Habits & Practices in the Treatment of Alcoholism

Posted by Jeff Berk, BOLT International;


I like martinis.  A lot.  Vodka.  Straight up.  Blue cheese stuffed olives.  A little spritz of vermouth.  When I was younger we’d throw some sodium metal into a still of reagent grade ethanol to dry out the last traces of water, toss the azeotrope, and voila – perfection.  Now that I’m old I don’t really care what the vodka is.  Not old enough, by the way, to drink gin martinis.  And whoever thought sticking pimentos into an olive was a good thing?


So after coming back from my AA meeting, I mixed said concoction, got comfortable in my floating pool chair (Our water’s 92 degrees.  And yours?  Still covered with snow?  So sorry.) trying to think about what we are going to talk about tonight.  I recently ran an Ad Board with BOLT’s Addiction Thought Leaders.  Most of these peeps were US based, so my apologies ahead of time to my European and Asian readers.  But without further ado here are some of their comments related to treatment differences between US specialists, community physicians and non-medical outfits such as Alcoholics Anonymous.


Specialty Physician Setting


  • Specialty physicians (psychiatrists) are used to a model where pharmacotherapy is coupled with monitoring, counseling and long-term behavioral therapy.  This group of treaters has been best able to use naltrexone, acamprosate  and disulfiram.


“It is not too different than hypertension.  If people are not followed for their hypertension they stop taking their medication and their blood pressure goes up.  The model is very similar.  I don’t see what kind of model you can have without appropriate monitoring unless you go to OTC pharmaceuticals.  Even before you get the primary care physicians there are a lot of specialty doctors, including psychiatrists, that are used to monitoring people for all kinds of things; depression, schizophrenia, and OCD.  It is just built into the way they are treated with medication”.




  • The centers with the best long-term results differ from the typical 28-day program in two key areas.  First, they perform more in-depth evaluations at in-take so that they can tailor treatment according to scoring on different domains of the Addiction Severity Index.  Not all patients need the same length of hospitalization.  Some have comorbid psychiatric conditions.  Second, the best programs have much more intensive long-term follow-up.


“If they have either insurance coverage or self-pay because the family has means then they can get private care and we have a very effective treatment program.   So one of the first things we do is an evaluation.  That is thing one because one of the weaknesses of many, if not most programs, is that they give everybody the same thing.  They will say okay you come to my famous program in Minnesota or California or whatever and I will treat you for 28 days and send you out.  And at the end of 28 days you are feeling great but you go right back to drinking.  Some of my patients have relapses on their way home actually.  (And what is missing in those programs?) Long-term follow up.  And also you don’t have to spend money on 28 days for everybody.  A lot of my patients just don’t even go into the hospital or they just get brief hospitalization.  But what really counts in the long-term, the relapse-prevention part with medications and very often it requires some psychiatric intervention for depression, for anxiety disorder, for bipolar disorder, for whatever additional psychiatric problem they have.  Plus it often involves marital therapy and family therapy.  You have to give them what is needed.  One of the studies that we did we randomly assigned treatment programs to give the patients what they always got vs. giving them treatment as determined by the addiction severity index.  ASI is a structured interview that we developed to measure the severity of the addiction in seven different domains of life and we got their agreement that they would give treatment according to the needs on the ASI.  At the end of six months the group that got the tailored treatment were doing far better than the group that just got the generic treatment that every patient gets.  You really do have to tailor the treatment to the individual’s needs.  You have to treat the comorbid, co-existing psychiatric disorder.  So if they have, for example, depression, you have to treat that”.






Community Physician (Internist, General Psychiatrist) Setting


  • Specialists think that community physicians are under-diagnosing and under-treating alcoholism.  Even when they do correctly diagnose they lack the tools to treat the disease, and will most often refer patients to an alcohol related facility for detox and an alcohol treatment program.  Most community physicians are not prescribing Vivitrol or RiVia.


“I try and refer those patients.  Most of them will not go to treatment.  I think really the problem is with the treatment system.  The model I would like to see is that treatment for mental health and substance abuse moves into primary care settings.  So somebody sees a car in the parking lot of a primary care setting they don’t know whether somebody is there for the flu or their alcohol problem.  Patients don’t want to be seen walking into alcohol treatment.  They don’t want to take a chance somebody is going to spot them there”.



“They may perceive that there is not much they can do.  I think that is part of the issue.  I think a big issue is time.  Once you get into this how are you going to back out of it and still not have patients stacked up in the waiting room?  I think physicians in general tend to be very efficient at managing problems they know a lot about.  When they don’t know much about alcohol problems they don’t know how to be efficient and what are the most important questions to ask and what are the key decision points in an assessment or treatment decision kind of algorithm”.



“Nobody prescribes it.  People don’t prescribe for the drugs.  These patients are saying it is very tough requiring multimodal treatment so they are not going to be treated by primary care doctors who can see them for 8 minutes.  Look at bupinorphine, different disorder, but for opiate addictions.  The hope was it was going to do away with methadone clinics that patients with opiate abuse problems were going to go in and see their primary care physician, pick up a scrip and come back in a month for another scrip.  Well the drug has been used but typically in place of people who sort of inter specialize; substance abuse settings or doctors who have committed to making a certain percentage of their practice related to substance abuse.  My sense is and I think I have seen something supporting this that your average primary care physician isn’t going to have one or two people on it unless they are inheriting the patient from somebody else because they are not comfortable taking care of these patients.  As a result the drugs, substance abuse related drugs are not widely used.  The ones that are out now have not been widely prescribed”.



“Possibly having to do with the founding of the National Institute on Alcoholism and Alcohol Abuse there have been specialists in this area, but still most doctors don’t know about it and most doctors don’t get any training in the area.  There have been numerous examples of people who just totally ignored it.  If you actually do a test on family doctors and you give them case records of someone with alcoholism they miss the diagnosis unless you tell them that they are drinking so much every day.  But they don’t know how to diagnose it and they don’t know the signs of it.  So they don’t even seem to care for the most part.  It is something that my colleagues and I have been really working on to try to raise consciousness about this”.



“I think the issue is the community physician’s definition of an alcoholic may not be what our definition of an alcoholic is.  But having said that, even if you get to a more mild situation of alcoholism most of the family physicians aren’t even picking it up; which is an issue.  They may still not want to deal with it mainly because they don’t have any tools in which to deal with it with”.



“The more important part of the question is “why” should they do it.  I think the why ranges all the way from they want to be a good doctor to they get reimbursed for it.  Or actually maybe that is the middle one and then the third one might be that they are going to be forced to do it by third party payers, health insurance companies or whatever, HMOs, who if they get religion about this thing may actually force the issue”.



“In general these are difficult patients to treat.  So general practitioners, either GPs or general psychiatrists, often would just assume not deal with it.  So that is one general issue.  Although they see a lot of it, it is tough to treat.  And as a result, when they get a patient with that they will often send them if they can to an alcohol related facility; detox and alcohol treatment program with the idea that they need specialty services”.




  • The community physician’s retort is that they are seeing a milder form of the disorder than the psychiatrist.  The patient seen in the community tends to have fewer and less severe comorbidities.  The community physician’s perspective is that alcohol consumption isn’t an “all or nothing” proposition.  Their patients are viewed as having more waxing and waning during the course of their lives, and the GP/FP sees the alcoholism in the context of a broad range of health related issues that brings the patient into his office.


“I think all of us tend to be slanted by the patient population we see and psychiatrists of course tend to see patients with mental illness and if they have alcohol and drug issues they tend to be more severe than patients in a primary care population.  So I think psychiatrists when they think of alcohol problems they tend to think of alcohol dependence and they may not recognize that somebody has a milder problem or are in a risky category and although they may not have problems yet they may be heading towards problems and some kind of preventive intervention is called for.  Whereas I think family physicians we tend to look at the whole spectrum because we see a broader spectrum of patients.  Of course most of our patients don’t have issues and the majority who do they are in more of an at-risk category or maybe they are just starting to develop a few negative consequences.  A minority will be dependent.  And even among those who are dependent we see a different spectrum there; many psychiatrists and many people in the alcohol and drug field assume the old adage that once an alcoholic always an alcoholic.  People have to get treatment, they have to abstain or they will always have problems and the illness is progressive and they will die.  But I think in family medicine our exposure to a greater breadth of patients has shown us that gee many patients do get better even though they may continue to drink a bit and patients may have more waxing and waning courses of illness.  I think we tend to see more of a longitudinal perspective.  So we recognize that problems can get worse as people get older or get better.  I think just because of our primary care bent and our longitudinal bent we just have a more accurate view of what happens in the general population”.




  • Pressed for time, the community physician tries to ask some basic “quantity and frequency” questions.  The most effective diagnostic strategy is to use open-ended questions, that allows the patient to “ventilate”.  Proponents say this only takes five minutes, but the average physician is not going to add a five minute screen onto each visit.  The instruments available for the community physician to diagnose alcoholism have not been brief or simple enough to be widely accepted.  The NIAAA has a set of guidelines for community physicians to use.  One laboratory test, CDT, is fairly effective in identifying heavy consumers.


“I honestly guess it depends how pressed I am for time.  If I am pressed for time I will ask some simple quantity and frequency questions.  I may ask some CAGE kinds of questions.  If I have more time or if I am concerned that a direct approach might put a patient off I will get them to start talking about what they see as advantages of their drinking.  Maybe it helps them get to sleep, they enjoy it, it relaxes them, it allows them to be more social, and then I will draw them out.  Well gee have they found that there are any other aspects of drinking that they don’t like as much and try and have some open ended questions in various aspects of their life’s: physical health, mental health, relationships, work, school, finances, legal issues”.



“You know it doesn’t really need to be (time consuming).  I frequently teach about this stuff and in the demonstrations that I do and this is true with real patients and within five minutes I can pretty accurately figure out whether somebody is in an at-risk, abuse or dependent category.  A lot of people think well gee you have to ask a lot of pointed questions really quickly.  I find when you ask those kinds of open-ended questions and you just get a patient comfortable talking they are glad to tell you what kind of stresses they are under.  They don’t get a chance to ventilate about this much.  They are glad to tell you gee does alcohol seem to help that for them or gee are there times when maybe their drinking makes it a little worse?  As long as you ask in a way that shows you are asking out of caring and concern rather than that you are ready to pounce on them and try to fix them, I tend to get very accurate information quite quickly from people.  I may not be making precise DSM4 diagnoses, but I bet that I am at least 90% accurate”.



“From a diagnostic point of view again it is just more of an educational thing.  There are tools.  I’ve worked with a lab test called CDT for many years and it is fairly effective in helping identify people that are heavy consumers.  There could be other diagnostic tests that other people are working on and are coming along.  There are relatively brief screening questionnaires that could be used.  The NIAAA actually has a manual out for primary care physicians about how to do these things”.



“It is going to take that paradigm shift.  Right now Tom McClellan who is a wonderful scholar of addictions and health systems has kind of said that we treat alcoholism backwards.  You are defined as an alcoholic and you don’t go to your primary care physician, no you need to be seen by a specialist immediately.  Therefore, most people don’t.  There is stigma attached and so only a third of people ever get into treatment.  Two-thirds don’t.  And I think NIAAA has been trying to promote that and say this is something that has primary care implications; that a primary care physician can treat alcoholism with naltrexone or with whatever”.




  • Until recently there was no Medicare / Medicaid approved CPT code.  Now primary care physicians can at least get reimbursed for seeing alcoholics, but the sense we get is that the current reimbursement disincentivizes the community physician from treating for alcoholism.


“One of the more important things that has happened recently is that there is a new CPT code that has been approved by Medicare and Medicaid I guess for screening for alcohol and brief intervention.  Primary care physicians can actually get paid for any time or effort they do in that area.  Now hopefully that will be adopted by other payers as well and so they may actually see some economic benefit”.



“There are new G-codes from Medicare.  Medicaid programs are now allowed by CMS to start reimbursing.  Most aren’t yet, but they probably will in the next few years.  There are also new CPT codes.  So doctors need to learn to use the codes.  The other option though is that they can step up their billing under E&M codes if they are seeing patients for other issues”.



“Actually as a family physician in most cases I will not get reimbursed for just an alcoholism diagnosis.  I am often seeing patients for another medical problem and I am providing care for the alcoholism during that same visit.  I may bill for that as a secondary diagnosis.  Some patients don’t want that diagnosis submitted, however.  So I may bill for their hypertension or their gastritis or their depression and be treating for the alcoholism at that same visit. However, there are newer codes”.



“I think if they have a special interest and if the reimbursement were there some of them might make the time.  But I agree, overall they are just not going to do that”.




  • One of the primary reasons that community physicians today refer their patients to alcohol treatment centers is that they have no drugs that are safe and effective.  This paradigm will change.  Community physicians will treat alcoholism, as they now do depression and smoking, once they have pharmacotherapies that shift some of the burden on the physician from time-intensive counseling to writing a scrip.  This is the “Prozac Model” or “Zyban Model”.  In this environment the physician will not need specialized addiction counseling protocols, but instead he and his staff will monitor patients primarily for compliance and adverse effects, while only secondarily providing maintenance, support and setting of short and longer term goals.  If these intensive behavioral modifications are needed, we expect to see the community physician refer as he does for other serious psychiatric conditions.


“I think the reason depression is destigmatized is because of Prozac and the other medications like Lexapro or whatever that followed on.  I think the reason that smoking cessation is desensitized is because in part because of nicotine replacement therapy that is on all these commercials”.



“I am old enough to remember when TCAs were there and psychiatrists were the only people who prescribed the tricyclics because they had cardiac side effects and made people noxious and sleepy.  Then along came Prozac and changed the whole revolution.  Now most antidepressants are prescribed by primary care physicians and the whole system is set up so that if you are depressed yeah you could go to a psychiatrist but usually a lot of insurance companies need the gatekeeper to send you to one”.



“The drug can be very important for helping that paradigm just like it did with depression.  So now depression is a primary care illness and PCPs are comfortable with it, they do depression screens.  You are calling me here at the VA.  I work part time for the VA.  Everybody gets a depression screen in the primary care clinic.  Actually everybody is getting an alcohol screen in the VA primary care clinic.  So that paradigm is shifting.  And actually there is a new dictum for the VA.  I don’t know if it has been implemented yet but it is going to be like the smoking cessation guidelines that everybody who is found to have an alcohol problem needs to be offered treatment, including a provision for pharmacotherapy.  Just like you would if a patient comes in and they are smoking and you say well here is some stuff to help you stop smoking; nicotine gum or varenicline or Zyban or whatever or a behavior program we have.  So smoking is now a primary care illness and it is something that the doctors have adopted.  It is interesting.  I used to be chief of psychiatry at one of the hospitals here and it is fascinating that only 50% of our patients…we once did a quality assurance thing and this was 1996 or 1998.  Only 50% of the patients came into the psychiatry clinic were ever asked if they smoked because psychiatrists said well that is not my thing.  I don’t deal with that.  Well it is a drug for God’s sake.  Now it is 100%.  Everything is smoking and smoking cessation or at least the recognition of smoking as a part of the whole picture is part of the psychiatrist’s routine questioning.  Nicotine dependence fits into it and we know that nicotine dependence can increase the dose of sedatives that you need or change metabolism of other drugs.  So it is complex but now it is at least considered as part of the whole picture and it is well within the frame work of the psychiatrists to prescribe treatment; either behavior and/or pharmacological for the treatment of nicotine dependence.  So these things have changed over time; depression, nicotine dependence, getting into more primary care sort of things.  I think the same thing will eventually happen to alcohol but we need the right drug and we need kind of the right situation, the right policy where people pay for it, etc”.




“In part the reason why existing treatment programs have largely, not exclusively but largely adopted a non-medical model is I think historically for a variety of reasons, one of which we didn’t really have previously, any drugs that look to be at all effective for the treatment of alcohol or other substances.  So there is that piece.  We have benzodiazepines for withdrawal for detox but there really wasn’t much else until very recently”.



“Don’t neglect primary care physicians in thinking about the marketing and development of medications for alcoholism”.



“I think data from the COMBINE study that I first authored suggests that the medication coupled with some medical monitoring could be helpful.  I think that at least for some alcoholics, maybe the vast majority of them who might ultimately be treated in primary care settings that pharmacotherapy will be useful”.



“I think there are models out there where you can monitor people without necessarily specialized addiction counseling being applied, if a medication is powerful enough.  So the monitoring involved is basically compliance, maintenance, support, setting of shorter and longer term goals”.




  • Community physicians receive virtually no training in the management of alcoholism.  The only medical school that requires a course in addiction is the University of Pennsylvania.  Direct-to-consumer advertizing can be particularly effective in getting patients to ask community physicians about new anti-alcoholic drugs.  These queries in turn motivate the physicians to educate themselves regarding new treatment options.


“There was not only good treatments, there were not even good studies and also and this is one of the biggest problems that even though this is a huge problem as far as I know my course at the University of Pennsylvania is the only required course on addiction at any medical school in the US.  I started teaching it as an elective in the early 1970s and it became a required course in 1989.  All these years I have been asking other people and what they typically get is a lecture here and there, something in pharmacology, something in psychiatry and something about cirrhosis, but hardly anything about addiction.  No comprehensive course.  Whereas I have a 25 hour course that is required of all students to get an MD from Penn and even though most of them are not going into psychiatry they all have to pass the exam.  Now that is lacking around the world and I think that is a major problem”.



“There has been no education.  I am not making light of the issue.  I think whoever is going to take that on is going to have to invest a considerable amount of time in education marketing of those physicians and probably payers.  It is not going to happen overnight.  I contend that perhaps a direct to patient marketing campaign is ultimately the way that one might have to go when you are developing a new market for something.  If people start coming in and saying “you know my husband drinks too much. Can you do something about that and I just saw this ad on TV that there is new medication”.  All of a sudden the physician starts saying well I hadn’t heard about that, let me look into it or something.  The problem is educating people that have been in practice for a while is almost impossible.  They are too busy.  They have practice patterns established, and unfortunately the only way they get educated is through a) the pharmaceutical reps or b) their own patients”.




Non-Physician Setting


  • Most of the people treating alcoholics are non-medical recovering alcoholics.  Non-physicians involved in this field traditionally have been hostile toward physicians and particularly hostile toward pharmacotherapy for alcoholism.  They are also hostile toward alcoholics; and use a tear-you-down then build-you-up approach.  While physicians who specialize in alcoholism consider it to be a disease, the general public considers alcoholism to be “a weakness of will”.


“Traditional treatment involves a very confrontational off-putting approach rather than the more current evidence-based motivational approach. The traditional treatment is sort of a tear-you-down, build-you-up again approach but most people never even stick with it for the build you up aspect of it.  So you are basically getting grilled, you are being forced to talk in groups which most people are uncomfortable about and there is really no evidence that kind of treatment even works”.



“Probably for a variety of reasons these treatment programs are often in the hands of non-physicians and more often at least early on based on AA models where the need for abstinence were often run by people who were themselves in recovery and often adopted a sort of adopted a tough love approach and the idea of taking medication for treatment of an addictive disorder was seen as in some ways feeding into the addiction.  So it was a combination of a moral overtone to treatment and the fact that there really wasn’t much available anyway”.



“First of all, doctors use medications.  So you want to know why things aren’t being prescribed.  Most of the people doing the treatment are recovering alcoholics themselves and they have hostility towards the medical profession in general and medications in particular.  So when I first wanted to study naltrexone, first of all, I couldn’t get any funding from the company that was making it for heroin addiction and I couldn’t get any funding from the National Institute on Alcoholism because at that time they were still dominated by the AA approach and they were not interested in studying medications in the early 1980s”.



“Let me just give you a bit of a historical perspective.  Alcoholism everyone agrees is a very, very important problem and it is considered by the people who have been treating it over the years as a disease and the more recent research indicates that it really is a disease but it has a reputation within the general public of being some kind of weakness of will.  So that is one problem.  And as a result of that, linked to that is that the medical profession has totally ignored alcoholism until very recently”.




  • These treatment facilities have until recently reserved the use of benzodiazepines for the acute medical management of withdrawal symptoms.  Rarely will they prescribe for alcohol cravings or for comorbid psychiatric conditions.  There has been some movement as of late in the prevailing attitudes toward pharmacotherapy at centers like Hazleton Foundation and Betty Ford; which now are requiring their graduating patients to be told about the availability of various medications.


“Those specialty services usually, at least until recently tend to be run on more psychosocial models:  therapeutic communities, AA and abstinence-based models.  As a result they are not generally medical models.  Usually in most of these places medications are reserved for acute medical management for withdrawal to facilitate detox and withdrawal symptoms”.



“In part the reason why existing treatment programs have largely, not exclusively but largely adopted a non-medical model is I think historically for a variety of reasons, one of which we didn’t really have previously, any drugs that look to be at all effective for the treatment of alcohol or other substances.  So there is that piece.  We have benzodiazepines for withdrawal for detox but there really wasn’t much else until very recently”.



“The problem is not necessarily the coverage, although that is I am sure a problem, but it is finding good places to send people.  There are again places that are based on these 12-step models that some of which are helpful, some of which are based on the clinician’s moral hands-on addiction and they may or may not be particularly open to integration with medication.  I will just give you an example.  I have a colleague who does reviews for a managed care company.  They were doing a review on a patient who was in a substance abuse in patient program, one of these kinds of communities where they go for a week or two weeks.  So they call up and the clinician says the patient is sort of settling in and they are going to meetings and so forth.  There were some questions about depression as well.  Is the patient on any medication?  No.  Well, are you going to get a medication consult?  The treating clinician doesn’t feel that consideration of medication is warranted.  That wasn’t based on anything except really the clinician’s belief about the potential role of medication in treating an addiction.  Those people are doing the bulk of the treating of addicts.  I don’t know if that is helpful but I think that is the reality.  Helpful to what you were asking but that is the flavor of what is going on out there.  And that is why at least in part the drugs that are out there for alcohol abuse have tanked from a commercial point of view anyway”.



“I don’t want to leave you with the notion that there has not been any movement.  I have been in this field a long time and I have seen movement.  Even the programs that once were anti-medication like the Hazleton Foundation and Betty Ford are now requiring that their people before they graduate they give them an interview and tell them about the various medications that are available and a lot of them are getting onto medications.  So it is better than it was before.  But we still don’t have enough physicians who know this field, who can write the prescriptions and follow the patients and so forth.  So things are getting better, but it has been a very slow movement”.




  • Most alcohol “treatment” for less wealthy patients in the US is through programs like Alcoholics Anonymous, which is administered by non-medical personnel.  Specialists do incorporate AA into their overall treatment strategy but they see AA as inadequate as a standalone behavioral therapy.


“Another thing completely independent of that is because of the medical profession’s disinterest, a treatment system was built up starting with AA which was actually founded by a salesman and general practitioner.  It is wonderful but it is not a treatment.  It is completely anonymous and we use it.  In my course we integrate AA within medical treatments and that is the way it should be.  Most people if you ask them about treatment they will say AA and it is not really treatment at all, although it is very helpful in the treatment context”.



“There are a number of sort of psychosocial interventions which look like they are helpful; primarily things like self-help groups like AA”.




3rd-Party Payers


  • Most healthcare insurance has some limited addiction coverage.  No longer is there reimbursement for 30-day hospitalizations.  It tends to be for short-term emergency care and detoxification, but not for long-term follow-up.


“(Coverage) is very variable.  Certainly the past model where patients would go to like a 30 day or 28 day in-patient treatment program those days are over.  They are not being supported anymore by insurances.  If people do that they usually pay out of pocket and as you can imagine that is not something that is reasonable for most people.  So if they do get admitted in-patient it is usually because they need a medical detox and they may get admitted for 3, 4 or 5 days get tapered down on benzos and then are discharged again.  My experience is that most of the outpatient programs if you can find good ones are paid for.  They can see doctors for medication and there are outpatient programs that do get paid for, like Blue Cross, for instance, but they are managed and they do require things like authorization and that sort of stuff.  Many insurance programs have caps on the amount of alcohol or substance abuse related stuff you can get.  I think they are covered usually at least as well or as badly depending on how you look as other psychiatric services”.



“As it is right now people who are insured have some limited addiction coverage.  It tends to be for short-term emergency care and detoxification.  That is wasted money if there is no long-term follow up.  I tend to treat people for years rather than days or weeks or months”.




  • Kaiser-Permanente is covering both oral and depo naltrexone.  Even in the absence of a pharmacoeconomic study, at a cost of $700 / mo the depo is perceived to be cost effective in preventing trips to the Emergency Room and in-patient hospitalizations.


“Depo naltrexone even at 700 dollars a month is cost effective.  That is based on the fact that it is so expensive not to treat their alcoholism.  If you could get people to take it on a daily basis it would be cheaper but the major cost is all the trips to the ER and inpatient hospitalizations that these people have absent treatment.  Ultimately if there is a single payer, for example, in even places like the Kaiser Permanente program they have been covering naltrexone and they certainly covered oral and I think they are covering depo.  They have found it to be very cost effective because they are covering these people for everything and if they have alcoholism it is going to be very expensive absent treatment”.



Categories: Psychiatry, substance abuse / alcoholism
Tags: , , , , , , , , , ,
Bookmark the permalink.

Post a comment

Comments on CourageToBeHealty.com are monitored.

You may use these HTML tags and attributes:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>