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A nonsolution to alcoholism.

I recently read Dr. Robert D. Martin's guest editorial saying that we should be able to remand alcoholism patients to inpatient rehabilitation facilities ("Expand Commitment for Alcoholism," Guest Editorial, March 2007, p. 10) and was moved to comment.

To be sure, alcoholism is terribly burdensome. Dr. Martin grossly underestimates direct medical costs of alcoholism ($7 million for inpatient detox care, but hundreds of millions more in medical care for alcohol-related complications). However, his solution would only cause more problems.

There are already state-run inpatient drug and alcohol detoxification programs. In South Carolina, for example, Morris Village is run by dedicated, experienced, excellent clinicians to treat unfunded patients who voluntarily or involuntarily are transferred to their facility. The rate of readmission of patients committed involuntarily is extraordinarily high. We sometimes feel like 95% are readmitted and the other 5% move out of state. Patients who have no desire or will to quit are never benefitted by such inpatient programs.

The bottom line is that inpatient alcoholism treatment is completely ineffective, and to suggest we build more hospitals to treat these patients involuntarily is ridiculous.

What is really needed is ongoing education of the general public to prevent alcoholism in the first place. Dual diagnosis assessment and treatment are critically important, since the vast majority of alcoholics suffer from coexisting mood disorders. Expansion and funding of Alcoholics Anonymous programs, research and development of better pharmaceutic agents, and more forceful driving-under-intoxication and public-drunkenness laws are what is needed--not more ineffective and expensive inpatient facilities.

Martin A. Duclos, M.D.

Conway, S.C.

Dr. Martin responds:

Dr. Hassman and Dr. Duclos present a despairing and pessimistic view of the problem of the recidivistic alcoholic.

My editorial referred to the repeatedly hospitalized, severely intoxicated, alienated alcoholic, not to alcoholism in general. Both physicians err in discussing their frustrations (and an apparent sense of hopelessness) with the general alcoholic type and miss my emphasis. If I understand Dr. Hassman, he would have us deny this specific recidivistic group care as they "taint the treatment process" for the other alcoholics who might be motivated and deserve attention. This problem should not be swept under the rug by talk of the "more deserving." At least, I offer a suggestion that should be addressed on its merits. We physicians are confronted with the intoxicated repeatedly hospitalized patients who want to avoid all treatment. What can be done with them? I address this.

Dr. Duclos insists on using the word "ridiculous" regarding my suggestion. His disagreement seems to incense him to the point that he avoids the practical issue: how to deal with these returning people. I offer one suggestion; his response alludes to an overall changing of the social framework. This is to be admired, but a direct focus on the problem of the recidivist is my concern in the article.

Both writers should know that Massachusetts already has a state-mandated program in place that operates along the idea of the forced hospitalization, which I outlined. Dr. Duclos considers in-patient care "ineffective." Studies have shown that in very aggressive hospital treatments with a dedicated staff, 20% or more of the hospitalized alcoholics respond with reduced readmissions. Some studies have suggested 50% in special hands. Agreed, that is not ideal, but it is also above zero.

Alcoholism is unequivocally a large social problem, but this goes beyond my editorial. Yet, this group of 106 who repeatedly returned to my hospital within a year, spent more than 10 days for each admission, used 63% of the cost of the total treatment applied to alcoholics, and required extensive detoxification, should not simply be discharged to the mud puddles of the street.

Whether you wish to devote your attention to the problem of alcoholism in general, or that of the man in the bed who should not be discharged to a repeat admission is a matter of choice. Both problems deserve attention, and neither should be disparaged. I offer a viewpoint for the care of that recidivist. I would enjoy comments and criticism limited to this.


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Title Annotation:LETTERS
Publication:Clinical Psychiatry News
Article Type:Letter to the editor
Date:May 1, 2007
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