Treating alcohol dependence - putting the "p" into rehabilitation
Dr Christos Kouimtsidis has been responsible for introducing a new therapeutic approach known as Structured Preparation before Alcohol Detox (SPADe), as well as 'pre-habilitation' into the treatment of addictions. This article provides an overview of his research and explains why he believes current treatment approaches for alcohol dependence require improvements.
Why is pre-habilitation for alcohol dependence important?
Alcohol dependence continues to be a major challenge for the individual affected, their families and for society as a whole. Existing treatment approaches have a high dropout rate. This is normally characterised by people who complete a program of detoxification not continuing with aftercare. This results in a high rate of relapse within the first one to three months. Furthermore, it seems that repeated detoxifications rather than improving any long-term outcome are in fact more likely to be associated with a compromised ability to make the changes needed for maintaining lifelong abstinence. Therefore, the adoption of a 'pre-habilitation' approach, based fundamentally on the following:
a) treatment planning, and
b) the assertive management of the anticipated risks and harms associated with detoxification,
results in significantly improved, long-term outcomes,
Scale of the need for detoxification from alcohol
Alcohol-related harm is currently estimated to cost the National Health Service (NHS) in England £3.5bn a year. 'Alcohol use disorder' is an umbrella term that describes a range of disorders of excessive drinking, with the most severe one that of 'alcohol dependence'. Alcohol withdrawal symptoms can be followed by epileptic seizures twenty-four to forty-eight hours after stopping. Delirium and tremens can occur between three to seven days. The symptoms can also lead to death due to respiratory and cardiovascular failure. Alcohol withdrawal therefore requires medical management.
Of the estimated 1.6 million people with alcohol dependence in the UK, it is believed that some 250,000 may benefit from intensive treatment such as medically assisted withdrawal (from now on referred to as 'detoxification').
Emphasis on planning prior to detoxification
Current UK treatment guidelines suggest that the treatment for moderate to severe alcohol dependence should be planned and emphasis should be given to the provision of structured aftercare. Planned detoxification should be provided at the first available opportunity, whereas urgent detoxification should be avoided as it leads to immediate relapse if not followed by intensive aftercare.
Detoxification can take place either in the community as an outpatient (home detox) or as an inpatient. The choice of detox will depend on the relative clinical risks. The type of detoxification has no effect on treatment outcomes (completion of detoxification or long-term abstinence). The choice of treatment location depends on a list of health risk factors and the availability of social support to help to reduce these risks during the detoxification process.
What causes relapse after detoxification?
Even with risk management the outcomes of detoxification are often poor and without good engagement in aftercare subsequent relapse rates are high (around 60% within the first month). Aftercare is therefore fundamental.
Furthermore, it has been found that people who go through multiple detoxifications show greater emotional and cognitive impairments. Individuals who have experienced multiple detoxifications find the environment more stressful, and lose the ability to resolve conflict and to respond appropriately to stress. In addition, the association between pre-existing anxiety and mood disorders and alcohol misuse, combined with drinking as a self medication strategy means that this is obviously not a happy or healthy combination. The course of the condition gets increasingly worse with more frequent and more severe relapses. Rather than accumulating more experience and having a better chance of achieving sustainable abstinence (as might normally be expected), the repeated detoxifications and treatment attempts mean that people actually get worse.
What is pre-habilitation?
Pre-habilitation is a new approach that my team have pioneered and aims to constructively apply existing experience with treatment modalities with the latest scientific knowledge. For the reasons stated above, every treatment or process of intervention may carry as much (or more!) risk as potential benefit. A pre-habilitation based approach therefore implements a proactive management of those identified harms and risks, and aims to get the overall treatment approach right first time.
Humans have evolved to learn from experience
Although pre-habilitation is considered a new approach it is based on a fundamental ability of all humans, an ability that underpins the evolution of human civilisation i.e. that of planning and learning. Planning is crucial in all aspects of everyday life, and the ability to predict or anticipate certain harms or to assess certain risks is associated with the human ability of learning from experience. This allows us to modify behavioural responses and to develop long-term and sustainable response strategies. These are also the essential qualities associated with individual survival and progress.To that effect planning in advance, in anticipation of risks can be considered as an essential strategy.
Structured Preparation before Alcohol Detoxification (SPADe)
A stage of 'structured preparation' prior to detoxification aims not just to maintain motivation and to prepare for the detoxification process itself (as per previous models), but also to prepare for long-term sustainable lifelong abstinence.
The immediate aims were to manage post detoxification cravings by stabilising the levels and pattern of drinking, as well as starting necessary lifestyle changes early in the process - and prior to detoxification. This approach is also combined with strategies to reduce levels of stress around the individual by encouraging family members and 'important others' such as friends, to help provide a supportive and comforting environment.
What is 'partial controlled drinking'?
The concept of controlled drinking has generated intense conflict amongst various professional groups. However, it is now generally recognised that controlled drinking could be a viable solution, but usually only for those people not dependent on alcohol, nevertheless, it is incorporated into the first phase of the SPADe approach.
Applying SPADe treatment and 'guided self-detox'
Within the SPADe treatment approach for alcohol dependence we refer to controlled drinking as “partial controlled drinking” for two main reasons. These are as follows:
a) it is an initial stage in the treatment process and not the final aim, which is lifelong abstinence;
b) the amount and pattern of drinking during this stage of treatment is not within healthy limits.
Within the SPADe treatment model, the main aim of the partial controlled drinking phase is stabilisation of both the amount and the patterns of drinking. In this context, alcohol is considered as if it were 'a form of medication', with frequent and regular dosing to prevent rather than treat withdrawal symptoms. This is important from both a biological and psychological perspective. From a biological stance the self 'medication' protects against brain acute dysregulation, and maintains the homeostatic system of the brain. From a psychological stance continued 'use' empowers the individual into regaining some control of the decision making process. There is also a reduction of the impulsivity associated with the experience, or avoidance of experiencing cravings and withdrawal symptoms. Once stability is achieved then gradual reduction can be safely achieved. This model of detoxification is called “guided self-detox”.
Early introduction of alcohol-free lifestyle changes
For a short period stabilisation of drinking provides a relatively secure environment for the individual and their immediate family, and allows for a social network to develop and to test lifestyle changes. This early and gradual implementation of change to an individual’s lifestyle are necessary to provide the following:
a) a routine in everyday life that will protect from early relapse,
b) fill in the void that alcohol detoxification will leave behind,
c) can be used as distraction strategies against cravings,
d) will enhance personal responsibility,
e) will de-mystify alcohol and challenge the omnipotence of cravings or withdrawal symptoms,
f) will protect from the acute stress experienced in the early days of abstinence.
Stress free and supportive environment
Recovery is easier and more sustainable within a respectful, stress free and supportive environment. It is far easier for the individual in recovery to maintain abstinence particularly the first few weeks, within an abstinent family environment. This removes any proximal cues or triggers (such as the smell or sight of alcohol), as well as the removal of distant cues such as elevated levels of stress or emotional negativity.
Therefore, the involvement of family members and immediate social support systems into the treatment will have an important impact by:
- educating those involved with managing the environment,
- modifying unrealistic expectations,
- supporting a more gradual adaptation to the new family dynamics (following the removal of alcohol),
- helping to manage anxiety and difficult feelings/emotions associated with broken trust,
- promoting a partnership approach.
Does SPADe work?
The SPADe approach has been offered and evaluated as a group intervention. The evidence to support the provision on an individual basis is anecdotal. These group treatment sessions were first called PAD (Preparation for Alcohol Detoxification) and more recently Abstinence Preparation Groups (APG) or SPADe groups.
Early results on PAD groups have indicated a major improvement in the completion rate of detoxification. It has been seen that there is an important educational effect on individuals and their families. PAD helped people to clarify their treatment goals and to follow alternative and appropriate treatment options. Later data demonstrated that significantly more people undergoing PAD group therapy maintained their abstinence (74.5% one-month post detoxification).
A more recent evaluation of APG treatment outcomes supports a positive medium term effect on the group at three and six months (48% and 50% respectively). Furthermore it has been demonstrated that participation in structured intervention prior to detoxification enhances subsequent participation in aftercare. 82% of the clients exposed to APG continued with aftercare. Qualitative research into the experiences of those people involved in APG care shows that the group finds the treatment acceptable, it increases a sense of improved control and reports a sense of their 'self-efficacy' into quitting alcohol.
More recently a feasibility Randomised Controlled Trial, funded by NIHR has been completed by the author and a large group of academics in the field. The protocol of this trial is available and the results will be published in the future.
The above article is based on the following research:
- C Kouimtsidis, T Duka E, Palmer, A Lingford-Hughes. 2019. Prehabilitation in Alcohol Dependence as a Treatment Model for Sustainable Outcomes. A Narrative Review of Literature on the Risks Associated With Detoxification, From Animal Models to Human Translational Research. Frontiers of Psychiatry. https://doi.org/10.3389/fpsyt.2019.00339
- Kouimtsidis C, Charge KJ, Moch J, Stahl D. 2017. Abstinence Preparation Group Intervention for dependent alcohol users. How does it work? Results of a process study. Journal of Substance Use, 22(2): 149-155. DOI: 10.3109/14659891.2016.1153164.
- Kouimtsidis C, Sharma E, Smith A, Charge KJ. 2015. Structured intervention to prepare dependent drinkers to achieve abstinence; results from a cohort evaluation for six months post detoxification. Journal of Substance Use, DOI:10.3109/14659891.2015.1029020.
- Croxford A, Notley C, Maskrey V, Holland R, Kouimtsidis C. 2015. An exploratory qualitative study seeking participant views evaluating group Cognitive Behavioural Therapy preparation for alcohol detoxification. Journal of Substance Use, 20(1), 61-68.
- Kouimtsidis C. Drabble K & Ford L. 2012. Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. Drugs: Education, Prevention and Policy, 19 (1), 81-83.
- 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. Drugs: Education, Prevention and Policy, 18 (3), 237-239.