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Further Outpatient Care:

• Frequent follow-up is essential to support the patient in recovery. The most common mistake physicians make is assuming too soon that the patient is stable. Ask patients about attendance at AA meetings and about their relationships with their sponsors. Less than 20% of patients remain abstinent for a full year. Among patients who have been sober for 2 years, the relapse rate is 40%. Patients who have been sober for 5 years are likely to remain sober, but they are still at risk for relapse.
• Warning signs for physicians that a patient has relapsed include missing appointments or attending AA meetings less frequently. Warn patients to avoid testing themselves, particularly early in sobriety. Encouraging involvement in exercise and other leisure activities also is helpful.
• The key step for the patient is to realize that treatment for alcoholism does not end with sobriety. Recovery means that patients can handle the stresses of everyday life without alcohol. Therefore, the patient must develop and rehearse strategies to cope with high-risk situations.
  • Successful recovery requires the patient to be able to do the following:
    • Learn to say no to drinking in social situations.
    • Handle heavy-drinking friends who will try to undermine the patient's sobriety.
    • Handle stress. (Patients should not ignore symptoms of anxiety.)
    • Avoid boredom. (Prior to recovery, patients spent a great deal of time drinking or recovering from drinking. Upon abstinence, patients will have more free time.)
    • Learn to get along again with family and close friends. (Family problems often increase when drinking stops.)
    • Identify other situations that can lead to drinking and develop ways to cope with them.
  • Patients should have a list of phone numbers of people they can call when they are having a difficult time coping. Importantly, patients should write out the list and put it in a convenient location because sometimes during high-stress periods they may become emotionally and mentally disorientated, necessitating written instructions.
    Patients should spend time thinking about circumstances during which they feel at highest risk for relapse. They should anticipate these situations (most alcoholic persons can quickly list the circumstances and/or emotions that led them to drink) and make a written list.
  • Patients need to identify specific responses (thoughts as well as behaviors) to each of these high-risk situations. Encourage patients to be very specific when considering their responses. For example, ask patients exactly what they are going to say and do when asked at parties what they want to drink. Once patients have made the list, they should practice responses to their high-risk situations.
  • When patients have the urge to drink, there are several techniques that can be used to deal with the situation, including (1) self-distraction (ie, getting involved with an alternate activity that they enjoy), (2) thought stopping (ie, patients should not dwell on thoughts of drinking but should stop these thoughts), (3) reprogramming (ie, patients should avoid activities that remind them of drinking), and (4) use of social support structure. The most common cause of relapse is failure to use coping strategies.
• If the patient has a relapse, find out what happened (make a diagnosis) in order to formulate a new treatment plan. Below is an outline for dealing with relapses. Insist that the patient be actively involved in devising solutions; do not attempt to solve the problem for the patient.
  • Make a diagnosis.
    • How long had the patient been sober before relapse?
    • What were the circumstances of the relapse?
    • What was (were) the triggering event(s)?
    • How does the patient feel about the relapse?
    • What social support systems are available to the patient?
    • Does the patient believe that he or she can quit again?
  • Institute a treatment plan.
    • Determine what the patient thinks is appropriate treatment.
    • Reinforce the patient's decision to seek help.
    • Emphasize that complete abstinence is the only solution.
    • Reframe the relapse as a learning opportunity.
    • Provide support and empathy. For example, reassure the patient with encouragement such as "We can do this together."
    • Have the patient come up with ways to avoid the triggering event or find alternative ways to deal with it.
    • Rehearse what to do in high-risk situations, including making use of the patient's social support system.

Prognosis:

• The prognosis for alcoholism should not be considered hopeless. As many as 30% of alcoholic persons stop drinking. Even a patient with cirrhosis might have a favorable prognosis if alcohol cessation is achieved.

Patient Education:

• For excellent patient education resources, visit our Mental Health and Behavior Center; Substance Abuse Center.

Medical/Legal Pitfalls:

• If a physician documents his or her diagnosis of an alcohol-related condition, efforts to educate the patient and to have the patient obtain appropriate treatment must also be documented.
• Document advice to not operate a motor vehicle or other machinery when under the influence of alcohol. Inform patients and their families that the patient is legally responsible for acts committed under the influence of alcohol.
• While a trial period of controlled drinking with careful follow-up might be appropriate for a diagnosis of alcohol abuse, this approach increases a physician's professional liability. Complete abstinence is the only treatment for alcohol dependence. The differential diagnosis between alcohol abuse and dependence can be a difficult judgment call.
• Beware of the dangers of suicide and homicide in working with a patient with an alcohol problem.

next: Treatment of Alcohol Abuse

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Reviewed: 04/2006