Effects of Alcohol Abuse

Criteria for Early Intervention (Adults)
Early intervention is the first intervention a professional will try to bring an alcohol problem under control.
            Examples: Student assistance programs, employment assistance programs, one-to-one counseling with at-risk individuals, education programs for first-time driving under the influence offenders.
Settings: Any appropriate setting, including individual clinical offices, schools, work sites, community centers, or an individual’s home.
Support Systems:

• Individual may be referred to ongoing treatment for alcohol dependence.
• Individual may be referred for medical, psychological or psychiatric services.
• Individual may be referred for an alcohol and drug assessment.
• Individual may be referred for community social services.

Interventions:

• Formal intervention may be conducted by any professional that is knowledgeable about intervention techniques.
• Planned educational programs designed to reduce or eliminate drinking.
• Helping the patient to recognize and avoid harmful consequences of inappropriate alcohol use.

Criteria for Admission

• Any biomedical problems are stable or are being actively addressed and will not interfere with intervention.
• Any emotional or behavioral conditions or complications are being addressed through appropriate mental health services.
• The individual expresses a willingness to gain an understanding of how his or her current drinking pattern may be harmful.
• The situation is characterized by one of the following:
• The individual does not understand the need to alter his or her current use pattern to prevent further harm related to drinking.
• The individual needs to acquire the specific skills needed to change his or her current pattern of drinking.
• The individual’s living environment is characterized by one of the following:
• The social support system is composed primarily of individuals whose substance use patterns prevent them from meeting social, work, school, or family obligations.
• Family members currently are abusing substances.
• Significant others express values concerning alcohol or drug use that create significant conflict to the individual.
• Significant others condone or encourage inappropriate use of alcohol or other drugs.

Criteria for Outpatient Treatment (Adults)
An adult patient qualifies for outpatient treatment if he or she meets the diagnostic criteria for Psychoactive Substance Use Disorder as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM), and if the patient meets all six of the following criteria:
1. Patient is not acutely intoxicated and is at minimal risk of suffering severe withdrawal symptoms.
2. All medical conditions are stable and do not require inpatient management.
3. All of the following:
a. The individual’s anxiety, guilt, and/or depression, if present, appear to be related to substance-related problems rather than to a coexisting psychiatric/emotional/behavioral condition. If the patient had psychiatric/emotional/behavioral problems other than those caused by substance use, the problems are being treated by an appropriate mental health professional.
b. Mental status does not preclude the patient from comprehending and understanding the program or participating in the treatment process. 
c. Patient is not at risk to harming self or others.
4. Both of the following:
a. Patient expresses a willingness to cooperate with the program and attend all scheduled activities.
b. The patient may admit that he or she has a problem with alcohol or drugs, but the patient requires monitoring and motivating strategies. The patient does not need a more structured program.
5. Patient can remain abstinent only with support and can do so between appointments.
6. One of the following:
a. Environment is sufficiently supportive to make outpatient treatment feasible. Family or significant others are supportive of recovery.
b. The patient does not have the ideal support system in his or her current environment but the patient is willing to obtain such support.
c. Family or significant others are supportive but they need professional interventions to improve chances of success.
Criteria for Inpatient Treatment (Adults)
An adult patient needs inpatient treatment if he or she meets the DSM diagnostic criteria for Substance Use Disorder and meets at least two of the following criteria:
1. The patient presents a risk of severe withdrawal or the patient has had past failures at entering treatment after detoxification.
2. Patient has medical conditions that present imminent danger of damaging health if use resumes or concurrent medical illness needs medical monitoring.
3. One of the following:
a. Emotional/behavioral problems interfere with abstinence and stability to the degree that there is a need for a structured 24-hour environment.
b. There is a moderate risk of behaviors endangering self or others. Current
suicidal/homicidal thoughts with no action plan and a history of suicidal gestures or homicidal threats.
c. The patient is manifesting stress behaviors related to losses or anticipated losses that significantly impair daily living. A 24-hour facility is necessary to address the addiction.
d. There is a history or presence of violent or disruptive behavior during intoxication with imminent danger to self or others.
e. Concomitant personality disorders are of such severity that the accompanying dysfunctional behaviors require continuous boundary-setting interventions.
4. Despite consequences, the patient does not accept the severity of the problem and needs intensive motivating strategies available in a 24-hour structured setting.
5. One of the following:
a. Despite active participation at a less intensive level of care or in a self-help fellowship, that patient is experiencing an acute crisis with an intensification of addiction symptoms. Without 24-hour supervision, the patient will continue to use.
b. The patient cannot control her or his use as long as alcohol or drugs are present in the environment; or
c. The treatments necessary for this patient require this level of care.
6. One of the following:
a. The patient lives in an environment in which treatment is unlikely to succeed (e.g., chaotic environment, rife with interpersonal conflict, which undermines the patient’s efforts to change, nonexistent family, or their environmental conditions, or significant others living with the patient manifest current substance use and are likely to undermine the patient’s recovery).
b. Treatment accessibility prevents participation in a less intensive level of care.
c. There is a danger of physical, sexual, or emotional abuse in the current
environment.
d. The patient is engaged in an occupation where continued use constitutes a substantial imminent risk to personal or public safety.
Criteria for Early Intervention (Adolescents)
This is the first intervention a professional will try to bring an alcohol problem under control.
            Examples: Student assistance programs, one-to-one counseling with at-risk adolescents, educational programs for first-time driving under the influence offenders.
Setting: Any appropriate setting, including clinical offices, treatment facilities, schools, work place, community centers or the adolescent’s home.
Support systems:

• Adolescent may be referred for ongoing treatment for substance abuse or dependency.
• The adolescent may be referred for medical, psychological, or psychiatric services.
• The adolescent may be referred to a substance abuse professional for an alcohol and drug assessment.
• The adolescent may be referred for community services.

Interventions:

• Individual, group or family counseling.
• Planned educational programs focused on helping the adolescent recognize and avoid harmful consequences of inappropriate substance use.

Criteria for Admission
The adolescent’s problems and risk factors appear to be related to substance use but do not meet the criteria for alcohol abuse or dependence.

• Any biomedical problems are stable or are being addressed.
• Any emotional or behavioral conditions are being addressed through appropriate mental health services.
• The adolescent expresses a willingness to gain an understanding of how his or her current use of alcohol or drugs may be harmful.
• The situation is characterized by one of the following:
• The adolescent does not understand the need to alter his or her current pattern of alcohol or drug abuse to prevent further harm.
• The adolescent needs to acquire the specific skills needed to change his or her current pattern of alcohol or drug use.
• The adolescent’s living environment is characterized by one of the following:
• The social support system is composed primarily of individuals whose substance use patterns are harmful.
• Family members currently are abusing alcohol or drugs.
• Significant others express values concerning alcohol or drug use that create significant conflict for the adolescent.
• Significant others condone or encourage inappropriate alcohol or drug use.

Criteria for Outpatient Treatment (Adolescents)
An adolescent patient qualifies for outpatient treatment if he or she meets DSM criteria for Substance Use Disorder and the following dimensions:
1. Patient is not intoxicated and presents no risk of withdrawal.
2. The patient has no biomedical conditions that would interfere with outpatient treatment.
3. The patient's problem behaviors, moods, feelings and attitudes are related to addiction rather than to a mental disorder, or the patient is being treated by an
appropriate mental health professional. Patient's mental status is stable. Patient is
not at risk for harming self or others.
4. Patient is willing to cooperate and attend all scheduled outpatient activities. Patient is responsive to parents, school authorities, and the staff.
5. The patient is willing to consider maintaining abstinence and recovery goals.
6. A sufficiently supportive recovery environment exists, which makes outpatient treatment feasible.
a. Parents or significant others are supportive of treatment and the program is accessible.
b. The patient currently does not have a supportive recovery environment but he or she is willing to obtain such support.
c. The family or significant others are supportive but require professional intervention to improve chances of success.
Criteria of Inpatient Treatment (Adolescents)
To qualify for inpatient treatment, the adolescent must meet the DSM criteria for Substance Use Disorder, all of the dimensions for outpatient treatment, plus at least two of the following dimensions:
1. The risk of withdrawal is present.
2. Continued use places the patient at imminent risk of serious damage to health; or biomedical condition requires medical management.
3. History reflects cognitive development of at least 11 years of age and significant impairment in social, interpersonal, occupational, or educational
functioning as evidenced by one of the following:
a. Current inability to maintain behavioral stability for more than 48-hour period.
b. Mild to moderate risk to self or others. Current suicidal/homicidal thoughts with no active plan or history of suicidal/homicidal gestures.
c. Behaviors sufficiently chronic and/or disruptive to require separation from current environment.
4. Patient is having difficulty acknowledging an alcohol or a drug problem and is not able to follow through with treatment in a less intense environment.
5. The patient is experiencing an intensification of addiction symptoms despite interventions in a less intense level of care; or, Patient has been unable to
control use as long as alcohol or drugs are present in the patient's environment; or, If abstinent, the patient is in crisis and appears to be in imminent danger of using alcohol or drugs.
6. One of the following:
a. Environment is not conducive to successful treatment at a less intense level of care.
b. The parents or legal guardians are unable to provide consistent   participation necessary to support treatment in a less intense level of care.
c. Accessibility to treatment precludes participation in a less intense level of care.
d. There is a danger of physical, sexual, or emotional abuse in the patient's current environment.
How to Share the Diagnosis
You need to discuss your findings with the patient and, if possible, with the patient's family. If you are in recovery yourself, this is not a good time to share much of your story. This may frighten patients, and make them wonder about your own state of health. Patients need a stable, well-adjusted counselor. You can tell a patient that you are recovering, but don't get into specifics about your drinking and using days.
As you share the diagnosis with the patient, make sure you take the time to encourage and reinforce him or her for having the courage to come into treatment. Check out how the patient feels. It is not good to be suffering, and your patient has been in misery for a long time. It was scary to come into treatment but he or she made it. You are proud of them. Most people who complete their first inpatient treatment ultimately achieve a stable recovery. They might have to come into treatment again, even again and again, but the first treatment is a major turning point. Patients learn things in the first treatment that they never forget. They learn that there is a disease called chemical dependency, that there is treatment for it, that treatment doesn't hurt, and that people can live happy, sober lifestyles.
How to Conduct a Crisis Intervention
Patients who are severely dependent and unwilling or unable to see the severity of their addiction need a crisis intervention. Crisis intervention is a confrontation by a group of concerned family and friends. This confrontation must be loving, gentle and supportive and it is best to use a trained interventionist to help you develop the intervention strategy. If you want to do the intervention yourself, first read the book Love First, by Jeff and Debra Jay (Hazelden, 1-800-328-9000). This is an excellent text and it carefully discusses the intervention techniques. Basically, an intervention has to be carefully organized, rehearsed and choreographed. Each member of the group should be a loving, caring significant other and not an alcohol abuser. Each person writes a letter stating exactly how the patient’s alcoholism has negatively affected his or her life. In this letter, group members share their love and concern for the patient and ask that the patient enter treatment. The patient is told it is not him or her that is the problem but the illness is the problem. It is a lethal problem, and it needs treatment. Each person reads his or her letter of concern and love for the patient and asks him or her to go into treatment that day. The treatment setting has been arranged and the patient’s bags are packed. The intervention needs to be held at a neutral location when the patient is sober, not in the patient’s home or office where the patient may feel more comfortable. It is difficult for the wall of denial to hold up under all of this love and most of the time the patient agrees to go into treatment. If the patient refuses, the truth has still come out and this often leads to treatment at a later time. Each participant is encouraged to exhibit the following behaviors:

• Positive regard for the patient and negative regard for the drinking.
• Give specific situations where the drinking negatively affected them.
• Validate that alcoholism is a disease and it’s not the patient’s fault.

Figure 1.1 Example of an intervention letter
Bob, you are my closest friend and I can’t tell you how much your friendship has meant to me. We have grown up together. Our kids love to play ball together and you and I enjoy being the vocal coaches on the sideline. There is no one in my life that has had a more positive effect on my life and successful business than you. Thank you for all of the years you have stood by me. When I made mistakes, you were always there to comfort me and give me good advice like a brother. Now comes the hard part of this letter and I might not handle this very well so bear with me. Lately, I have been concerned with your drinking. I see you driving the car with the children after you have had too much to drink. In fact, after the Halloween party on Saturday, you were so drunk you could hardly walk, yet you insisted on driving your wife and your children home. We all tried to stop you but you wouldn’t listen to anyone. Bob, alcoholism is a disease, just like the alcoholism that killed your father. It’s genetic and life threatening. I am here to ask you to get the treatment that you need to get well. It hurts me too much to see you suffer. You and I know you can’t drink in a healthy way anymore. These problems have happened too much. My own kids don’t want to come over here anymore, and I avoid you myself. This hurts me too much for it to go on. Please help yourself and your family and get the help you need. The counselor has set up treatment for you today at ________ Treatment Center and we would all be incredibly proud of you if you would go for help. I love you very much, brother. Please do this for all of the people who love you.
Love, Fred.
Save the best letter for last. This is someone very tender and special to the patient. It might be the patient’s child, a friend or family member. It’s someone whose letter breaks your heart. It is very difficult for denial to work in this tremendous atmosphere of love and truth. Most patients agree and go to treatment. Remember that no intervention is a failure. Even if the patient refuses to get treatment, the truth came out and that’s always a victory.
Interventions and treatment are going to take time. If you are a primary care physician, emergency room doctor, cardiologist, or surgeon, you might not have the time to struggle with this problem. All addiction treatment is a long journey toward the truth and this journey is slow and painful. Patients have to face the demons they have hidden from for years. They need to walk into the dark forest of fear and need a trustworthy guide. They need someone with time, energy, patience and love, a person who has been on this journey many times and come out alive. At some point you need to decide if you are going to take on this problem yourself or refer to an addiction professional. Remember that alcoholism is a chronic relapsing brain disease. It is only at the five-year sobriety point that the relapse rate drops to around zero (Vaillant, 1996). So if you take this battle on, it’s going to be a long one. If you look at addiction programs around the country, you will see that about half of the patients who leave treatment stay sober for the next year. This does not mean that they quit; this means that the person helping the patient quit. The recovery community was not tenacious enough to make sure the patient was working his or her program. Ninety percent of patients who work the program stay clean and sober. So if you want to take on this job, remember that you are in a five-year fight for the patient’s life. You must do everything in your power to make sure that they work the program. Because of protracted withdrawal, dual diagnoses, organic brain syndrome and many other factors, about half of all alcoholics are not able to work their program. They do not have the spiritual, mental, or physical ability to work the program. These patients may need years in a structured facility.
Sometimes you will want to refer an alcoholic to an addiction professional. There are excellent alcohol and drug counselors and physicians that specialize in addiction. They are used to the battle and they have specialized training to deal with the special problems of addiction. A treatment facility locator can be found at https://findtreatment.samhsa.gov. Other times, you will want to try to help the patient yourself but remember you are in for a five-year battle. Never forget that you are the healer and you will do everything in your power to keep your patient sober.

I'm Dr. Robert R. Perkinson I specialize in alcoholism treatment, drug abuse treatment, teen drug abuse treatment, and problem gambling treatment. I have been treating alcoholics and addicts for over 30 years and have written the leading treatment manual for addiction counselors in the world. I thought I would give you an opportunity to learn more about addiction.

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