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Transcript
Alcohol Abuse
Original Source: http://www.mentalhealthchannel.net/alcohol/index.shtml
Overview
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Alcohol abuse, which is not the same as alcoholism, can lead to dependence
Alcoholism is characterized by excessive, frequent drinking and alcohol dependence
Alcoholism and alcohol abuse often have serious consequences
People who begin drinking alcohol at a young age are at increased risk for these conditions
Americans have a complicated history with alcohol. At the end of the 19th century, politicians, women's
groups, and churches banded together to convince lawmakers to outlaw alcohol. In 1919, the U.S. Congress
passed the 18th Amendment, making the sale and distribution of alcohol illegal. Alcohol consumption
declined but did not stop. In 1933, Prohibition ended and since then, millions of Americans have made
alcohol a part of their social life.
In the 1960s, E. M. Jellinek pioneered the idea that excessive and harmful use of alcohol was a disease.
Within a decade, public campaigns were launched in the United States to educate people about alcoholism
as an illness.
Definitions
In 1980, the American Psychiatric Association's Diagnostic and Statistical Manual III refined the definition of
alcoholism by differentiating between alcohol abuse and dependence. People continue to use the terms
"alcoholism" when they mean any harmful use of alcohol and "problem drinking" when they mean abuse,
when in fact alcoholism and abuse have specific clinical definitions.
Alcoholism, also known as alcohol dependence, is a chronic, progressive, and potentially fatal disease. The
characteristics include:
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Drinking excessive amounts frequently
Inability to curb drinking despite medical, psychological, or social complications
Increased tolerance to alcohol
Occurrence of withdrawal symptoms when the person stops drinking
Alcohol abuse is a chronic disease in which the person refuses to give up drinking even though it causes
neglect of important family and work obligations. Abuse, left untreated, can lead to dependence.
Characteristics include:
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Drinking when it is dangerous (e.g., while driving)
Frequent, excessive drinking
Interpersonal difficulties with family, friends, or coworkers caused by alcohol
Legal problems related to drinking
Incidence and Prevalence
Alcohol use typically begins in the late teens and early twenties, though a substantial number of people start
drinking even earlier. The National Institutes of Health reports that the younger the age, the greater the
chance the person will abuse or become dependent on alcohol.
1
Currently, over 7.4% of Americans abuse or are dependent on alcohol. Five times more men than women
become dependent. Most people who are dependent do not receive proper medical treatment.
In 1997, $94.5 billion was spent on alcoholic beverages in the United States. The National Institutes of
Health (NIH) estimates that in 1998, alcoholism cost $184.6 billion in lost productivity, medical care, legal
services, and costs from traffic accidents.
Risk Factors and Causes
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There are a number of risk factors for alcohol abuse and alcoholism
Genetic, biological, environmental, and psychological factors can increase risk
People who have multiple risk factors are at greater risk for abusing alcohol
Alcohol abuse and alcoholism increase the risk for death
Risk Factors and Causes
Genetic, biological, environmental, psychological, and sociocultural factors play a part in alcoholism.
Genetic
Scientists suggest that genetics may play a role in the following:
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Increased risk for alcoholism
Increased tolerance
Ongoing craving for alcohol
Genes that may be involved in alcoholism have not been identified. A number of studies of twins and
adoptions support the idea that genetics may be involved in alcoholism. In one study, identical male twins,
raised in separate environments, shared patterns of alcohol use, including dependence. Another study
showed a continued likelihood of alcoholism in male siblings born into alcoholic families but adopted into
nonalcoholic families.
Biology
Research notes that Chinese, Japanese, and Koreans with a deficiency or absence of alcohol dehydrogenase
(a liver enzyme) tend to drink less and are at lower risk for alcoholism. Because their livers do not break
down alcohol, these people experience vomiting, flushing, and increased heart rate and don't drink as often.
Researchers hope to provide a biological account for the low incidence of alcoholism in Jews who consume a
large amount of alcohol. Other groups are at an increased risk for alcoholism. Native Americans (a
population with a high incidence of alcoholism) generally don't become intoxicated as quickly as other races
and so may tend to drink more.
At least two studies have shown a possible correlation between certain brain wave patterns and an
increased risk for alcoholism.
Environment, Psychology, and Culture
Gender, family history, and parenting influence drinking behavior. A substantially higher number of men
than women abuse alcohol; some estimate the ratio to be as high as 5:1. However, the number of women
who drink, abuse, and become dependent on alcohol is rising. Studies indicate that up to 25% of sons of
alcoholic fathers will develop alcohol abuse or dependence.
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Most children of alcoholics do not develop dependence. Children in families with multiple risk factors are at
greater risk for alcohol abuse and/or dependence. Some of these risk factors include growing up with
parents who:
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are dependent on alcohol
have coexisting psychological disorder(s)
use alcohol to cope with stress
Family violence and having several close blood relatives who are alcohol dependent are also risk factors.
The expectations and beliefs about alcohol may influence alcohol use. Younger family members tend to
mimic the alcohol use patterns of their parents, siblings, and other family members. Peers also influence
drinking behavior.
Some studies show that regardless of a family history of alcoholism, a lack of parental monitoring, severe
and recurrent family conflict, and poor parent-child relationships can contribute to alcohol abuse in
adolescents. Children with conduct disorders, poor socialization, and ineffective coping skills as well as those
with little connection to parents, other family members, or school may be at an increased risk for alcohol
abuse and/or dependence.
Recently, the NIH reported that lower educational levels and unemployment do not cause higher rates of
alcoholism. Results from a 1996 study show that the rates of alcoholism in adult welfare recipients were
comparable to those of the general population. The study did show higher rates of death from alcoholism in
welfare recipients.
Signs and Symptoms
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Alcohol abuse is characterized by frequent drinking that affects daily life
Signs include intoxication, tolerance, dependence, and withdrawal
Symptoms of intoxication include poor judgment and coordination difficulties
Alcohol abuse often results in an inability to take care of responsibilities
Signs and Symptoms
Intoxication
Alcohol is absorbed by the small intestine into the bloodstream. The blood then enters the liver, where most
of the alcohol is metabolized. The body excretes a small amount of unprocessed alcohol. The body absorbs
alcohol more quickly than it metabolizes, so the blood alcohol concentration increases quickly and effects
occur rapidly.
Alcohol is a central nervous system depressant. In general, the first noticeable effects of alcohol—reduced
anxiety, sedation—occur when blood alcohol concentration is at 0.04 gr per 100 mL of blood. As blood
alcohol levels rise, the person may show the following signs:
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Confusion
Coordination difficulties
Expansive mood
Impaired memory
Poor judgment
Sense of well-being
Short attention span
Slurred speech
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Talkativeness
On average, between three and six standard drinks cause legal intoxication, which, depending on state laws,
is defined as blood alcohol concentration of 0.08 gr or 0.10 gr per 100 mL of blood.
When blood alcohol levels fall, the person experiences symptoms such as being withdrawn, sedate, and/or
depressed. Eventually, the body metabolizes and excretes the alcohol and the person sobers up.
Very high levels of blood alcohol cause the person to fall asleep or pass out. More rarely, severe intoxication
caused by alcohol poisoning is life threatening:
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At .40 BAC, alcohol suppresses the cardiorespiratory system. Coma or death may result.
At .45 BAC, alcohol suppresses major organ systems. Death results.
Several factors, such as the amount of alcohol consumed, body weight, and food intake, affects the rate at
which a person becomes intoxicated. Water content also affects the rate at which alcohol is metabolized: the
higher the water content, the more alcohol absorbed. Women, whose bodies typically have a higher
percentage of water content, show signs of intoxication more quickly.
Tolerance
Tolerance occurs when a person's body is less responsive to alcohol because of repeated exposure. Alcohol
causes neurons (nerve cells) in the central nervous system to adapt to its presence. Those who are tolerant
require more alcohol to produce an effect, such as reducing anxiety.
In addition, liver enzymes that detoxify alcohol increase with frequent drinking; thus, the liver of an
alcoholic breaks down alcohol more quickly than it did when first exposed to alcohol, contributing to the
development of tolerance. Tolerance levels can increase to the point that a long-term alcoholic can consume
a quantity of alcohol that would be extremely dangerous to a nondrinker.
Abuse
Abuse is characterized by frequent drinking that causes the person to neglect responsibilities such as
working, caring for children, or attending school. Difficulties with family, friends, and coworkers because of
drinking are also signs of abuse. The person may drink when it is dangerous, for example while driving. It is
common for those who abuse alcohol to have legal problems related to drinking, such as being arrested for
disorderly conduct. Abuse may lead to dependence.
Withdrawal
In clinical withdrawal, two or more of the following symptoms occur several hours or up to a few days after
someone stops drinking:
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Anxiety
Autonomic hyperactivity (i.e., sweating, pulse rate greater than 100)
Delirium tremens (i.e., anxiety, increased heart rate, sweating, trembling, confusion)
Difficulty performing tasks involving coordination
Grand mal seizures (i.e., convulsions resulting in loss of consciousness and muscle contractions)
Hallucinations (sights, sounds, or physical sensations on the skin, elevated or decreased
temperature)
Hand tremor
Insomnia
Nausea, vomiting
Symptoms vary in incidence and severity, and usually subside within hours or a few days. The risk for
symptoms depends on drinking patterns, coexisting illnesses, genetic factors, and the make-up of the
person's central nervous system. In general, larger amounts of alcohol correlate with more severe
symptoms. Medical attention may be necessary to prevent serious complications. Chronic alcoholism causes
vitamin deficiencies, particularly vitamin B, which contributes to withdrawal symptoms.
4
Dependence
People who are alcohol dependent are unable to reduce the amount they drink or to stop drinking, though
they often try. Most telling, alcohol use takes over more and more of the person's life, and he or she may
deny the complications it causes. Those who are dependent often experience physical and psychological
dependence. Psychological dependence is characterized by the belief that alcohol is necessary in order to
perform everyday activities. Dependence is confirmed when alcohol use is accompanied by signs of
tolerance, withdrawal, abuse, and the compulsion to drink even when there are clear signs that it interferes
with daily life.
Course
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Alcohol abuse can follow different courses
People who rely on alcohol are at risk for dependence
Drinking patterns include binge drinking, daily drinking, and weekend drinking
Frequent drinking can increase tolerance to alcohol
Course
There is no one course for alcohol dependence. Some begin drinking early in life; others begin later. Some
abuse alcohol for a short period of time; others are dependent for life.
When a person begins to rely on alcohol to enhance all social interactions, he or she is at risk for
dependence. Alcoholics believe that alcohol is necessary to get through everyday activities, alleviate stress,
and cope with problems. The alcoholic denies the overpowering role alcohol plays. He or she may drink in
secret to avoid confrontations with family or friends, and then feel guilty afterwards; drink more to alleviate
the emotional stress, feel guilty; drink again; and so on, thereby creating a cycle of abuse.
Others use alcohol in isolation to ease the pain of loneliness and alienation. Depression may also be a factor,
and alcohol use may serve as a form of self-medication. Alcohol produces sedative effects that relieve
anxiety. However, these initial effects subside and more severe depressive symptoms follow. The alcoholic
may drink to relieve these symptoms. Once again, alcohol creates a cycle of abuse.
Those who are dependent on alcohol show a variety of patterns of drinking, including:
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Binge drinking: heavy drinking which lasts for days, weeks, or months followed by long periods
of sobriety
Daily drinking: moderate to heavy drinking each day which may or may not occur at specific
times of the day
Weekend drinking: heavy drinking to the point of intoxication, but only on weekends
Over the course of months of drinking, the central nervous system adapts to the alcohol and tolerance
develops. The drinker requires increased amounts of alcohol to achieve the desired effect. Despite
experiencing adverse effects, the person continues to drink and will likely increase the amount and
frequency.
Over time, withdrawal symptoms, a sign of physical dependence, may develop. Symptoms include high
blood pressure and accelerated pulse rate, and tremors which occur when not using alcohol.
Alcohol dependence has a variable course. Sometimes a crisis such as having a car accident while drunk will
cause alcoholics to stop drinking for a short period of time (i.e., go into remission). After a while, they may
relapse, or begin drinking again. Once the alcoholic begins drinking again, the amount and frequency likely
escalate.
Two courses of alcohol dependence have been clinically defined:
5
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Young males who typically begin drinking in the teens or early 20s, with abuse developing
rapidly. Young men with a significant family history of alcoholism may become dependent within
1 or 2 years. Dependence often lasts through the 30s, and sometimes into the 50s and 60s. Of
the two courses, this has the worse prognosis.
People of both genders who experience a late onset of abuse. There may or may not be a
family history of alcoholism, and the progress from abuse to dependence is slower, taking from
5 to 15 years. The prognosis for recovery is better for this group.
Complications
Complications
Excessive drinking over a long period of time creates medical, psychological, and social problems. The
amount and frequency of the drinking and the general health of the alcoholic affect the degree to which
complications develop.
Medical
Chronic alcohol abuse and dependence can damage all organ systems, including:
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Blood forming
o Anemia
o Easy bruising
Cardiovascular
o Abnormal heart beat
o Heart failure
o Hemorrhoids
o High blood pressure
o Increased heart rate
Gastrointestinal
o Diarrhea
o Esophageal varices
o Gastritis
o Inflammation and/or cancer of the esophagus
o Increased risk of infectious diseases (e.g., tuberculosis)
o Liver damage, hepatitis, liver cancer
o Low blood sugar
o Pancreatic cancer
o Pancreatitis
o Ulcers
Neurological
o Confusion
o Coordination difficulties
o Depression
o Loss of coordination
o Nerve damage
o Psychosis
o Short-term memory problems
o Wernicke-Korsakoff syndrome
o Stroke
o Visual difficulties
Some neurological complications are related to vitamin deficiencies. Blackouts, the inability to recall events
that occurred while drinking, are common. Wernicke-Korsakoff syndrome, or permanent short-term memory
loss, is a rare but possible result of severe vitamin B deficiency caused by chronic alcoholism.
6
Drinking excessive amounts of alcohol during pregnancy may result in fetal alcohol syndrome (i.e., low birth
weight, short length, small head size, mental retardation, and damage to muscles, including the heart).
Psychological
Upwards of 44% of alcoholics have mental health disorders that were present before alcohol dependence.
Mood disorders are the exception; it is common for alcoholics to develop mood disorders such as major
depression after onset of dependence. Studies show a strong association between alcoholism and
depression, and 25% of suicides involve alcohol.
Social
Alcoholism causes suffering in relationships with family, friends, and coworkers. Alcoholics have a higher
rate of divorce and separation and of engaging in domestic violence and other types of violent and
aggressive behavior. Missed work, poor job performance, and in some cases, on-the-job accidents are
common. Legal problems are also common, such as citations for driving under the influence and/or traffic
accidents.
Most disturbing, alcohol use kills. Estimates are as high as 150,000 deaths each year from alcohol use.
According to the American Psychiatric Association's Diagnostic and Statistical Manual-IV, more than one-half
of all murderers and their victims are believed to have been intoxicated at the time of the murder. The
National Highway Traffic Safety Administration reports that in 1997, over 16,000 fatalities from traffic
accidents were attributed to drunk driving. There are also a number of alcohol-related deaths from acute
alcohol poisoning and accidents, which are reported on college campuses with increasing frequency.
Diagnosis
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Family members and friends often are the first to notice alcohol abuse
Criteria for diagnosing alcoholism are defined by the American Psychiatric Association
Alcohol abuse often leads to dependence to alcohol and increased tolerance
Health care providers often use a questionnaire to help diagnose alcohol abuse
Diagnosis
Friends and family members of the alcoholic are often the first to notice problems and seek professional
help. Many times, the alcoholic does not realize the severity of the problem or denies it. Some signs cannot
go unnoticed, such as loss of a job, family problems, or citations for driving under the influence of alcohol.
Dependence is indicated by symptoms such as withdrawal, injuries from accidents, or blackouts.
The American Psychiatric Association has developed strict criteria for the clinical diagnosis of abuse and
dependence. The Diagnostic and Statistical Manual-IV (DSM-IV) defines abuse as:
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A maladaptive pattern of substance use leading to clinically significant impairment or distress, as
manifested by one (or more) of the following, occurring within a 12-month period:
1. recurrent substance use resulting in a failure to fulfill major role obligations at work,
school, home (e.g., repeated absences or poor work performance related to substance
use; substance-related absences, suspensions, or expulsions from school; neglect of
children or household)
2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired by substance use)
3. recurrent substance-related legal problems (e.g., arrests for substance-related
disorderly conduct)
4. continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance (e.g., arguments with
spouse about consequences of intoxication, physical fights)
7
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The symptoms have never met the criteria for Substance Dependence for this class of
substances.
[DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric
Association (AMA). 1994.]
Most often, abuse is diagnosed in individuals who recently began using alcohol. Over time, abuse may
progress to dependence. However, some alcohol users abuse alcohol for long periods without developing
dependence.
Dependence is suspected when alcohol use is accompanied by signs of the following:
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Abuse
Compulsive drinking behavior
Tolerance
Withdrawal
DSM-IV defines dependence as:
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A maladaptive pattern of substance use, leading to clinically significant impairment or distress,
as manifested by three (or more) of the following, occurring at any time in the same 12-month
period:
1. tolerance, as defined by either of the following:
 a need for markedly increased amounts of the substance to achieve intoxication
or desired effect
 markedly diminished effect with continued use of the same amount of
substance
2. withdrawal, as manifested by either of the following:
 the characteristic withdrawal syndrome for the substance
 the same (or a closely related) substance is taken to relieve or avoid withdrawal
symptoms
3. the substance is often taken in larger amounts or over a longer period than was
intended
4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
5. a great deal of time is spent in activities to obtain the substance, use the substance, or
recover from its effects
6. important social, occupational or recreational activities are given up or reduced because
of substance use
7. the substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance (e.g., continued drinking despite recognition that an ulcer was made
worse by alcohol consumption)
[DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric
Association (AMA). 1994.]
Assessment
The clinician relies on interviews and self-report questionnaires to assess quantity and frequency of drinking.
Questions focus on two aspects:
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Consequences of drinking
Perceptions of drinking behavior
Clinicians determine risk for abuse and dependence based on how much and how often the patient drinks.
The definition of moderate drinking differs for men and women:
Men
4 to 14 drinks per week
8
Women
3 to 7 drinks per week
A drink is 12 grams of alcohol (e.g., 12 ounces of beer; 5 ounces of wine; 1.5 ounces of 80-proof liquor).
Typical risk-assessment questions include:
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How many days a week do you drink alcohol?
On a typical day when you drink, how many drinks do you have?
What is the maximum number of drinks you had on any given occasion during the last month?
The CAGE questionnaire is commonly used to determine the risk of alcohol-related problems:
C Have you ever felt that you should Cut down on your
- drinking?
A
Have people Annoyed you by criticizing your drinking?
G
Have you ever felt bad or Guilty about your drinking?
E Have you ever had an Eye opener - a drink first thing in
- the morning to steady your nerves or get rid of a
hangover?
One "yes" answer indicates a risk for abuse and/or dependence alcohol use problems; more than one "yes"
indicates a high likelihood.
The Alcohol Use Disorders Identification Test (AUDIT) and the Primary Care Evaluation of Mental Disorders
(PRIME-MD) are based on the CAGE. The five-question Trauma Scale targets problem drinking in both men
and women. The T-ACE and the TWEAK are designed to identify alcoholism in pregnant women.
Because these less formal interviews and questionnaires have the risk of underreporting, additional tests are
used to solicit information, especially if the patient is evasive or intoxicated at the time of the interview:
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Short Michigan Alcoholism Screening Test (S-MAST) determines general alcohol abuse.
Short Alcohol Dependence Data Questionnaire (SADD) determines dependence severity.
Once abuse or dependence is verified, the clinician administers a comprehensive assessment to develop a
treatment plan. The assessment includes detailed medical and psychological histories from the individual.
The clinician may request copies of medical records and may interview family members.
Differential Diagnosis
The clinician must rule out medical problems that cause symptoms similar to intoxication and withdrawal,
such as the following conditions:
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Brain trauma
Hypoglycemia
Electrolyte imbalance
Diabetic acidosis and ketoacidosis
Meningitis
Neurological conditions such as multiple sclerosis
Pneumonia
Stroke
If a patient has one of these conditions, he or she may be disoriented, unable to hold a conversation, have a
short attention span, or may have trouble walking or maintaining balance. In the case of brain trauma and
stroke, the patient may be unconscious.
9
Diagnosis also includes evaluations for depression and anxiety disorders, which often coexist with
alcoholism. Abuse of other intoxicants, such as benzodiazepines and barbiturates, is common. The presence
of a mixed drug and alcohol problem must be determined.
Treatment, Prognosis
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Excessive drinking can cause serious complications that require immediate medical care
Treatment for alcohol abuse often involves detoxification and rehydration
In severe cases, alcoholism requires inpatient hospital care
Treatment may include medications, behavior therapy, and counseling
Treatment
Intoxication
In general, intoxication does not require treatment. After alcohol enters the body, the liver detoxifies the
blood, the body excretes the alcohol, and the person sobers up.
In rare instances, excessive alcohol consumption can cause potentially fatal complications that require
emergency medical treatment. Alcohol poisoning, or acute intoxication, can cause liver and/or respiratory
failure, which may result in heart failure. For example, in drinking rituals or contests, participants (usually
young males) consume large amounts of alcohol as fast as they can. The blood alcohol level rises so high
and so quickly that the liver cannot metabolize the alcohol. The person may become comatose, may suffer
cardiac and respiratory failure, and can die. In such cases, emergency medical support can be life saving.
Withdrawal
Mild withdrawal symptoms do not require treatment. More serious symptoms may require medical attention.
Admission to a detoxification unit or a hospital can be lifesaving in cases of severe symptoms.
Physicians first assess the severity of symptoms, the existence of any coexisting medical or psychiatric
conditions, and the risk for complications. A questionnaire, the Clinical Institute Withdrawal Assessment for
Alcohol (CIWA-Ar), is often used in assessing the potential for withdrawal symptoms and their intensity. A
high score indicates a high risk of severe symptoms and these patients are typically treated on an inpatient
basis, often with benzodiapines. A lower score indicates moderate symptoms, which require observation but
no medication.
Treatment involves detoxification, hydration, and replenishing vitamins to prevent complications such as
hallucination, convulsions, and delirium tremens (DTs). Without intervention, DTs have a 5% mortality rate.
Detoxification
Detoxification is a process in which the alcoholic becomes alcohol free. Detoxification must take place before
treatment of dependence begins. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
questionnaire is often used to evaluate the potential for withdrawal symptoms and their intensity. Patients
with a high score (i.e., at high risk for severe symptoms) are typically treated with medication in a
controlled environment. A lower score indicates that treatment may require observation but no medication.
Severe symptoms usually occur in those with chronic alcoholism and a history of withdrawal symptoms.
Cross-tolerant medications—drugs with effects similar to those of alcohol—may be given to control tremor,
racing heart, and high blood pressure, and reduce the chance of seizure. Patients who take these
medications, such as benzodiapines, must be closely monitored because they carry the risk for dependence.
The physician gives a dosage sufficient to reduce symptoms, gradually tapers, and then discontinues the
medication. Some patients need an antipsychotic to treat hallucinations.
Dependence
The severity of dependence, availability of facilities, insurance coverage, and other considerations factor into
a patient's choice of treatment program. Inpatient and outpatient facilities have similar success rates,
although outpatient facilities are sometimes the only option. Some facilities provide both detoxification and
10
long-term treatment. Treatment modalities include education, behavioral approaches, and
pharmacotherapy.
Inpatient
Inpatient treatment is provided in a residential program or a hospital. Patients admit themselves for
treatment, which usually lasts a month. Alcohol education and different types of therapy, including group,
individual, and sometimes family or couples therapy, are provided. Inpatient treatment is recommended for
alcoholics who lack healthy social networks, have failed outpatient programs, or who suffer from serious
medical or psychological conditions. These facilities administer medication when needed.
Outpatient
Outpatient treatment programs provide alcohol education and counseling (group and individual) several
times a week. Alcoholics who have strong social networks and have no other psychiatric or medical
conditions are good candidates for outpatient treatment. In addition, some find outpatient programs helpful
after inpatient treatment. Patients must attend sessions regularly and abstain from alcohol and other
substances. There are a variety of outpatient programs, ranging from community programs that provide
only alcohol education to all-day programs in hospitals.
Intensive outpatient day programs in hospitals are becoming a common treatment option. Although they
vary, most programs offer 8-hour treatment sessions during the week for adults who need a treatment plan
that occurs frequently. Group therapy is the primary modality, with emphasis on preventing relapse,
managing stress, and communicating with family.
Behavioral Therapy
In cognitive behavioral therapy (CBT), the patient and therapist work in one-on-one sessions to identify
factors that cause relapse, called cues. The therapist provides strategies for defusing high-risk situations.
The patient practices the techniques with the therapist, and when confronted by the cue outside the therapy
setting, is better able to cope with the situation without drinking. Motivational enhancement therapy (MET)
is a nonconfrontational therapy that focuses on motivating the patient to modify behavior. Therapists
provide structured, positive feedback that enhances the patient's desire to change.
Alcoholics Anonymous
Alcoholics Anonymous (AA) is a self-help organization founded by alcoholics. Anyone is welcome to attend
meetings. Members facilitate group meetings, which take place on a regular basis. Some AA chapters offer
meetings 7 days a week. The framework of AA is a spiritual-based, 12-step program through which
attendees admit their dependence on alcohol and seek to modify their behavior. Attendance is voluntary. AA
uses a buddy system and group intervention to help members when they are tempted to relapse or when
they do relapse. Alateen provides support for adolescents affected by alcoholism in the family, and Alanon
helps adults affected by someone else's alcohol addiction.
Alcoholics Anonymous and other 12-step programs are considered interactional group therapy. Because of
AA's commitment to anonymity and deliberate lack of professional guidance, research has been difficult to
conduct. However, it is generally known as having helped more alcoholics than any other organization, and a
recent study by the National Institute on Alcohol Abuse reports only slight differences in the effectiveness of
cognitive behavioral therapy, motivational enhancement therapy, and AA.
Pharmacotherapy
A physician must prescribe and monitor treatment with medication. Pharmacotherapy alone has not been
shown to be effective but can be beneficial when used as a part of a treatment plan. Two kinds of
medication are used to treat alcohol dependence: aversive and anticraving.
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Disulfiram (Antabuse®), an aversive medication, has been used to treat alcohol dependence
since the 1940s. This drug creates a chemical reaction with alcohol, and if the patient drinks
within a 2-week period, he or she experiences vomiting, flushing, and increased blood pressure
and heart rate. Disulfiram causes sensitivity to other forms of alcohol, such as aftershave and
cooking wine, and mild reactions may occur. The drug has not been shown to increase the rate
of abstinence, but it has reduced the number of days patients drink.
Naltrexone (Revia®), an anticraving medication, has been shown to reduce the effects of
alcohol and to reduce the amount of alcohol consumed when used with behavioral therapies.
11
Short-term studies report that naltrexone cut the occurrence of relapse in half. Another
anticraving medication, acamprosate (Campral®), also has shown promise.
Medication can also be used to treat co-occurring conditions such as depression, social phobia, or panic
disorder.
Prognosis
Abstinence is necessary for successful treatment. Alcoholics cannot resume social drinking without risking a
return to dependence. Many feel they are the exception to the rule; however, for every 10 people who say
they will stop drinking, only 4 do. Motivation and intervention by family or friends can help the alcoholic
achieve abstinence.
Recovery from alcohol dependence is possible. DSM-IV reports one study in which 65% of patients who
abused or were dependent on alcohol abstained for at least a year following treatment. Another study
showed 40% to 60% of alcoholics abstaining for longer than 1 year.
Over 700,000 people per day receive treatment for alcohol dependence. Approximately 20% of people with
alcohol dependence achieve long-term sobriety without treatment.
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