CHAPTER 4
ALCOHOL ABUSE AND ADDICTION

Alcohol is an addictive substance, but not everyone who drinks it becomes addicted. Most of those who drink alcohol do not become alcoholics. Scientists cannot explain what individual traits account for the difference, but they suspect that a wide variety of factors may make a person more susceptible to addictions of all kinds.

Alcoholism was recognized as a disease more than two hundred years ago. In 1785 Benjamin Rush, a signer of the Declaration of Independence and the first physician-general of Washington's Continental Army, wrote an essay on "the effects of ardent spirits," calling intemperance a disease and an addiction. Throughout the nineteenth century, physicians considered intemperance a disease. Opposition to the disease concept was widespread, however, especially among those who advocated a moralistic view of alcoholism. The temperance movement, for example, espoused that alcoholism could be cured through personal dedication or as part of a commitment to God.

THE DEFINITION OF ALCOHOLISM

As scientists and researchers learned more about alcoholism, its definition was revised and refined. Most people consider an alcoholic to be someone who drinks too much and cannot control his or her drinking. Alcoholism, however, does not merely refer to heavy drinking or getting drunk a certain number of times. The diagnosis of alcoholism applies only to those who show specific symptoms of addiction.

In 1992 Drs. Robert Morse and Daniel Flavin, writing for the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine ("The Definition of Alcoholism," Journal of the American Medical Association, 1992), defined alcoholism as:

[A] primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.

"Primary" refers to alcoholism as a disease independent from any other psychological disease (for example, schizophrenia), rather than a symptom of some other underlying disease. "Adverse consequences" for an alcoholic can include physical illness (liver disease, withdrawal symptoms, etc.), psychological problems, interpersonal difficulties (such as marital problems or domestic violence), and problems at work.

This definition of alcoholism incorporated "denial" as a major concept for the first time. Denial includes a number of psychological maneuvers by the drinker to avoid the fact that alcohol is the cause of his or her problems. Family and friends may reinforce an alcoholic's denial by covering up his or her drinking (for example, calling an employer to say the alcoholic has the flu rather than a hangover). Such behavior is also known as enabling. In other words, the friends and family make excuses for the drinker and enable him or her to continue drinking as opposed to having to face the repercussions of his or her alcohol abuse. Denial is a major obstacle in recovery.

The Institute of Medicine (IOM) has defined addiction as a brain disease "manifested by a complex set of behaviors that are the result of genetic, biological, psychological, and environmental interactions."

ALCOHOL ABUSE OR ALCOHOLISM?

The American Psychiatric Association, publisher of the Diagnostic and Statistical Manual of Mental Disorders (DSM), first defined alcoholism in 1952 (DSM-I). DSM-III renamed alcoholism as alcohol dependence and introduced the phrase "alcohol abuse." According to DSM-III's definitions of alcohol abuse, the condition involves a compulsive use of alcohol and impaired social or occupational functioning, while alcohol dependence includes physical tolerance and withdrawal symptoms when the drug is stopped. The most recent edition of this publication as of this writing, the Manual's Fourth Edition, Text Revision 2000 (DSM-IV-TR), refined these definitions further, but the basic definitions remain the same.

The World Health Organization publishes the International Classification of Diseases (ICD), which is designed to standardize health data collection throughout the world. The Tenth Edition (ICD-10) generally defines abuse and tolerance similarly to the DSM-IV-TR.

Symptoms of Alcoholism and Alcohol Abuse

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), in its September 2004 update of Alcoholism: Getting the Facts, states that alcoholism (alcohol dependence) is a disease that includes the four symptoms listed and described in Table 4.1.

According to Alcoholism: Getting the Facts, "alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control over drinking, or physical dependence." The symptoms of alcohol abuse according to this publication are listed in Table 4.2. The NIAAA notes that "although alcohol abuse is basically different from alcoholism, many effects of alcohol abuse are also experienced by alcoholics."

Other warning signs of alcohol abuse include the need to drink before facing certain situations, frequent drinking sprees, a steady increase in intake, solitary drinking, early-morning drinking, and the occurrence of blackouts. Blackouts for heavy drinkers are not episodes of passing out, but are periods drinkers cannot remember later, even though they appeared to be functioning at the time.

PREVALENCE OF ALCOHOL ABUSE AND
ALCOHOLISM

The Strategic Plan 2001-2005 of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) noted that nearly fourteen million Americans—one in every thirteen adults—have alcohol-abuse or alcohol-dependence problems. As Table 4.3 shows, people ages eighteen to twenty-five are far more likely to engage in alcohol use, binge alcohol use, or heavy alcohol use than those twelve to seventeen or those twenty-six and older. This can be attributed, in part, to the fact that this is a young, social group that—for those over twenty-one years of age—have just reached the age where they may drink legally. What is of particular concern about the data represented on this table is that the rates of binge drinking and heavy

drinking for eighteen- to twenty-five-year-olds increased steadily from 2000 to 2003—from 37.8% to 41.6% for binge drinking and from 12.8% to 15.1% for heavy alcohol use.

Figure 4.1 shows the trend in binge drinking in adults aged eighteen years and over from 1997 to 2004. These data provide a slightly different picture than those that single out the eighteen- to twenty-five-year-old group. The graph shows that the rate of binge drinking in the overall population over eighteen has decreased somewhat since 1997, from slightly over 21% in 1997 to a bit under 19% in 2004.

Figure 4.2 compares the rates of binge drinking for males and females in four age groups. As shown in Table 4.3, the age group with the highest percentages of binge drinking in 2004 was composed of eighteen- to twenty-four-year-olds; the percentages decline with each subsequent age group. However, in each age group, the rate of binge drinking in males was substantially higher than that of females. The percentage of males aged eighteen to twenty-four who binge drank in the first six months of 2004 was about 42%, while the percentage of females in that age group who binge drank was half that—about 21%. In the twenty-five to

forty-four age group, the percentage of males who binge drank was nearly 35%, but the percentage of females was about 15%. At forty-five to sixty-four years the gap widens more, with slightly over 21% of males having binged on alcohol, while the percentage of females who binged was not quite 7%. When adults reached age sixty-five years and older, only about 7% of men and 1% of women binge drank.

Figure 4.3 shows that a higher percentage of whites binge drank in the first six months of 2004 (nearly 22%) than did Hispanics (nearly 16%) or African-Americans (over 11%).

Table 4.4 shows trends in the prevalence of alcohol abuse by age, sex, and race/ethnicity by comparing data collected in 1991-1992 with data collected in 2001-2002. As one might expect after studying the data in Table 4.3 and Figure 4.2, the eighteen- to twenty-nine-year-old group quite consistently shows the highest percentages of alcohol abuse across races/ethnicities. In general, alcohol abuse rose over the decade between which these two data sets were gathered—quite substantially in some groups. There are exceptions, however. The rate remained somewhat stable in eighteen- to twenty-nine-year-old white males and dropped in this age group in Native American males and females. It also dropped in forty-five- to sixty-four-year-old Asian females. Overall decreases in the prevalence of alcohol abuse over this ten-year period are most notable in Native Americans.

Table 4.5 is similar to Table 4.4 and shows trends in the prevalence of alcohol dependence by age, sex, and race/ethnicity. Alcohol dependence is generally extremely low or nonexistent in the two oldest age groups, and has dropped off in the sixty-five and over age group of Native Americans. Once again, those most likely to be dependent on alcohol within any of the ethnic groups listed are those aged eighteen to twenty-nine.

ALCOHOL ABUSE AND ALCOHOLISM IN
VARIOUS RACIAL/ETHNIC GROUPS

Patterns of alcohol consumption vary across racial/ethnic groups as shown in Table 4.4 and Table 4.5. The NIAAA suggests that low alcoholism rates occur in certain groups because the drinking customs and sanctions (permissions) are well established and consistent with the rest of the culture. Conversely, multicultural populations have mixed feelings about alcohol and no common rules; they tend to have higher alcoholism rates. A population's alcohol norms (how one should behave in relation to alcohol) and attitudes (general beliefs about drinking) have been found to be strong predictors of drinking (Galvan et al., "Alcohol Use and Related Problems among Ethnic Minorities in the United States," Alcohol Research and Health, vol. 27, no. 1, 2003).

In addition, certain populations may be at higher or lower risk because of the way their bodies metabolize (chemically process) alcohol. For example, many Asians have an inherited deficiency of aldehyde dehydrogenase, a chemical that breaks down ethyl alcohol in the body. Without it, toxic substances build up after drinking alcohol and rapidly lead to flushing, dizziness, and nausea. Therefore, many Asians experience warning signals very early on and are less likely to continue drinking. Conversely, research suggests that Native Americans may lack these warning signals. Therefore, they are less sensitive to the intoxicating effects of alcohol and are more likely to develop alcoholism.

RISK FACTORS OF ALCOHOL ABUSE
AND ALCOHOLISM

The development of alcoholism is the result of a complex mix of biological, psychological, and social factors. Table 4.6 summarizes risk factors for alcohol use, abuse, and dependency. Genetics and alcohol reactivity (sensitivity) are biological factors. The rest are psychosocial factors.

Biological Factors

GENETICS.

A variety of studies investigating family history, adopted vs. biological children living in the same families, and twins separated and living in different families all indicate that genetics plays a substantial role in some forms of alcohol dependence and heavy drinking. A large number of genes is likely involved, each contributing a small part of the overall risk (Rachel F. Tyndale, "Genetics of Alcohol and Tobacco Use in Humans," Annals of Medicine, 2003).

Table 4.7 shows the percentage of U.S. adults eighteen years of age and over with prior-to-past year (2001-2002) alcohol dependence by selected characteristics. Notice that more than 75% of this alcohol-dependent sample had a family history of alcoholism. Most studies

suggest that genetic factors play a role in alcoholism and alcohol use in women as well as in men. Nonetheless, controversy remains as to the comparative strength of this role across genders. (See Table 4.6.)

ALCOHOL REACTIVITY (SENSITIVITY).

Alcohol reactivity or sensitivity refers to the sense of intoxication one has when drinking alcohol. The research on this topic has been primarily conducted on sons of alcoholics and reveals that, in general, they have a lower reactivity to alcohol. That is, when given moderate amounts of alcohol, sons of alcoholics report a lower subjective sense of intoxication compared with sons of nonalcoholics. Sons of alcoholics also show fewer signs of intoxication on certain physiological indicators than do the sons of nonalcoholics. Without early signals of intoxication, men with a low reactivity to alcohol may tend to drink more before they begin to feel drunk and thus may develop a high physiological tolerance for alcohol, which magnifies the problem. Susan Nolen-Hoeksema notes in "Gender Differences in Risk Factors and Consequences for Alcohol Use and Problems" (Clinical Psychology Review, 2004) that "long-term studies of men with low reactivity to moderate doses of alcohol suggest they are significantly more likely to become alcoholics over time than are men with greater reactivity to moderate doses of alcohol." (See Table 4.6.)

Psychosocial Factors

SOCIAL SANCTIONS, GENDER ROLES, AND COPING STYLES.

Social sanctions are a mechanism of social control for enforcing a society's standards. Social sanctions may be one factor explaining why men drink more alcohol than women. A "double standard" appears to exist for men and women in American society with regard to consuming alcohol. Research findings support this idea. For example, a national survey conducted by Wilsnack in 1996 found that women thought that 50% of people at a party would disapprove of a woman getting drunk, but only 30% would disapprove of a man doing the same. (See Table 4.6.)

In addition to social sanctions against women drinking as heavily as men, the American culture appears to identify alcohol consumption as part of the male gender role but not as part of the female gender role. The results of several studies reviewed by Nolen-Hoeksema (Clinical Psychology Review, 2004) "find that people, particularly women, who endorse traditionally feminine traits (nurturance, emotional expressivity) report less quantity and frequency of alcohol use." (See Table 4.6.) In contrast, traits often associated with the male gender role, such as aggressiveness and overcontrol of emotions, have been associated with heavy and problem alcohol use in both men and women.

In fact, heavy drinking may be a way that some people cope with stress and avoid emotions, a behavior referred to as "avoidant coping."

DRINKING MOTIVES, EXPECTATIONS, AND DEPRESSION/DISTRESS.

People consume alcohol for various reasons—as part of a meal, to celebrate certain occasions, and to reduce anxiety in social situations. But Nolen-Hoeksema comments that people also consume alcohol to cope with distress or depression, or to escape from negative feelings. Consequently, people expect that drinking alcohol will reduce tension, increase social or physical pleasure, and facilitate social interaction. Those who have positive expectations for their drinking, such as the belief that alcohol will reduce distress, tend to drink more than those who have negative expectancies, such as the belief that alcohol will interfere with the ability to cope with distress. In general, men have more positive expectations concerning alcohol consumption than women. These stronger motives to drink are more strongly associated with alcohol-related problems in men than in women (see Table 4.6), although Nolen-Hoeksema reports that the relationships among depression, general distress, alcohol consumption, and problems are quite complex.

SELF-ESTEEM, IMPULSIVITY, SENSATION-SEEKING, BEHAVIORAL UNDERCONTROL, AND ANTISOCIALITY.

As Table 4.6 shows, research results are inconclusive regarding the relationship between self-esteem and alcohol use. However, impulsivity, sensation-seeking, and behavioral undercontrol (not controlling one's behavior well) are consistently associated with alcohol use and problems in men. This association is less clear in women and may be another factor determining why a higher percentage of men than women are alcohol dependent. (See Table 4.7.)

Antisociality is a personality disorder that includes a chronic disregard for the rights of others and an absence of remorse for the harmful effects of these behaviors on others. People with this disorder are usually involved in aggressive and illegal activities. They are often impulsive and reckless and are more likely to become alcohol dependent. Males are more likely than females to demonstrate antisociality. (See Table 4.6.)

INTERPERSONAL RELATIONSHIPS AND SEXUAL ASSAULT.

Married couples often have strongly similar levels of drinking. It is unclear whether men and women with problem drinking patterns seek out partners with similar drinking patterns, or whether either is influenced by the other to drink during the marriage. However, marital discord is often present when spouses' drinking patterns differ significantly.

Sexual assault is a risk factor for problem drinking. The results of numerous studies have shown that women with a history of sexual assault, whether during childhood

or as an adult, are at increased risk for problem drinking and alcohol use disorder. The correlation is not as clear in men (Nolen-Hoeksema, Clinical Psychology Review, 2004).

SUBTYPES OF ALCOHOLISM

Based on studies of adopted children and twins, researchers have described several subtypes of alcoholism. Type I alcoholism affects both males and females, usually develops later in life, and is thought to be both genetic and environmental in cause. Type II occurs more often in men, usually develops during adolescence or young adulthood, and is primarily genetic in cause. (See Table 4.8.)

Another classification is called the Type A-Type B subtype. (See Table 4.9.) Type A and Type B alcoholics are defined by a range of factors, including family history of alcoholism, psychological disorders, and the severity of their alcoholism. There also appears to be a gender factor: more women than men tend to be Type A alcoholics, while men outnumber women in the Type B subtype.

Type A alcoholics typically have less severe dependence symptoms, and are more responsive to treatment than are Type B alcoholics. In contrast, Type B alcoholics tend to develop alcoholism at earlier ages, display more problem behaviors early in life, and have more severe dependence symptoms and alcohol-related problems (health, social, and psychological) than Type A alcoholics.

THE COST OF ALCOHOL ABUSE

Living with someone who has an alcohol problem affects every member of the family. Children seem to suffer the most. The National Association for Children of Alcoholics (NACoA) estimated that there were more than twenty-eight million children of alcoholics (COAs) in the United States in 1992, including nearly eleven million under the age of eighteen. In "Children of Addicted Parents: Important Facts" (NACoA Fact Sheet, http://www.nacoa.net/pdfs/addicted.pdf), researchers suspect that children of alcoholics have a risk for alcoholism and other drug abuse two to nine times greater than that of children of nonalcoholics. They are also thought to be more likely to suffer from attention-deficit hyperactivity disorder (ADHD), behavioral problems, and anxiety disorders. They tend to score lower on tests that measure cognitive and verbal skills. COAs are also more likely to be truant, repeat grades, drop out of school, or be referred to a school counselor or psychologist.

Alcohol abuse and addiction impose a burden not only on alcoholics and their families, but also on society as a whole. Alcohol-related problems are costly in terms of medical care, treatment, rehabilitation, reduced or lost productivity, and the expenses of law enforcement.

According to the 10th Special Report to the U.S. Congress on Alcohol and Health (Washington, DC: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, June 2000), the estimated cost of alcohol abuse in 1998 was projected to have been $184.6 billion, up about 25% from $148 billion in 1992. In contrast, the cost of alcohol abuse in 1985 was $70.3 billion. In 1998 health-care costs were projected to have been $26.3 billion (14.2% of the total alcohol-related costs). The value of lost productivity due to illness ($87.6 billion), lost future earnings due to premature death ($36.4 billion), and lost productivity due to alcohol-related crime ($10 billion) together totaled an estimated $134.2 billion—nearly 73% of the total

alcohol-related costs. Other related alcohol-abuse costs were projected at $24 billion. This triennial report has been discontinued, so these figures are the most up-to-date at this writing. (See Table 4.10.)

TREATING ALCOHOL DEPENDENCE

Alcoholism cannot be "cured," if cured refers to one's ability to return to normal social drinking. Many authorities use the term "recovering," as in "recovering alcoholic." Once sobriety is restored, staying sober by learning to cope with the personal and social situations that contributed to one's drinking is an ongoing effort.

The 10th Special Report to the U.S. Congress on Alcohol and Health (2000) notes that more than seven hundred thousand people in the United States receive treatment for alcoholism daily. In Treating Alcoholism: The Illness, the Symptoms, the Treatments (Washington, DC: not dated) the NIAAA lists three stages of treatment:

• Detoxification, or managing acute intoxication and withdrawal to overcome the effects of drunkenness, safely rid the body of alcohol, and help the body adjust to the absence of alcohol.
• Correcting health problems that may have been brought on or aggravated by heavy drinking.
• Altering long-term behavior so that drinking patterns are not reestablished.

Some physicians prescribe the drug disulfiram (Antabuse) for daily use. If combined with alcohol, this drug produces violent headaches, nausea, and other discomforts. Many doctors, however, question the effectiveness of Antabuse, believing it to be more of a psychological than a physical agent. In other words, patients taking Antabuse who believe they will become sick if they drink alcohol tend to become ill. This drug has been marketed since 1948.

Approved by the U.S. Food and Drug Administration (FDA) in 1994, naltrexone (ReVia) has been shown to be very effective with low- and medium-risk alcohol-dependent patients when used in primary-care-based alcohol intervention programs. Naltrexone lowers the "high" associated with drinking and diminishes the craving.

Acamprosate is now being used effectively in Europe. Acamprosate was approved for use in the United States by the Food and Drug Administration (FDA) in July 2004. In Pharmacotherapy for Alcohol Dependence (Rockville,

MD:

Agency for Health Care Policy and Research, 1999), researchers reported that both naltrexone and acamprosate can be effective in the treatment of alcoholism. They found that the drugs can help reduce cravings, decrease the frequency with which a person drinks, minimize relapse, and, in some cases, improve abstinence rates. The combination of two or more medications given simultaneously may be even more efficient. Results of a recent study showed that monthly injections of naltrexone in patients who are seeking treatment, combined with biweekly low-intensity psychosocial therapy, resulted in a 25% decrease in the number of days patients drank heavily (Garbutt et al., "Efficacy and Tolerability of Long-Acting Injectable Naltrexone for Alcohol Dependence," Journal of the American Medical Association, April 6, 2005).

The main side effect of Acamprosate is mild diarrhea, which usually goes away after a few days. By contrast, Antabuse can be toxic if the patient drinks enough alcohol, while naltrexone can cause liver damage if prescribed in too high a dose.

A Long-Term Process

In 1996 Dr. George E. Vaillant of Harvard Medical School and Brigham and Women's Hospital in Boston announced the results of a long-term study of recovering alcoholics. The study followed the lives and drinking patterns of problem drinkers for fifty years. Researchers found that relapse was common after two years of sobriety but was rare after five years. While 56% of the abusers in the study achieved two years of sobriety, 41% of them relapsed. Generally, an alcoholic needs to live free of symptoms for five years before he or she can be considered recovered, although alcoholism can return even after five years.

Treatment Settings

Many types of long-term treatments are available for alcohol dependence, including both inpatient and outpatient treatment programs. These programs can involve psychological approaches, medications, or a combination of the two. The 10th Special Report to the U.S. Congress on Alcohol and Health notes that a broad range of therapies are currently available to treat alcohol dependence, including social-skills training, motivational enhancement, behavior contracting, cognitive therapy, marital and family therapy, aversion therapy, and relaxation training. Complete abstinence from alcohol and other drugs is the main goal of these treatments.

Jane Ellen Smith, in "The Community Reinforcement Approach to the Treatment of Substance Use Disorders" (The American Journal on Addictions, 2001), describes a program that has repeatedly proven successful. The Community Reinforcement Approach (CRA) is a cognitive-behavioral treatment for all substance-use disorders. It is founded on the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. When used with alcoholics, the goal is to rearrange multiple aspects of an individual's "community" so that a sober lifestyle appears more rewarding to the alcoholic than a lifestyle including alcohol dependence.

A variation of CRA, called Community Reinforcement Family Training (CRAFT), has also been developed. This program works with family members and significant others to motivate individuals who refuse to seek treatment to do so.

Research in treatment for alcoholism has also led to an important advancement called the "brief intervention." This approach is used with patients who are at-risk or problem drinkers, but who may not be alcohol dependent. With this approach, the health-care provider identifies patients who are problem drinkers, provides them with feedback and advice on their drinking, and works toward doctor-patient agreement on an appropriate course of action to stem the problem.

In past decades treatment for alcohol abuse and dependence occurred most often within hospitals and treatment facilities (inpatient treatment). In recent years inpatient treatment has changed dramatically. The length of stay has dropped sharply, often as a result of pressure from the health insurance industry to cut costs. Admissions to state facilities for alcohol-only treatment dropped 24% between 1992 and 2002, according to the government's Treatment Episode Data Sets (TEDS, as it is called, only covers admissions to facilities that receive state funding). However, there was a rise in people receiving assistance in outpatient treatment programs. Clients are also more likely to be addicted to other drugs along with alcohol, so treatment has shifted focus from alcohol-only dependence to dependence on alcohol and other drugs. Admissions to state facilities for drug treatment with a secondary diagnosis of alcohol dependence rose by nearly 50% between 1992 and 2002.

Alcoholics Anonymous

In 1935 two alcoholics started a group called Alcoholics Anonymous, which effectively laid the foundation for the modern self-help movement (including Alcoholics Anonymous, Al-Anon, Alateen, Overeaters Anonymous, Gamblers Anonymous, etc.). Alcoholics Anonymous (AA) groups are self-governed and independent of formal alcoholism-treatment facilities. Meetings are conducted by recovering alcoholics, without regard to formal counseling training and experience. As of January 2002, AA had nearly 2.1 million members in more than 103,000 groups. Participation in AA or in treatment programs based on the Twelve Steps of AA is the dominant approach to alcoholism treatment in the United States today (10th Special Report to the U.S. Congress on Alcohol and Health).

Critical elements of the AA program include fellowship meetings, with members expected to attend ninety meetings in ninety days during the early recovery period; a sponsor system in which newly recovering alcoholics are linked with an established member for assistance and advice; and the Twelve-Step philosophy, which spells out a series of activities, or steps, that alcoholics must undertake in their recovery process.

Al-Anon and Alateen are similar programs for the families of alcoholics. At Al-Anon meetings, families learn how to deal with alcoholic family members and their own feelings about these people. Al-Anon members also work to break their own codependent behaviors—the cycle of denial, anger, and unconscious facilitation of their family members' alcoholism. Alateen groups offer support for the children of alcoholics. Families Anonymous is generally designed to offer support for the parents of alcohol-or drug-dependent children.

Project MATCH—Patient-Treatment Matching

Caregiving professionals recognize that no single treatment is successful for everyone suffering from alcohol abuse and dependence. For many years, based on the outcomes of more than thirty studies, professionals have suggested that treatments for alcoholism should be matched to the particular characteristics of the patients. The characteristics to be considered include psychiatric and sociopathic problems, severity of alcohol involvement, cognitive impairment, and level of social support.

In 1989 the NIAAA began a study called Matching Alcohol Treatments to Client Heterogeneity (Project MATCH) to determine if the outcome of treatment is affected by matching patients to certain treatments. The study recruited 1,726 patients, of whom 75% were men and 25% women; 15% were minorities. The patients were divided into two groups: those who were recruited directly from the community on an outpatient basis, and those who had just completed an inpatient or intensive day hospital treatment (the "aftercare" group). Each patient was randomly assigned to one of three treatments (all of which were conducted by qualified therapists):

• Twelve-Step Facilitation (TSF)—Twelve weekly sessions that explained Twelve-Step principles and introduced the first five steps. Patients were encouraged to join Alcoholics Anonymous and become involved in its activities, in addition to the TSF program.
• Cognitive-Behavioral Therapy (CBT)—Twelve weekly sessions in which therapists taught skills that could help patients cope with situations and moods that are known to trigger relapses.
• Motivational Enhancement Therapy (MET)—Four sessions over a span of twelve weeks in which therapists used motivational psychology techniques. Patients were encouraged to consider their situations and how alcohol had affected their lives, develop a plan to stop drinking, and implement the plan.

Patient characteristics were studied to evaluate whether treatments that were appropriately matched to a patient's needs produced better outcomes than treatments that were not matched. By the late 1990s, the data were analyzed and the results showed that patient-treatment matching had little effect on the outcomes. In all the programs, patients decreased their drinking days per month to six, compared with twenty-five before treatment. While almost all patients reported both heavy drinking and recurrent problems when they entered the project, only 50% reported these problems one year after treatment.

Only four patient characteristics (out of a potential twenty-one characteristics) showed any differences in outcome when matched with particular programs:

• Alcohol dependence—In the aftercare group, individuals highly dependent on alcohol benefited more from the Twelve-Step treatment than from cognitive-behavioral treatment. The reverse was true for patients with low alcohol dependence.
• Psychopathology—In the outpatient group, individuals without mental and behavioral disorders benefited more from the Twelve-Step treatment than from cognitive-behavioral treatment.
• Anger—In the outpatient group, individuals with high levels of anger benefited more from the motivational enhancement treatment than from the other two treatments.
• Social Network Support for Abstinence—Individuals without strong social support networks benefited more from the Twelve-Step treatment than from motivational enhancement therapy.