treatment and which went voluntarily, as one would suspect that the last two groups, Young Antisocial and Chronic Severe, would have high rates of coerced treatment since they have high rates of ASPD. However, NESARC did not collect data on coercion.

Another interesting way to look at the data from the three year follow-up period (Wave 2) is in terms of harm reduction outcomes. In Figure 5 we show the outcome data in terms of the following categories:
  • Still Dependent: The subject continues to meet three or more of the criteria necessary for a diagnosis of Alcohol Dependence.
  • Partial Remission: The subject meets at least one but less than three of the criteria for Alcohol Dependence or Alcohol Abuse. The number of criteria met has dropped below the three or more found at the initial interview. This is a harm reduction outcome.
  • Symptom-Free Heavy Drinking: The subject no longer meets any of the criteria for Alcohol Dependence or Alcohol Abuse. However, the subject exceeds the moderate drinking limits of 14 per week and 4 per day for men or 7 per week and 3 per day for women. This is a harm reduction outcome.
  • Moderate Drinking: The subject no longer meets any of the criteria for Alcohol Dependence or Alcohol Abuse and the subject remains within the moderate drinking limits of 14 per week and 4 per day for men or 7 per week and 3 per day for women.
  • Abstinence: The subject no longer drinks alcohol. 
We can clearly see that the outcome data puts a lie to the old saw from AA and 12 step treatment facilities that “alcoholism is a progressive disease that results in death and can only be arrested by abstinence and lifelong attendance at AA.”


The reality is that the harm reduction outcomes of Partial Remission and Symptom-Free Heavy Drinking are the most common outcomes; total abstinence is a relatively uncommon outcome as is perfect moderation.-Kenneth AndersonThe reality is that the harm reduction outcomes of Partial Remission and Symptom-Free Heavy Drinking are the most common outcomes; total abstinence is a relatively uncommon outcome as is perfect moderation. It would be very interesting to see if treatment programs which focused on harm reduction outcomes could show better recovery rates for the Chronic Severe and Young Antisocial subtypes than do current treatment programs which focus almost exclusively on total abstinence as the only acceptable outcome. This is an experiment which is definitely worth trying if it could improve the rather dismal recovery rates produced by the typical alcoholism treatment programs we have at present.


The above data also helps us to understand why clinicians often have such a skewed and inaccurate picture of individuals with alcohol dependence and why clinicians frequently tout the existence of the mythical “addictive personality” which is characterized by pathological dishonesty and other character defects. Clinical samples are not representative of the general population. As the data show us, large numbers of people with alcohol dependence who show up in treatment settings or AA meetings rank high in ASPD. The Chronic Severe subtype is the highest treatment utilizer with 65.95% of this subtype ever receiving treatment and 36% receiving past year treatment. This subtype also ranks second highest in antisocial personality disorder (ASPD) with a prevalence of 47%.


The next highest treatment utilizer is the Young Antisocial subtype with 34.36% of this subtype ever receiving treatment and 10.3% receiving past year treatment. This subtype ranks highest in antisocial personality disorder (ASPD) with a prevalence of 54%.


It would be interesting to see how many of these two subtypes who failed to meet criteria for ASPD instead met criteria for Adult Antisocial Behavior; perhaps some future study could measure this. It also seems that these two subtypes frequently go through treatment repeatedly, whereas many falling into the other subtypes either resolve the problem on their own or with a single treatment admission. Is it any wonder that clinicians develop such an inaccurate perception of people with alcohol dependence given the skewed sample they are exposed to?


This is exactly why it is essential that clinicians learn the truth about the populations they are dealing with in order not to lump everyone together into one homogenous class based on prejudice and stereotype.


For me, personally, nothing was more damaging than the treatment I received at the hands of addiction treatment professionals when I voluntarily checked myself into a hospital to try and deal with a depression driven alcohol problem which was spiraling out of control.-Kenneth Anderson


For me, personally, nothing was more damaging than the treatment I received at the hands of addiction treatment professionals when I voluntarily checked myself into a hospital to try and deal with a depression driven alcohol problem which was spiraling out of control. Instead of getting help with the depression and other issues which were driving the alcohol use, it was immediately assumed that I was a pathological liar and the first sin I had to confess to was pathological lying in order to effect the cure. It did little good to tell them that I was a pathological truth teller; this was simply more proof to them that I was a liar and in denial.


In reality, the fact that I had no tact had led me into a lonely existence which was driving the depression and what I needed to learn was that a tactful response was more appropriate than blatant, unvarnished truthfulness.


It took me many years to recover from the damage wrought by my alcoholism treatment and in retrospect I would have done better and gotten better much more quickly had I kept myself away from these so-called professionals. This is why it is incumbent on addiction treatment providers to recognize that there are a broad variety of people with substance use problems, all of whom require uniquely individualized treatment. Confrontation and ego-deflation are as outmoded as exorcisms and ducking stools.

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