Research Design | Risks to Relapses in Alcoholism

CHAPTER I

INTRODUCTION

“There is this to be said in favor of drinking that it takes the drunk and first out of society then Out of the world.” – Ralph Waldo Emerson

Alcohol is a central nervous system stimulant at low doses, and depressant at higher doses. Alcohol beverages come in range of different strengths. Alcohol can include beer, wine, spirits (e.g. vodka, gin, whiskey, brandy, rum etc.).In India spirits, i.e. government licensed country, Indian made foreign liquors like rum, whiskey, vodka, gin and illicit distilled spirits constitute more than 95% alcohol consumption. (Jerald .K and Allan .T, 2006)

Alcohol use disorders are among the most prevalent psychiatric disorder. Data from several epidemiological studies suggest that lifetime prevalence of alcohol use disorder in US is around 8 %.with as many as 25% suffering severe psychiatric disturbances. The most prevalent psychiatric symptoms are anxiety and depression disorders. (Hasin et al., 2007)

According to current concepts alcoholism is considered a disease and alcohol a “disease agent” which causes acute and chronic intoxication, cirrhosis of the liver, toxic psychosis, gastritis, pancreatitis, cardiomyopathy and peripheral neuropathy. Alcohol is an important etiological factor in suicide, automobile and other accidents and injuries and deaths due to violence. The health problem for which alcohol is responsible is only part of total social damage which includes family disorganization, crime and loss of productivity. (Morgan, M. Y. & Ritson, E. B, 2009)

The pattern of drinking in India has changed from occasional and ritualistic use to social use. These developments have raised concerns about the health and the social consequences of excessive drinking. Nearly 30% of Indian men and 5% of Indian women are regular users of alcohol. (Balakrishnan. D and Subirkumar Das, 2006)

Canvin Rebecca, (2012) reported that social factors such as affordability and availability of alcohol, peer pressure and buying of rounds in groups may have a role in causing alcohol dependence.

National institute of alcohol abuse and alcoholism (NIAAA, 2000) reported that Tolerance, impaired control, withdrawal and compulsive use are the elements of alcohol dependence and also they reported that 40% of genetic factors and 60% of environmental factors plays a role in consuming alcohol.

A serious problem with the treatment of alcohol dependence individuals is very low rate of compliance abstinence about 20%.( Noda et.al 2001) and treatment success rates are 30-60% depending on outcome measures like abstinence, heavy drinking and social functioning.

Alcohol detoxification can be defined as a period of medical treatment, usually including counselling, during which a person is helped to overcome physical and psychological dependence on alcohol (Chang and Kosten 1997).

The immediate objectives of alcohol detoxification are to help the patient to achieve a substance free state, relieve the immediate symptoms of withdrawal, and treat any co- morbid medical or psychiatric conditions. Alcohol detoxification can be completed safely and effectively in both inpatient and outpatient treatment settings. The process of detoxification in either setting initially involves the assessment and treatment of acute withdrawal symptoms, which may range from mild (e.g., tremor and insomnia) to severe (e.g., autonomic hyperactivity, seizures, and delirium).Medications are provided to help the patient to reduce the withdrawal symptoms. Benzodiazepines (e.g., diazepam and chlordiazepoxide) are the most commonly used drugs for this purpose, and their efficacy is well established. Benzodiazepines not only reduce alcohol withdrawal symptoms but also prevent an alcohol withdrawal seizure, which is estimated in 1 to 4% of withdrawal patients (Schuckit, 1997).

Disulfiram (Antabuse) is used as an adjunct to enhance the probability of long-term sobriety. Although patient compliance is problematic, disulfiram therapy has successfully decreased frequency of drinking in alcoholics who could not remain abstinent. A study of supervised disulfiram administration reported significant periods of sobriety of up to 12 months in 60% of patients treated. (Hester., R.K and Miller, W.R., 1989)

Additional components of alcohol detoxification may include education and counselling to help the patient prepare for long-term treatment, attendance at Alcoholics Anonymous meetings, recreational and social activities, and medical or surgical consultations. (Boyd, M.A, 2005).

For patients with mild-to-moderate alcohol withdrawal syndrome, characterized by symptoms such as hand tremor, perspiration, heart palpitation, restlessness, loss of appetite, nausea/ vomiting, outpatient detoxification is as safe and effective as inpatient detoxification and is much less expensive and less time consuming. Among the drawbacks associated with outpatient detoxification is the increased risk of relapse resulting from the patient’s easy access to alcoholic beverages. In one of his study of 164 patients randomly assigned to inpatient or outpatient detoxification, significantly more inpatients than outpatients completed detoxification. (Hayashida et al. 1989)

Miller et al. (1996) conducted a time expensive prospective study on post discharge functioning of 180 alcoholic patients. They concluded that relapse is a multidimensional construct that may be better understood if assessed in its multiple dimensions.

Relapse promoting factors include anxiety, craving negative mood, childhood sexual abuse and psychological distress. (Gordon et al., 2006).

Relapse inhibiting factors are self efficacy, social suppression, coping (Brown et al., 1995), spirituality, peer support, group attendance, continuing care and progressive involvement (Miller et al., 1999)

The warning signs of relapse are Denial, Avoidance, Crisis, Confusion, Depression, Loss of Control regarding Behavior, Struggling with Personal Schedule and Self-Pity.(Ballard,K.A.,Kennedy,W.Z and O’Brien 2008).

An analysis of 48 episodes of relapse revealed that most relapses were associated with three high-risk situations: (1) frustration and anger, (2) social pressure, and (3) interpersonal temptation. (Cooney. 1987)

Desai et al, (1993) conducted a treatment outcome study of alcoholism and reported that among those who relapsed, the most common factor for drinking was negative emotional states.Among treated individuals, more severe alcohol-related problems and depressive symptoms, lack of self-efficacy and poor coping skills have been associated with short-term relapse.

Terence T. Gorski & Merlene Miller, (1982) Relapse does not begin with the first drink. Relapse begins when a person reactivates patterns of denial, isolation, elevated stress, and impaired judgment.

Polich J.M, (1981) Relapse is so common in alcohol dependence patients and that it is estimated more than 90% of those trying to remain abstinent have at least one relapse before they achieve lasting sobriety.Foster et al (2000) report a study of 64 alcohol-dependent patients admitted for either 7 or 28 days of alcohol detoxification treatment. About 60% relapsed over the 3-month follow-up period.

Marlatt G.A and Gardon J.R (1980) Another way to reduce drug relapse is through relapse prevention strategies. Relapse prevention attempts to group the factors that contribute to relapse into two broad categories: 1. Immediate determinants 2. Covert antecedents. Immediate determinants are the environmental and emotional situations that are associated with relapse, including high-risk situations that threaten an individual’s sense of control,andexpectancies. Covert antecedents, which are less obvious factors influencing relapse, include lifestyle factors such as stress level and balance, urges and cravings. The relapse prevention model teaches addicts to anticipate relapse by recognizing and coping with various immediate determinants and covert antecedents.

NEED FOR THE STUDY

APA (2000), reported that Alcohol dependence, or alcoholism, is often a progressive chronic disorder and recognized as a disease. It is a common disorder posing a heavy burden on patients, their families, and society. It has a high prevalence rate compared with many other diseases and highlights the public health significance.

At international level, GISAH (2005). The Global Information System on Alcohol and Health reported that the harmful use of alcohol results in the death of 2.5 million people annually. There are 60 different types of diseases where alcohol has a significant causal role. It also causes harm to the well-being and health of people living around the drinker. In 2005, the worldwide total consumption was equal to 6.13 liters of pure alcohol per person at 15 years and older. Unrecorded consumption accounts for nearly 30% of the worldwide total adult consumption. (Pratima Murthy, 2010)

Alcohol dependence is recognised as mental health disorders by the World Health Organization. It ranked alcohol as the third most important risk factor for the increase in the number of disability-adjusted life years in Portugal, as well as in Europe, preceded by tobacco smoking (second risk factor) and hypertension (first risk factor) .WHO ,(2005)

Alcohol related hospital admissions increased by 85% between 2002/03 and 2008/09, accounting for 945,000 admissions with a primary or secondary diagnosis wholly or partly related to alcohol in 2006/07 and comprising 7% of all hospital admissions. (North West Public Health Observatory, 2010). (Pratima Murthy, 2010)

Manickam, (1994) reported that in Kerala the approximate number of people being de addicted would be 255 in a year at one centre. Through all the centres, the number of people de addicted would be 308557.

After the first month following an alcohol detoxification, relapse rates range between 19% for inpatients and 34% for outpatients and increase to about 46 and 48% respectively, after 6 months (Hayashida et al.,1989) in California

In national alcohol survey to assess the risk of relapse in people with remitted alcohol dependence, they assessed 17772 adults of alcohol use and alcohol use disorder and followed for 3 years. At the baseline interview, 25% of subjects drank risky amounts, 38% drank lower-risk amounts, and 37% abstained. They concluded that relapse is common among people in remission from alcohol dependence and much more likely if they are drinking risky amounts. The results support the need to carefully monitor and support abstinence in people with remitted alcohol dependence.

NIAA (2000) National Institute on Alcohol Abuse and Alcohol reported approximately 90% of alcoholics will experience one or more relapses during the four years after treatment. By understanding what the common relapse triggers are, we will be better prepared to maintain sobriety and live the healthy life we want.

Prasad (1996) in a treatment outcome study reported a relapse rate of 41% at 6 months follow up of alcohol dependence patients which was conducted in NIMHANS, Bangalore.

Prakash et al. (1997), conducted a study on relapse in alcoholism, found negative emotional states as a major interpersonal trigger for relapse in Bangalore.

Elis and McClure, (1992) conducted a meta analysis and found that about 6 of 10 patients with alcohol dependence will relapse in the 6 months following detoxification, as estimated by the median of 61% relapse rate obtained in several studies. This high rate of relapse in a relatively short period is a reason for searching for the factors that better predict treatment outcomes.

During the observational visit, in Kasturba deaddiction centre, the researcher came across many alcohol dependence patients. There she identified the relapsed cases of alcohol dependence patients and she enquired with the relapsed patients about their return to drinking. They said many of the reasons like family problems, financial problems, participation in ritual functions, peer pressure and unable to control their thoughts of drinking. This triggers the researcher to reduce the relapse cases by identifying the risk factors earlier by using the relapse risk assessment tools during their follow up periods in deaddiction centre. So the researcher undertook this study as a stepping stone to identify or to explore the risk of relapse of alcohol dependence patients under detoxification treatment.

STATEMENT OF THE PROBLEM

A study to explore the risk of relapse in alcohol dependence patients who are under detoxification treatment in kasturba deaddiction centre, Coimbatore.

OBJECTIVES OF THE STUDY

• To assess the risk of relapse in alcohol dependence patients under detoxification treatment
• To associate the risk of relapse in alcohol dependence patients who are under detoxification treatment with selected demographic and clinical variables.

OPERATIONAL DEFINITION

Relapse

• Refers falling back into a state of previous drinking after detoxification treatment which is measured by alcohol relapse risk scale.

Alcohol dependence patient

• Alcohol dependence is a substance related disorder in which an individual is addicted to alcohol both physically and mentally, and continues to use alcohol despite significant areas of dysfunction. In this study it refers patients who are coming for follow up under detoxification treatment in kasturba deaddiction centre.

Detoxification treatment

• Refers to a treatment in alcohol dependence patients for removal of existing toxins from the body which is accumulated because of alcoholism by using drugs like Librium, Diazepam, and Lorazepam.

ASSUMPTION

• Relapse may be common and predictable in alcohol dependence patients under detoxification treatment.

CONCEPTUAL FRAMEWORK

A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to an idea or thought. Also its a theoretical structure of assumptions, principles, and rules that holds together the ideas comprising a broad concept.

The transtheoretical modelof behavior change assess an individual’s readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to Action and Maintenance.

James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model of behaviour change in 1977^.It is based on analysis and use of different theories of psychotherapy, hence the name “transtheoretical.”

STAGES OF CHANGE

There are 5 stages in transtheoretical model.

Change is a process involving progress through a series of stages.

STAGE I: PRECONTEMPLATION (NOT READY)

The process of change of alcohol drinking behaviour of an alcohol dependence individual starts with consciousness- raising about ill effects of alcohol by public medias like television, radio, and internet and also through newspaper, health magazines etc.

STAGE II: CONTEMPLATION (GETTING READY)

The alcohol dependence individual evaluates himself about his alcohol drinking behaviour and imagines how he will be when he stops the alcohol drinking behaviour.

STAGE III: PREPARATION (READY)

The individual realizes that the society is also not supporting the unhealthy behaviours like alcohol drinking. So he makes commitments to change this unhealthy behaviour by believing his ability to change.

STAGE IV: ACTION

The alcohol dependence individual makes discussion with his family and friends about changing the alcohol drinking behaviour.With family and friends support he approaches deaddiction centre to change his alcohol drinking behaviour.

STAGE V: MAINTENANCE

After getting inpatient detoxification, the alcohol dependence individuals are coming regularly for follow up visits to deaddiction centre and they are teaching about cue control measures,mainteneance of self efficacy and how to manage high risk situations.

After the maintenance the alcohol dependence individual will enter either into:

TERMINATION – the alcohol dependence individual possess zero temptation and craving and they are sure they will not return to their old unhealthy habit as a way of coping.

RELAPSE-The alcohol dependence individual return from Action or Maintenance stage to his earlier unhealthy alcohol drinking behaviour because of stimulus induced vulnerability factors,emotionality problems,compulsivity for alcohol,lack of negative expectancy for alcohol and positive expectancy for alcohol.