Social , health and conSumption profileS and perceptionS of treatment in a group recovering alcoholicS , medellín , colombia

Alcohol is responsible for 2.5 million deaths annually and is a risk factor in certain communicable diseases. The negative of its consumption can be felt in all areas of life. The object of this descriptive study was to determine the social, health and consumption characteristics and the perceptions of rehabilitation treatment in alcoholics. The information was collected using a questionnaire for the social and health variables and a semi-structured interview to determine perceptions of treatment. The majority were male, middle class and had begun consuming alcohol at 11 years of age, with depression being the most common psychological comorbidity. They perceived treatment as welfare.


Introduction
The WHO (World Health Organization) calculate that chronic alcohol use is the cause of 2.5 million deaths annually, with alcohol consumption occupying third place in the global ranking of risk factors for poor health and is also one of the four risk factors for suffering from preventable non-communicable diseases; there are indications that its use contributes to an increased burden of communicable diseases (tuberculosis, HIV) (1).
Chronic alcohol consumption is a public health problem with harmful consequences for health.According to the WHO, alcohol abuse is one of the main causes of accidental deaths in the world, and it has been linked to diseases such as cirrhosis of the liver, mental disorders, neurological disease and various cancers and infections (2) .
In Colombia, in 2008, the prevalence of alcohol abuse was 6.7% and dependence 2.3%.In the same year, the age at which alcohol consumption begins was 15.1 years old SD 3; for 12.2% of Colombians, their alcohol intake was harmful; the age group most at risk of harmful consumption was between 18 and 24.Although there are data indicating higher frequency in higher (5 and 6) socio-economic groups, the most harmful use can be found in lower groups (1 and 2) (3)(4) .
According to the socio-demographic characteristics of those who attend support groups for alcoholics, a mean age of 48.7, SD 10.9 was found; 86.9% were male, 42% had completed elementary education, 50.6% were married and 75.9% were employed (5)(6)(7) .
A study carried out in an alcoholic care program in a city in Brazil found that the mean age for starting to consume alcohol was 15.91, SD 5.43, some 67.9% also used marihuana, 67.1% cocaine and 58.1% tobacco.Around 63.7% suffered from mental illness, the most commonly consumed drink was cachaça (alcoholic drink made from sugar cane and with alcohol content between 38% and 51%) (8).
As for rehabilitation treatment, a study comparing the severity of addiction and the recovery in self-help groups with another group receiving rehabilitation treatment found that 50% of those in the self-help group remained abstinent, whereas this figure was 93.75% for those who received treatment (9) .
The most frequently described comorbidities in this group of alcoholics were high blood pressure, 33.1%, followed by gastro-intestinal disease, 30.6%, and diabetes, 8.8%.The most frequently mentioned mental comorbidities reported in this study were smoking 58.1% and depression 8.8% (8) .
As for psychological comorbidities, studies in Colombia have shown the statistical association between alcoholism and depression and vice versa, as with a study in the general population in Colombia, which found that alcohol consumption is a risk factor for depression, with an OR of 2.6 (10) .
In a study on alcoholism in the university population, a positive association OR 3.33 was found between positive CAGE (Cut Annoyed Guilty Eyes) and severe symptoms of depression (11) .
In alcoholics undergoing detoxification, also in Colombia, a total prevalence of symptoms of anxiety was found in 65.5% and of depression in 75.9%, with more symptoms of anxiety found among women than men (12) .
Another comparative study between alcoholics who received treatment and those who did not, revealed personal and socio-familial advantages for those who underwent treatment, such as: higher levels of schooling, job stability, more family integration and broader knowledge of the disease (9).
The aim of this study was to describe the social, health and consumption variables of 13 alcoholics attending a recovery group on an outpatient basis in a private clinic in the city of Medellín Colombia.This study was conducted by the care research group belonging to the Nursing Faculty of the Universidad Pontificia Bolivariana.This study is important for nursing as they are the professionals responsible for planning and delivering the necessary care, depending on the needs of these individuals.Moreover, nurses are an essential part of the inter-disciplinary team charged with the rehabilitation and social recovery of the alcoholic.Their training in the social and human sciences enables them to lead educational and motivational groups for alcoholics and those addicted to other substances.

Materials and methods
This was a descriptive cross sectional mixed study, meaning that both quantitative and qualitative methodology was used; the latter in order to describe the situation, providing meaning and interpretation to that expressed by the alcoholics undergoing rehabilitation.
The sample was a non-probabilistic convenience sample made up of 13 alcoholic individuals, of both sexes, aged over 18 and attending a rehabilitation group, who had been abstinent for over 6 months and who agreed to participate in the study.
The quantitative data were collected using an instrument constructed by the researchers based on the objectives and the operationalization of the variables; it enabled us to discover socio-demographic characteristics as well as those of alcohol consumption, health and psychological comorbidities.This instrument was applied to the medical records of each individual who participated in the study, with patients consulted directly about data that were not recorded.
The qualitative component was ascertained using a semi-structured interview using a previously drawn up script based on the objectives and on a review of the literature.The guiding questions were: How do you perceive the treatment group to have helped your recovery?How do you perceive your colleagues (other group members) to have supported your recovery?How have your family helped your recovery?And, how do you perceive treatment with disulfiram (antabuse)?
The data for the questionnaire were taken from the medical record from the most recent consultation; later, all participants were invited for a private interview.
From the questionnaires, a database was created using the SPSS program, version 14 and this same program was used to calculate absolute and relative frequencies for the nominal variables and to measure the central trends in the quantitative variables.
The interviews were recorded in MP3 format, following the consent of all interviewees.They were then transcribed and read individually, analyzed at the semantic level, broken up into tables and text matrices and categorized.Throughout the process of the study the ethical principles of welfare, respect and justice were maintained, the project was deemed to be of minimal health risk according to resolution 008430 4 th October 1993, emitted by the Ministry of Health of the Republic of Colombia (13) .

Results
The treatment group studied was composed of a social worker, a psychiatrist, a toxicologist and several students and teachers from the health area (medical and nursing).
The socio-demographic characteristics found were: the majority, 84.6% were male and the mean age was 56.The youngest was 43 and the oldest 72; most were middle class (76%); 23.1% had not finished elementary education, 7% had finished primary school, 23.1% had not graduated from high school and 7.7% had finished high school.
Around 30.8% had graduated from university; 30.8% were retired and 15.4% were working at the time the questionnaire was conducted, more than half, 53.9% lived in a nuclear family.
The mean age at which they began to consume alcohol was 11.1 years old, standard deviation 3.8 years.The mean age at which they first got drunk was 12.3, standard deviation 3.9 years; one had got drunk for the first time at age 7.
The most commonly consumed drink, by 92.3% was aguardiente (distilled alcohol); followed by beer (fermented), with 65% and the least commonly consumed was ethyl alcohol, 46.2%.
The most frequent consumption pattern was daily, with 38%, followed by several times a week and binges, 23.1% for both.The mean number of years abstinent in the group was 6.1 years, with the longest period being 15.4 years.
Other drugs consumed by these individuals included: tobacco 76.9%; followed by coca derivatives 30.8%, further data can be found in table 1.
When questioned about alcoholism in the family, it was found that almost all, 92.3%, had siblings who drank to excess, 76.9 had uncles or aunts and 69.2% had a parent in the same situation.
Regarding family psychological history, excluding alcoholism, it was found that those with the most common was in siblings, 30.8%, followed by parents and aunts and uncles, 14.4% each.
In the medical notes, it was found that 79.6% had a psychological comorbidity and 61.5% a physical comorbidity; distribution can be seen in Table 1.
All of the patients, 100% had family problems stemming from alcoholism, other social problems included: economic 84%, followed by employment 76.9 %, school 38.5 % and 30.8 % legal.
As for perceptions of treatment, it is noteworthy that five interviewees viewed conceived alcoholism as a disease; it should be highlighted that this was not an aspect included in the guiding questions and was brought up spontaneously by the interviewees.Some illustrative phrases include: ( When referring to help from the treatment, seven of the patients saw the team of professionals as well qualified academically, empathetic; as seen in the following excerpts: (it helps you release the moods and in your personal life) E-2; (I was invited to the group, with their help I managed to stay off alcohol and drugs) E-11; The social worker was the most important E-1; (without her I'd be in the cemetery) E-2.(we need to understand that we are ill, when we understand this, we need the help of a psychiatrist with the capabilities of a doctor) E-5.(Ah… the social worker is the one I love best, she opened the doors to her office for me for a year, more than a year, every 8 day; I got myself back as a person, a son and a father, I got my daughter back, I think of her like the virgin Mary) E-6.
Six of them said that God had been a great help and support in their treatment, as in the following spontaneous exclamations.(I am nothing without the Lord, I respect everyone's right to think the way they want to, I take my medication.You have to believe in God.) E-3.Around 61% took disulfiran (alcohol deterrent), and said the following: (It is for prevention, you could die if you drink liquor, you have to take it) E-4.(I think it's a powerful weapon) E-5.(At first I was reluctant to take antabuse, I started taking it, I took it in one, it started to run out, so I took a half, it's a vitamin of life, is not for not drinking it's a vitamin that gives life, it's not punitive, it is positive I should share that with the group) E-13.(it's the best present I've ever had.I have enough for 200 days, I gave 30 to a girl, but no more, it's my health, it's a vitamin for life that has done me a lot of good, I've been fanatical about the lotions, once I used more than I should and felt bad, so I stopped using it) E-7.
More than half of the patients viewed the other group members as support, helping them to stay abstinent, some of their opinions are shown below: (and I started to get guidance from them) E-4.(A group like that there, are willing to give everything they know, once I found a job, chose not to go take care of a farm to lose the group, if I hadn't met the group I wouldn't be here) E-6 As for the families' help in staying abstinent, one patient said he had not received any type of help: (I don't have any help, my family haven't done anything to help me) E-3.Others think that, at the start of treatment, their families did not believe it would work, as they had suffered a lot, they were distrustful, but now they supported them and were proud of them.(Family is essential, those times when I wasn't suffering too much, they came with me to the meetings, my daughters helped me a lot "keep going Daddy").(My family didn't believe in me, they were distrustful, they thought I wasn't taking it seriously, but now they recognize that it's not like that; they've seen changes in my physical state, in behavior, in emotional capacity; now they talk to me, greet me, they didn't do that before, and it helps me, raises my self-esteem, they didn't believe I would get out of the hole, poor little mother!It's difficult, but I'm the one who has to do it) E-1.

Discussion
The individuals studied have certain socio-demographic characteristics that may affect abstinence, such as belonging to the middle class, having a medium level of schooling, being married, working or being retired.Having somewhere to live, having a job, may decrease the chances of relapse in drug addicts (14) ; other studies have found that those undergoing the rehabilitation process have more job stability, are better paid and have more knowledge of the disease (9) .The average age at which these individuals start drinking alcohol is lower than that indicated in studies of the Colombian general population (3) and lower than that of alcoholics in other countries, where ages between 14 and 19 have been found (8) .
The most commonly consumed drug among the alcoholics in our study was tobacco, similar to the findings reported in other studies, showing it as the most commonly consumed, by up to 93% of the alcoholic individuals studied (8).
A large percentage of these individuals had close relatives with a history of drinking to excess.Other researchers have found similar behavior, either through family attitudes encouraging consumption or through the influence of an alcoholic parent (15).
Alcoholics frequently suffer from mental illness, the most common being affective disorders, which include depression.One study reports that there is a statistically significant association between positive CAGE and symptoms of depression with an OR of 3.3 (11).In alcoholics undergoing a detoxification process, the prevalence of depressive symptoms found was 75.9 (12) .As in the above mentioned studies, this study found that the most common mental disorders wee depression, 61.5%, and bipolar disorder, 15.4%; a lower frequency than that found in other studies, possibly because they applied specific diagnostic tests, whereas this study took the information from medical records.
This study found that all of the patients suffered from family problems, as in other studies which report family breakdown (16) and negative feelings between children and authority figures (17) ; however, in the interview, several of the individuals with whom we are concerned stated that rehabilitation had helped them recover their role in the family, this being one of the advantages ascribed to the treatment (18).
Antabuse is a medication used with those with good insight.Its use should be accompanied by psycho-social treatment in order to be effective.More than half of those investigated had taken this medication, and for them it was essential to their treatment.They saw it as a support, or a barrier, they all made good use of the medication, in contrast to another study which states that the patients pretended to take it, but threw it away or took it and drank and ended up being hospitalized (19).
Alcoholism is a chronic disease (14) ; nine of those studied saw it as a disease and a chaos that caused them to lose their family and lead to mental and physical illness.They clearly perceive alcoholism to be a disease as they worked through the rehabilitation process.As in this study, others indicate that alcoholics view alcoholism as a serious, incurable disease associated with unhappiness and from which they need help to recover (20) .In contrast with the above, research into individuals who are not undergoing treatment do not see alcoholism as a disease, attributing beneficial qualities to it; this indicates the lack of introspection essential to an addict's recovery process (21).
The individuals studied perceived the treatment as well-being and as a change; such descriptions are in consonance with the literature, confirming that treatment has many advantages such as improving physical and mental health and decreasing personal conflicts (18).
The treatment group that works with these patients are perceived as empathetic and admirable; similar perceptions of other individuals belonging to a help group, describing them as roses, and placing a lot of importance on inter-disciplinary work and strengthening the therapeutic bond (20).For half of this group, the help of God was essential in maintaining abstinence.It is important to note that one of the domains on which recovery works is that of spirituality and belief in a supreme being (14) .Others, not part of this study, conceive that divine aid has a hierarchy superior to the treatment groups, God, they say, can change one's life; "first God, then there was light" (16) .
Members of the group describe these individuals as a support and help in staying abstinent; this concept is in concordance with the domains of intervention for alcoholics who describe the patient groups as indispensable in order to remain abstinent and to avoid relapses (14) ; another qualitative study, which opines that the help group is like a house that protects the family, a space free of temptation, to share with the group, exchange experiences and find a new path (16) .

Conclusions
Through this study, it can be concluded that these individuals started to consume alcohol early in life.These individuals had, on average, spent a long period of abstinence.Some had resumed their family roles lost through disease.They perceive rehabilitation as a total change in life.They see alcoholism as a disease.For them, the group members and the treatment group are important in remaining abstinent.

(
I found the Lord attend a Christian church, I found the Lord, He gave me the chance to go on living.I was baptized in a church, my God gave me the chance to go on living) E-10.

Table 1 -
(At first I had a lot Álvarez-Gómez M, Valencia-Prieto G. Comorbidities in alcoholics undergoing outpatient rehabilitation treatment in a clinic in Medellín, Colombia, 2012 Some interviewees saw their life before the treatment as in chaos (I accept that they didn't want to go out with me because I was a drunk, I fell asleep) E-3; (people didn't see how bad it was, but I did) E-7.(I would drink Now I understand that what I have is a disease and not an addiction) E-3; (It is an incurable disease you need to guardagainst every day so as not to relapse) E-10.The best thing that ever happened to me, finding God and the group, I've come back to life, I've become another person, totally positive; I can live again, I feel very privileged; they help you escape from this hell, I love this group) E-13.(It's a well-organized group, each one very professional in their area, they work on a personal level, as a professional, physically, mentally, mental