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Monday, December 19, 2011


Cunningham & McCambridge’s [1] thoughtful analysis
excavates long-standing questions about conceptualizing and pursuing the intertwined, but distinct, goals of advancing scientific knowledge about alcohol misuse versus positioning alcohol services within clinical and public health care. Their sound basic argument would benefit from further qualification distinguishing the utility of the dependence concept for these related, but not identical, enterprises. Dependence has been defined variously as a clinical diagnostic category, a syndrome, a continuum reflecting problem severity and biological involvement and, most recently, a chronic health disorder [2]. Like the earlier disease concept of alcoholism [3], these conceptions, especially McLellan’s [2], have value in positioning services in the health-care system for patients who experience withdrawal and relapse and who make multiple quit attempts. Such patients often require repeated treatment before achieving stable sobriety, typically abstinence. The thesis is persuasive that serious alcohol dependence should be managed like other chronic health problems(e.g. diabetes, hypertension) with long-term monitoring and stepped-care interventions and, accordingly, reformed reimbursement schemes and evaluation metrics.

Despite benefits for advancing long-term care of people with serious alcohol problems, a generalized chronic care model breaks down quickly in two key directions. First, it has little relevance for guiding interventions outside specialty health care. It does not fit with the robust success of screening and brief interventions for resolving mild to moderate alcohol problems in nonspecialty settings [4]. It serves little purpose for guiding public health programs for risky drinkers and problem drinkers who do not seek clinical care and comprise the majority of drinkers with problems [5,6]. As Cunningham& McCambridge noted, a population perspective indicates that a spectrum of interventions encompassing clinical, community-based and telehealth interventions is needed to close the gap between need and service access.
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