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Alcohol Abuse Original Source: http://www.mentalhealthchannel.net/alcohol/index.shtml Overview 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: 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: 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 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: 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. 2 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: 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 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: Confusion Coordination difficulties Expansive mood Impaired memory Poor judgment Sense of well-being Short attention span Slurred speech 3 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: 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: 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 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: 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 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: 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 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: 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 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: Abuse Compulsive drinking behavior Tolerance Withdrawal DSM-IV defines dependence as: 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: 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: 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: 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: 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 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. 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. 12