What can be Done?
Multiple agencies, for example ministries of law, health, social welfare, industry, revenue, medical associations, alcohol manufacturers, NGOs, each lobbying for its point of view often create confusion in the clear formulation and effective implementation of the alcohol policy. Thus, coordination between various government departments and civil societies is essential for the implementation of a comprehensive and evidenced based alcohol policy.
Alcohol and the law: Policy strategies for prevention of harm from alcohol
Worldwide experience shows that total prohibition of the production, sale, and consumption of alcohol usually does not succeed unless firmly rooted in the local culture or based on strong religious conviction of the majority of the population – and even here significant problems prevail.
So, for most countries, total prohibition of alcohol is an unachievable goal. It does not affect the amount of alcohol consumed; instead it promotes organizes crime, cross-border smuggling and brewing of illicit liquor. More than a national prohibition policy, a change in value systems should be the objective.
Responsibility while Intoxicated
The lawful position of self-inflicted intoxication has been controversial. It seems that in principle, laws of most countries judge intoxicated persons as if they were sober. The actual practice of judges and juries is likely to reflect society’s general attitude towards intoxicated persons. Defence lawyers have stated if the dependent has been intoxicated at the time of committing a criminal act, this fact may lead to a milder sentence or increase the chance for a suspended sentence.
In many societies, there have been laws against public drunkenness (being in a public place while intoxicated), and against obnoxious behaviour while intoxicated and drinking alcohol in public places. However, the general belief is that criminalizing public drunkenness may not be very effective in changing the behaviour of those who have little to lose.
Prohibitions on driving after drinking more than a special amount are now in effect in most countries. Legislation that makes it illegal to drive while at or above a defined blood-alcohol level, has been shown to be effective in changing driver’s behaviour and reducing rates of alcohol-related problems on the road. The quickness and certainty of punishment, as well as its severity, are important in the deterrent value.
Regulating the Availability and Condition of Use
Minimum age limits: A minimum age limit is a partial prohibition applied to one segment of the population, usually under 18 years of age. There is good evidence showing the effectiveness of establishing and enforcing minimum-age limits in reducing alcohol-related problems and in reducing the alcohol consumption by minors.
Taxes and other price increases: Generally, consumers show response to the price of alcoholic beverages, as for all other commodities. If the price goes up, the drinker will drink less. Data from developed societies suggest this is at least as true of the heavy drinker as of the occasional drinker. Studies have found that alcohol tax increases reduce the rates of traffic casualties, of death from liver disease and of incidents of alcohol-related violence in the community.
Limiting sales outlets and hours and conditions of sale: There is substantial evidence showing that levels and patterns of alcohol consumption, rates of alcohol-related casualties and other problems are influenced by sales restrictions, which typically make purchase of alcoholic beverages inconvenient. Enforcement of rules influencing “house policies” in drinking places on not serving intoxicated customers, etc, has also been shown to have beneficial effects.
Monopolizing production or sale: Studies of the effects of privatizing retail alcohol monopolies have often shown some increase in the levels of alcohol consumption and problems, in part because the number of outlets and hours of sale typically increase with privatization. From a public health perspective, it is the retail level, which is important for consumption, while monopolizing the production or wholesale distribution may facilitate revenue collection and effective control of the market.
Rationing sales: Rationing the amount of alcohol sold to an individual potentially directly impacts on heavy drinkers, and has been shown to reduce levels both of intoxicated-related problems such as violence and of drinking-related illnesses as liver damage.
Advertising and promotion restrictions: Many societies have regulations on advertising and other promotion of sales of alcoholic beverages. While it is well accepted that advertising can strongly affect consumers’ choices between products in the market, it has proved difficult to measure the effects of advertising on demand for alcoholic beverages as a whole, in part because the effects are likely to be cumulative and long-term, making them difficult to measure. However, there is strong evidence in recent studies, that advertising and promotion increase overall demand and influence teenagers and young adults towards increased and problematic drinking. Even where alcohol advertising is not allowed in the mass media, these messages are conveyed to the consumers and potential consumers in a variety of other ways called “surrogate advertising”, e.g. advertising apple juice or mineral water in bottles which resemble bottles of alcohol made by the same company or having the same brand name. Some countries require health warnings alcohol containers.
Community Action for Prevention of Harm from Alcohol
In recent decades, there have been efforts to form partnerships, often involving both official agencies and grassroots groups to work on alcohol problems, at the level of the local community. Community action is not in itself a strategy but rather is a mode of working, which uses one or more of the prevention strategies. Such community action projects have been able to show a modest record of success, depending in part of the strategies adopted.
Role of the Community
Strong family and community bond is of high importance. This bond serves as a social support system, particularly in times of need such as sickness and even in family problems, such as harm to a family from the husband consuming too much alcohol. Recognition of harm from alcohol within the community is an important step in organizing community-based efforts to control this harm.
The community should understand that…..
- Alcohol problems do not mean weakness.
- Alcohol problems do not mean that the person consuming alcohol is bad.
- Alcohol problems do mean that the person has a medical problem or a lifestyle problem.
Women’s Initiative Against Alcohol
There have been reports of community-based strategies initiated by women’s groups for controlling the availability of alcohol in specific communities or townships through direct action. These initiatives have often been prompted by the impact of alcohol abuse and dependence on women and their families, and have been reported with enthusiasm in the media and research literature.
It needs to be recognized that while such initiatives are politically right and appealing, their long-term impact remains to be established.
Information and Education: Role of the School
The role of the school is not only to promote academic curriculum, but also to assist pupils in developing skills and competencies that enable them to live healthy lives and respond appropriately to the environment. Schools traditionally have promoted sporting activities, and some have promoted religious values, but more recently, schools are beginning to teach pupils skills, which they need to better themselves in life such as stress management and handling peer pressure. Part of these skills is to stay away from habits such as smoking and drinking alcohol. An interactive approach of getting students to openly talk about the subject of alcohol use, their attitudes, the environmental pressures on them and giving them information on harmful effects of alcohol can go a long way in preventing the initiation of alcohol use, particularly harmful use.
Role of Family
Even though the family suffers from one member´s alcohol habit, the role of the family in helping the person get rid of the habit and in rehabilitation is crucial. The first step is recognizing when alcohol consumption is reaching harmful levels. The next step is to obtain appropriate treatment for the person. Family support to the person not only in seeking treatment, but also to persist with the treatment, which sometimes is unpleasant, is needed. Finally, rehabilitation, which includes return to normal family responsibilities and a position of respect within the family, is essential.
Alcohol at Workplace
A large majority of people affected by harm from alcohol are blue-collar workers employed in offices and factories. Impairment at the workplace is one of the major harms related to alcohol use. Most serious of these harms is grievous injury to workers from heavy machines. This can completely cripple a worker, depriving him of any opportunity to earn a living. To be terminated from work because of alcohol-related inefficiency can compound poverty in the family. Although it is not mandatory for an employer to provide counselling and treatment for alcohol-related problems, more and more employers are beginning to view harm from alcohol as a social problem and its treatment as a corporate responsibility. This positive move can not only help a worker to recover, thereby saving him and his family from financial ruin, but can also save a skilled worker for the employer. Professional counselling, treatment and rehabilitation services should thus be provided.
Indicators of alcohol-related problems at work….
- frequently late at work
- difficulty in concentration
- high accident rate
- sporadic work pattern
- deteriorating efficiency
- poor inter-personal relations
Persuasive media campaigns have also been a favourite modality in recent decades for the prevention of alcohol-related problems. In general, evaluation of such campaigns has been able to demonstrate impacts on knowledge and awareness about alcohol, but can show only modest success in affecting attitudes and behaviours. Evidence suggests that the media companies contribute more to influencing the community in terms of attitudes for alcohol policy measures, than directly persuading the drinker to quit consuming alcohol. Thus, media messages can be effective as agenda-setting mechanisms in the community or for increasing and sustaining public support for preventive strategies.
In countries where advertising in the media is not banned, there is a never-ending portrayal of alcohol in the media, particularly on television. The mainstream of these portrayals represents alcohol consumption as a natural pursuit without problems, de-emphasizing health risks and other negative consequences. When negative social, economic or health consequences are addressed, they tend to be depicted as occasional afflictions touching only a minority of unfortunate or weak individuals, not as an inherent risk present to some degree in every consumers life. Entertainment television has been considered a particularly powerful agent in the formation of alcohol-related beliefs and behaviours.
The print media is seen to play an important role through their agenda-setting functions. The media, through their selection of topics, focus both the public’s and decision-makers´ attention to certain issues. The agenda-setting function is accompanied by a framing function: by highlighting some aspects and downplaying others, the media affects the way issues come to be defined in public and political discussions. Decision-makers tend to consider the media agenda as an indicator of the public agenda. The public agenda, set or reflected by the media, may thus influence the political agenda. In some cases the media may have a more direct influence on the political agenda: the media may speed up decision-making processes by positive issue coverage, or slow them down by negative coverage.
Treatment Approaches to Alcohol use Disorder
There are three different approaches in treatment towards alcohol use disorders, which are available to persons in need of help
- Moralistic religious approach
- Social correctional approach
- Health care approach – The disease concept
These approaches are based on different concepts about substance use disorders and involve different techniques for management of the problem. Although there are some treatment programmes, which adhere to only one of these approaches, most treatment programmes and agencies utilize techniques from several approaches. Patients do, on their own, and sometimes with the consent and even active encouragement of professionals and paraprofessionals involved, avail of the services offered by multiple agencies and programmes simultaneously.
These approaches are based on the understanding that problematic use of alcohol occurs due to moral weakness and/or do to lack of faith and religious belief. Help for problematic use is provided through religious retention and moral strengthening. Many programmes and agencies have become sensitive to incorporating the themes of moral values and religion into their activities. Religious approaches like religious affiliation can be utilized as significant elements potentiating recovery, maintaining sobriety, and encouraging social rehabilitation. The full potential of this approach remains to be understood and exploited.
Social correctional approach
The social correctional approach is based on the underlying premise that problematic alcohol use is a form of social deviance and requires only correctional methods. Many residential programmes with youth and juvenile delinquents follow this approach. Successful programmes have been developed for both drug and alcohol treatment. Therapeutic communities (TCs) have been the most prominent and well-known model based on the social correctional approach. Long-term residential care facilities for the rehabilitation of persons with alcohol use disorder, especially those with associated personality problems, have been developed and are being operated.
TCs are founded on a social learning model that fosters change in behaviour and attitude brought about by behavioural modelling and peer pressure. In a TC, the person learns social values and addresses self-destructive, antisocial behavioural patterns through intensive peer-based interactions. The person will learn and use social skills and assume responsibilities (take up work) to help maintain the TC. As the person progresses in the treatment, more challenging and responsible assignments are earned with a higher level of status. In addition “morning meetings”, “encounter groups”, seminars, and request groups provide the opportunity to learn. Thus, a TC is a powerful concept designed to provide its clients with the tools for growth – emotionally, spiritually and intellectual during a stay of about 6-12 months.
Good candidates for treatment in a TC include patients lacking sufficient motivation who need a highly structured setting in which to initiate treatment, and patients whose level of denial is such that interpersonal and group confrontation is deemed an important part of the initial phase of treatment.
Currently, apart from adopting a social correctional approach, most TCs have modified themselves to suit the changing needs of clients. Thus, they provide a number of other services to address issues, such as medical and psychiatric co morbidity, HIV infection, and educational and vocational rehabilitation.
Health Care Approach – The Disease Concept
The emphasis here is to consider alcoholism similar to any other disease having a specific cause, characteristic clinical features, course and outcome in which the interventions (usually multimodal) are planned. Alcoholism is considered a primary, chronic and if untreated ultimately fatal disease. The treatment facility and its staff are equipped and trained to achieve and maintain abstinence from alcohol, to relieve him or her of adverse health and psychosocial consequences of alcohol use and prevent relapse into the alcohol drinking habit. Thus, the treatment/intervention in the health care approach needs to be comprehensive, to be executed preferably by a multidisciplinary team, requires some motivation and adherence to the treatment on the part of the patient and adequate support and participation of family members – particularly if it is an outpatient programme.
Role of the medical profession:
The formulation of an actual treatment plan for each individual should be based on detailed assessment conducted individually with each patient. Depending upon the severity of alcohol-related problems, its medical and psychosocial consequences, available social support system, the available health care facilities, treatment setting and modalities are individualized.
Patients with alcohol-related problems receive treatment in a wide variety of hospital, non-hospital and community settings. The hospital settings range from specialized treatment centres for substance use disorder, to psychiatric hospitals or centres and psychiatric services in a general hospital to medical services in general hospitals. The treatment modalities include pharmacological treatment for acute detoxification, medical/psychiatric problems, long-term medical treatment, and non-medical treatments like individual psychotherapy, family programmes, group therapy, and occupational rehabilitation and relapse prevention programmes.
Planning the treatment: Four phases of treatment
Intervention programs have immediate, short-term and long-term targets and goals. The immediate goal and target is to attend to urgent needs related to alcohol such as detoxification, treatment of acute medical complications and crises interventions. Short-term goal and target is usually the treatment of chronic medical or psychiatric conditions, maintaining abstinence from alcohol and family reintegration and beginning of rehabilitation.
The long-term goals and targets focus on the larger issue of relapse prevention, occupational rehabilitation, social reintegration, abstinent lifestyle and improvement of quality of life.
Based on these goals, treatment can be divided into four phases: pre-treatment, detoxification phase, active treatment phase and after-care phase.
Pre-treatment (contact establishing phase/preparatory phase):
Early identification of a person with alcohol-related problems along with motivational interviewing forms the basis of the pre-treatment phase. Motivational interviewing is aimed at helping the person accept the problem and the need for external help. Clinicians in primary health care setting, community-based NGO´s, employers, friends and family member can be very effective in this important task of preparing the patient for treatment in this phase, which may last from a few days to many weeks or months.
Detoxification (abstinence achieving phase):
The duration of the detoxification phase is usually one week to a couple of months depending on drugs used, the quantities taken and the duration of the abuse. Detoxification is usually carried out with benzodiazepines to control the withdrawal symptoms occurring after stopping drinking or using other mood altering drugs. Thiamine and other B-complex vitamins are also needed. The period of detoxification is also utilized for the assessment of health effects, other problem areas of the patient’s life, as well as for the evaluation of the patient’s strengths and weaknesses.
This phase runs from 3-12 months or more and involves the process of choosing from the many medicine-based, psychotherapeutic and psychosocial modalities of treatment. Based on the assessment made, one or more of the specific treatments are selected. Specific treatments commonly used are group and individual based psychotherapy, family intervention and rehabilitation plans. These treatments are executed in a highly structured but individualized form to meet the needs of the patients.
Individual psychotherapies tried in patients of alcohol use problem before 1960 were not very successful. However, individual psychotherapies have again been in use since the 1980s, partly as a result of the modifications in psychodynamic therapies and development of a number of other therapies (like supportive expressive, interpersonal and cognitive behaviour therapies) as well as due to the realization of the limitations of pharmacotherapy when used alone.
After-care (relapse prevention phase)
The post-treatment or after-care phase focuses on the long-term objectives being realized and can continue for 3-5 years or even longer. In this phase, the role of the family and other social agencies is more active and necessary. In the follow-up and after-care of treated patients, the most crucial element is to maintain continued treatment contact. The other critical aspect in this phase is the recognition of relapse. Prevention of relapse is often attempted by appropriate coping skills, occupational rehabilitation and involvement of family members.
Recovery from substance abuse involves not only abstinence from the substance as well as making changes towards an improvement in the quality of life. The process of recovery is difficult.
The use of alcohol during the after-care phase can be considered as lapses or relapses. Recognition of the possibility of relapse is an important phenomenon in the course of the disorder and recovery process, which can be tackled meaningfully. It can help avoiding a sense of dejection and helplessness that surrounds the patient, the family or the treating team if it is seen as a failure of treatment. Everybody will be in a better position to help in the total process of recovery if they accept the phenomenon of relapse, alongside working towards preventing relapse.
Specific strategies for relapse prevention incorporate the identification of risk factors for relapse and the implementation of interventions or approaches, which help in reducing these factors. The focus of these specific relapse prevention models is to help the patient identify the potential precipitants of relapse and corresponding coping skills.