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===Detoxification=== ===Detoxification===
] or 'detox' for alcoholics is an abrupt cessation of alcohol intake coupled with the substitution of drugs that have similar effects upon the brain so as to offset the withdrawal symptoms. ] are the standard treatment, particularly such long-acting benzodiazepines as ] or ]. ] can be used similarly, though only a few programs still administer them for this purpose. ] or 'detox' for alcoholics is an abrupt cessation of alcohol intake coupled with the substitution of drugs that have similar effects upon the brain so as to offset the withdrawal symptoms. ] are the standard treatment, particularly such long-acting benzodiazepines as ] or ].


Detoxes are performed in multiple ways. The first takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur, which is safe only with relatively mild alcohol users. Detoxes are performed in multiple ways. The first takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur, which is safe only with relatively mild alcohol users.

Revision as of 22:04, 31 October 2006

"King Alcohol and his Prime Minister" circa 1820

Alcoholism is the consumption of or preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic's normal personal, family, social, or work life. The chronic alcohol consumption caused by alcoholism can result in psychological and physiological disorders. Alcoholism is one of the world's most costly drug use problems; with the exception of nicotine addiction, alcoholism is more costly to most countries than all other drug use problems combined.

While alcohol use is required to trigger alcoholism, the biological mechanism of alcoholism is uncertain. For most people, moderate alcohol consumption poses little danger of addiction. Other factors must exist for alcohol use to develop into alcoholism. These factors may include a person's social environment, emotional health and genetic predisposition. In addition, an alcoholic can develop multiple forms of addiction to alcohol simultaneously such as psychological, metabolic, and neurochemical. Each type of addiction must be treated individually for an alcoholic to fully recover.

Terminology

Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The introduction of politics and religion further muddles the issue and exacerbates ambiguity.

Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol.

Misuse and heavy use do not have standard definitions, but suggest consumption of alcohol beyond the point where it causes physical, social, or moral harm to the drinker. Social and moral harm are highly subjective and therefore differ from individual to individual.

The term abuse has a variety of possible meanings. Within psychiatry, the DSM-IV has a specific definition involving a set of life circumstances which take place because of substance use. Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescribed medication in excess of the prescribed dosage or to use of a prescription drug without a prescription. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion due to audiences that do not necessarily share a single definition.

Dependence also has multiple definitions, but is not as commonly used as abuse outside of the medical profession. Physical medicine considers dependence to be the body's physical adaptation to the persistent presence of alcohol. Psychological medicine considers dependence to be a person's mental reliance upon something to maintain their mental status quo. These two are occasionally differentiated as physical and psychological dependence.

The precise definition of addiction is debated, but in general it refers to any condition which causes a person to continue behaviors demonstrated as harmful to that person. For alcoholism, that behavior is the consumption of alcoholic beverages. Some conditions which contribute to alcoholism include physical dependence, neurochemical conditioning, and a person's perception that alcohol benefits them psychologically or socially.

Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full. Others (most notably Alcoholics Anonymous) use the term exclusively to describe those who have completely stopped consumption of alcohol.

Epidemiology

Substance use disorders are the major public health problem facing many countries. In the United States today, more than 15 million Americans are estimated to suffer from alcoholism. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol." In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001..

There is considerable debate regarding the Disease Theory of Alcoholism. Proponents argue that any structural or functional disorder having a predictable course, or progression, should be classified as a disease. Opponents cite the inability to pin down the behavioral issues to a physical cause as a reason for avoiding classification.

Identification and diagnosis

Identification of alcoholism may be difficult because there is no detectable physiological difference between a person who drinks a lot and a person who can't control his or her drinking. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared to the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are still a large number of borderline cases that can be difficult to classify.

Genetic predisposition testing

At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism.

Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

  • The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.
  • The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions - a high score earning a deeper investigation.

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcoholism diagnosis is:

...maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

Effects

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging. The secondary damage caused by an inability to control one's drinking manifests in many ways.

Long-term physical health effects

See also: Alcohol consumption and health

The long-term health effects caused by the consumption of large amounts of alcohol (both by alcoholics and non-alcoholics) may include:

Social effects

The social problems arising from alcoholism can be significant. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of accommodation. Drinking at inappropriate times and behavior caused by reduced judgment can earn criminal convictions, such as drunk driving or public disorder. An alcoholic's behavior and prioritization while drunk can profoundly impact the family and friends around them possibly leading to marital conflict and divorce. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).

Alcohol withdrawal

Alcohol withdrawal differs significantly from withdrawal from other drugs in that it can be directly fatal. While it is possible for heroin addicts, for instance, to die from other health problems made worse by the strain of withdrawal, an otherwise healthy alcoholic can die from the direct effects of withdrawal if it is not properly managed. Heavy consumption of alcohol reduces the production of GABA, which is a neuroinhibitor. An abrupt stop of alcohol consumption can induce a condition where neither alcohol nor GABA exists in the system in adequate quantities, causing uncontrolled firing of the synapses. This manifests as hallucinations, shakes, convulsions, seizures, and possible heart failure, all of which are collectively referred to as delirium tremens.

Treatments

Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach the condition medically as disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.

The effectiveness of alcoholism treatments varies widely. When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own.

Detoxification

Detoxification or 'detox' for alcoholics is an abrupt cessation of alcohol intake coupled with the substitution of drugs that have similar effects upon the brain so as to offset the withdrawal symptoms. Benzodiazepines are the standard treatment, particularly such long-acting benzodiazepines as diazepam or clonazepam.

Detoxes are performed in multiple ways. The first takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur, which is safe only with relatively mild alcohol users.

Detoxification treats the physical effects of alcohol withdrawal, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs'), as with detoxes, may take place in an inpatient or outpatient setting.

Group therapy and psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service, including Alcoholics Anonymous, LifeRing Secular Recovery, Rational Recovery, Smart Recovery, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs do not mandate complete abstinence. Since one of the effects of alcohol is to reduce a person's judgment, each drink makes it more difficult to decide that the next drink is a bad idea. Additionally, for those who are predisposed towards alcoholism, drinking in moderation can result in the strengthening of the endorphin-based addiction.

While most alcoholics are unable to limit their drinking in this way, moderate drinking works for some people, and it may avoid the physical, financial, and social costs of other treatments - particularly in the early phase of recovery. Research by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that nearly 18% of such individuals in the US whose drinking habit began more than one year earlier are now drinking in moderation. Professional help can be sought for rationing from programs such as Moderation Management.

Medications

Although not necessary for treatment of alcoholism, a variety of medications may be prescribed as part of treatment. Some may ease the transition to sobriety, while others cause physical hardship to result from the use of alcohol. In most cases, the desired effect is to have an alcoholic abstain from drinking.

  • Antabuse (disulfiram) prevents the elimination of (acetaldehyde), a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hang over symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast acting and long lasting uncomfortable hang over. This discourages an alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on antabuse can cause severe illness and death.
  • Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. It also appears to act on glutamate neurotransmission. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction. Naltrexone comes in two forms. Oral naltrexone, originally but no longer available as the brand ReVia, is a pill form and must be taken daily to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.
  • Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse...Campral proved superior to placebo in maintaining abstinence for a short period of time..." While effective alone, it is often paired with other medication treatments like naltrexone with great success. Acamprosate reduces glutamate release. The COMBINE study was unable to determine the presence of efficacy for Acamprosate.
  • Sodium oxibate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in Italy in small amounts under the trade name Alcover.
  • Baclofen has been shown in animal studies and in small human studies to enhance detoxification.This drug acts as a GABA B receptor agonist and this may be beneficial.

Pharmacological extinction

See also: Sinclair Method

Pharmacological extinction is the use of opioid antagonists like naltrexone combined with normal drinking habits in order to eliminate the craving for alcohol. This technique has had success in Finland, Pennsylvania, and Florida, and is sometimes referred to as the Sinclair Method. While standard naltrexone treatment uses the drug to curb craving and enforce abstinence, pharmacological extinction targets the endorphin-based neurological conditioning. Our behaviors become conditioned when our neurons are bathed in endorphins following that action. Conversely, we receive negative reinforcement when we perform that action and yet do not get our endorphins. By having the alcoholic go about their normally drinking habits (limited only by safety concerns), and while preventing the endorphins from being released by the alcohol, the pull to drink is eliminated over a period of about three months. This allows an alcoholic to give up drinking as being sensibly unbeneficial. The effects persist after the drug is discontinued, but the addiction can return if the person drinks without first taking the drug. This treatment is also highly unusual: it works better if the patient does not go through detoxification prior to starting it.

There is a lot of professional resistance to this treatment for two reasons. Studies have demonstrated that controlled drinking for alcoholics was not a useful treatment technique. Other studies have also shown naltrexone to be of questionable value in supporting abstinence alone.. The individual failure of these two separate treatments suggests that their use in combination is equally ineffective. This would be the case if the two treatments were merely additive, as for two people pushing a car. Experimental evidence indicates that the presence of naltrexone causes alcohol to have a reverse effect on drinking, decreasing the alcoholic's attachment to it when they drink instead of increasing it.

Nutritional therapy

Preventative treatment of alcohol complications includes long-term use of a multivitamin as well as such specific vitamins as B12 and folate.

While nutritional therapy is not a treatment of alcoholism itself, it treats the difficulties that can arise after years of heavy alcohol use. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be diminished by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, causing poor treatment outcomes.

Societal impact

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, for example, money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there is also the pain and suffering of the all individuals besides the alcoholic affected. For instance, heavy alcohol consumption by a pregnant woman can lead to fetal alcohol syndrome, an incurable and damaging condition.

Today, alcohol use and alcohol dependence are major public health problems on many continents, including North America where dependence costs the region's inhabitants as much as 170 billion dollars annually by some estimates. Of the 50% of the North American population who consume alcohol, it has been estimated that 10% are heavy alcohol users and alcohol dependents, and 6% account for more than half of all the alcohol consumption in the region.

Stereotypes

Stereotypes of alcoholics are often found in fiction and popular culture. Common examples include the 'town drunk' or the portrayal of certain nationalities as alcoholics. In modern times, the recovery movement has led to more realistic depictions of problems that stem from heavy alcohol use. Authors such as Charles R. Jackson and Charles Bukowski describe their own alcohol addiction in their writings. Films like Days of Wine and Roses, My Name is Bill W, Leaving Las Vegas and Clean and Sober chronicle similar stories of alcoholism.

Politics and public health

Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

Organizations working with those suffering from alcoholism include:

See also

References

  1. ^ Gabbard: "Treatments of Psychiatric Disorders". Published by the American Psychiatric Association: 3rd edition, 2001, ISBN 0-88048-910-3
  2. ^ Cabinet Office Strategy Unit Alcohol misuse: How much does it cost? September 2003
  3. New York Daily News (William Sherman) Test targets addiction gene 11 February 2006
  4. Ulf Berggren, Claudia Fahlke, Erik Aronsson, Aikaterini Karanti, Matts Eriksson, Kaj Blennow, Dag Thelle, Henrik Zetterberg and Jan Balldin The TaqIA DRD2 A1 Allele Is Associated with Alcohol-Dependence although its Effect Size Is Small Alcohol and Alcoholism 2006 41(5):479-485; doi:10.1093/alcalc/agl043
  5. Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984
  6. CAGE Questionnaire (PDF)
  7. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care
  8. Alcohol Dependence Data Questionnaire (SADD)
  9. Michigan Alcohol Screening Test (MAST)
  10. Giuliani N, Girasole G, Vescovi P, Passeri G, Pedrazzoni M (1999). "Ethanol and acetaldehyde inhibit the formation of early osteoblast progenitors in murine and human bone marrow cultures". Alcohol Clin Exp Res. 23 (2): 381–5. PMID 10069572. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  11. BBC Q&A: The costs of alcohol 19 September 2003
  12. Spontaneous Recovery in Alcoholics: A Review and Analysis of the Available Research, by R. G. Smart Drug and Alcohol Dependence, Vol. 1, 1975-1976, p. 284.
  13. National Institute on Alcohol Abuse and Alcoholism 2001-2002 Survey Finds That Many Recover From Alcoholism Press release 18 January 2005
  14. "FDA Approves New Drug for Treatment of Alcoholism". Retrieved 2006-04-02.
  15. "Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: The role of patient motivation". 2006-03-17. Retrieved 2006-04-10.{{cite web}}: CS1 maint: year (link)
  16. "COMBINED ACAMPROSATE AND NALTREXONE, WITH COGNITIVE BEHAVIOURAL THERAPY IS SUPERIOR TO EITHER MEDICATION ALONE FOR ALCOHOL ABSTINENCE: A SINGLE CENTRES' EXPERIENCE WITH PHARMACOTHERAPY". 2006-02-08. Retrieved 2006-04-10.{{cite web}}: CS1 maint: year (link)
  17. ^ Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism
  18. ContrAl Clinics ContrAl Results
  19. The Sinclair Method
  20. University of Pennsylvania Health System
  21. Pendery et al. Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study. Science 1982 Jul 9;217 (4555):169-75
  22. Renault, P. F. (1978) Treatment of heroin-dependent persons with antagonists: Current status. Bulletin on Narcotics 30: 21-29 ¶ Renault, P. F. (1980) Treatment of heroin dependent persons with antagonists: Current status. In: Naltrexone: Research Monograph 28, Willett, R. E., and Barnett, G., (eds.), Washington, DC: National Institute of Drug Abuse, 11 22.
  23. O'Malley, S.S., Jaffe, A.J., Rode, S., and Rounsaville, B.J. (1996) Experience of a “slip among alcoholics treated with Naltrexone or placebo. American Journal of Psychiatry, 153(2): 281-283.
  24. Maxwell, S., and Shinderman, M. S. (1997) Naltrexone in the treatment of dually-diagnosed patients. Journal of Addictive Diseases 16: A27, 125, 1997 ¶ Maxwell, S., and Shinderman M. S. (2000) Use of Naltrexone in the treatment of alcohol use disorders in patients with concomitant severe mental illness. Journal of Addictive Diseases 19:61-69.
  25. The Hypoglycemic Health Association of Australia

Further reading

  • Berry, Ralph E.; Boland James P. The Economic Cost of Alcohol Abuse The Free Press, New York, 1977 ISBN 0-02-903080-3
  • Royce, James E. and Scratchley, David Alcoholism and Other Drug Problems Free Press, March 1996 ISBN-10: 0-684-82314-4 ISBN-13: 978-0-684-82314-0

External links

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