Alcoholism: Abuse or dependence.
Mark A. Schuckit
Harrison's Principles of Internal Medicine Chapter 386, 14th Ed., 1998.
Because many drinkers occasionally imbibe to excess, temporary alcohol-related pathology is common in nonalcoholics. The time of heaviest drinking is usually the late teens to the late twenties, when between one-third and one-half of male drinkers experience some isolated (although potentially dangerous) alcohol-related social, occupational, or driving difficulty. These include alcohol-related blackouts, a single drunk driving arrest, and arguments with friends. This prevalent alcohol-related morbidity, however, is temporary and is a separate problem from alcohol dependence. The following sections describe diagnostic criteria for alcoholism, offer suggestions for identifying the usual (i.e., middle-class) alcoholic in everyday medical practice, review evidence that alcoholism is a biologic and genetically influenced disorder, and offer advice on intervention, detoxification, and rehabilitation of alcoholics.
DSM-IV defines alcohol dependence as repeated alcohol-related difficulties in at least three of seven areas of functioning. These include any combination of tolerance, withdrawal, taking larger amounts of alcohol over longer periods than intended, an inability to control use, spending a great deal of time associated with alcohol use, giving up important activities to drink, and continued use of alcohol despite physical or psychological consequences. This constellation of symptoms is likely to occur in both men and women, in individuals of all socioeconomic strata, and in people of all racial backgrounds. It also predicts a course of recurrent problems with the use of alcohol, and the consequent shortening of the life span by a decade or more. In the absence of alcohol dependence, an individual can be given a diagnosis of alcohol abuse if he or she demonstrates repetitive problems with alcohol in any one of four life areas, including an inability to fulfill major obligations, use in hazardous situations such as driving, legal problems, or use despite social or interpersonal difficulties.
Thus, the clinical diagnosis of alcohol abuse or dependence rests on the documentation of a pattern of difficulties associated with alcohol use and is not based on the quantity and frequency of alcohol consumption. This approach is used because an individual's pattern of drinking is difficult to establish and because the amount of alcohol associated with high blood levels differs with a person's age, sex, weight, percent body fat, and concomitant use of other medications. Thus, in screening for alcohol abuse or dependence in a clinical setting, it is important to probe for life problems and then attempt to tie in use of alcohol or another substance. A patient's pattern of life difficulties is important for a clinician to understand, and thus information regarding marital or job problems, legal difficulties, histories of accidents, medical problems, evidence of tolerance, etc., are important components of all evaluations and yield information that is of use even for nonalcoholic individuals.
The lifetime risk for alcohol dependence in most western countries is about 10 percent for men and 3 to 5 percent for women. When alcohol abuse is also considered, the rates double. The average alcoholic (just like the average person) is a blue-collar or white-collar worker or homemaker. Homeless or skid row alcoholics represent only 5 percent or less of the total.
Alcoholism is a multifactorial disorder in which biologic and genetic factors interact. The importance of genetic factors in alcoholism is supported by family, twin, and adoption studies. Close relatives of alcoholics who themselves have no other psychiatric disorder have an approximately fourfold increased risk for alcoholism but are not significantly more vulnerable to other psychiatric illnesses. The risk for the identical twin of an alcoholic is higher than for the fraternal twin of an alcohol-dependent person. Finally, adoption studies reveal that the fourfold increased risk for children of alcoholics is true even if they were adopted away at birth and raised without knowledge of the problems of their biologic parents.
The evidence supporting genetic influences in alcoholism has stimulated studies attempting to identify possible trait markers of a vulnerability toward the disorder before alcoholism appears. A 10-year follow-up of 453 men originally studied at age 20 has shown that subjects with alcoholic fathers demonstrated relatively lower levels of response to alcohol, including less intense subjective feelings of intoxication, less alcohol-related impairment in cognitive and psychomotor tests, and less intense alcohol-related changes in prolactin and cortisol secretion. This low level of response to alcohol at around age 20 was a powerful predictor of alcoholism a decade later. Taken as a whole, these data underscore the probability that alcoholism is biologically influenced and not related to a lack of "moral fiber." It is not surprising that the average alcoholic may continue to work, has a family, and may be difficult to identify if the physician persists with old stereotypes.
For the "average" alcoholic, the age of first drink and first minor problems (e.g., an argument with a friend while drunk or an alcoholic blackout) are similar to those in the general population. However, by the early to mid-twenties, most men and women moderate their drinking (perhaps learning from minor problems), whereas difficulties for alcoholics are likely to escalate, with the first major life problem from alcohol appearing in the mid-twenties to early forties. Once established, the course of alcoholism is likely to be one of exacerbations and remissions. As a rule there is remarkably little difficulty in stopping alcohol use when problems develop, and this step often is followed by days to months of carefully controlled drinking. Unfortunately, these periods are almost inevitably followed by escalations in alcohol intake and subsequent problems. The course is not hopeless, because a fifth or more of alcoholics achieve permanent abstinence without formal treatment or aid from self-help groups such as Alcoholics Anonymous (AA). However, should the alcoholic continue to drink, the life span is shortened by an average of 15 years, with the leading causes of death, in decreasing order, being heart disease, cancer, accidents, and suicide.
Physicians even in affluent areas should recognize that 20 percent or so of patients have alcoholism. Therefore, it is important to pay attention to physical findings and laboratory tests that are likely to be abnormal in the alcoholic. These include a high-normal or slightly elevated MCV (e.g., 91 fL or higher), gamma-glutamyl transferase (GGT) (30 or more units), serum uric acid [7 mg/dL], carbohydrate-deficient transferrin (CDT) (20 g/L or more), and triglycerides [2.0 mmol/L (180 mg/dL) or more]. Mild and fluctuating levels of hypertension (e.g., 140/95), repeated infections such as pneumonia, and otherwise unexplained cardiac arrhythmias all suggest that the patient might be an alcoholic. Certain specific clinical findings also should raise suspicions, including cancer of the head and neck, esophagus, or cardia of the stomach as well as cirrhosis, unexplained hepatitis, pancreatitis, bilateral parotid gland swelling, and peripheral neuropathy.
Once the likelihood of alcoholism is established, only a few moments are needed to gather the history of alcohol-related life problems. The patient and the spouse or another close family member should be asked about patterns of accidents, marital difficulties, problems on the job, and driving-related difficulties, after which the role played by alcohol should be identified. All physicians should be able to take the time needed to gather such information. In addition, a simple 25-item form to be answered by the patient, the Michigan Alcohol Screening Test (MAST), is available to aid in identifying alcoholics. However, this is only a screening tool, and a careful face-to-face interview is still required for a meaningful diagnosis. The CAGE, which consists of asking about alcohol-related trouble cutting down, being annoyed by criticisms, guilt, or use of an eye-opener, can also be helpful as an initial screen.
After alcoholism is identified, the diagnosis must be shared with the patient. The presenting complaint can be used as an entrée to the alcohol problem. For instance, the patient complaining of insomnia or hypertension could be told that these are clinically important symptoms and that laboratory tests and physical findings indicate that alcohol appears to have contributed to the complaints and is increasing the risk for further medical and psychological problems. The physician should share information about the course of alcoholism and explore possible avenues of attacking the problem. Some patients and family members will benefit from the opportunity to read additional material, and several items are suggested in the reading list.
The process of intervention is rarely accomplished in one session. It is helpful to let patients know that they are responsible for their own actions and that the decision to quit drinking rests with them. For the person who refuses to stop drinking at the first intervention, a logical step is to "keep the door open," establishing future meetings so that help is available as problems escalate. In the meantime the family may benefit from counseling or referral to self-help groups such as Alanon (the Alcoholics Anonymous group for family members) and Alateen (for teenage children of alcoholics).
Those patients who refuse to stop but who want to "cut down" should be reminded that the average alcoholic successfully cuts back scores of times but that sooner or later drinking again escalates. The patient who refuses to stop might be offered a guideline of drinking no more than two drinks [115 mL (4 oz) of wine, 340 mL (12 oz) of beer, or 43 mL (1.5 oz) of 80-proof beverage amounts to one drink] in any 24-h period, but it is very unlikely that this measure will be effective for an extended period. This is another way of keeping the door open in the hope that the patient will return as drinking escalates.
In the presence of ethanol-induced cellular tolerance, any sudden decrease in ethanol intake may lead to symptoms of withdrawal from the CNS-depressant effects. As with most syndromes, most patients do not develop every symptom, and the usual clinical picture is mild, resembling a mild to severe hangover that lasts several days. Features include a tremor of the hands (shakes or jitters); autonomic nervous system dysfunction such as increases in pulse, respiratory rate, and body temperature; insomnia, possibly accompanied by bad dreams; feelings of generalized anxiety or panic attacks; and gastrointestinal upset. Symptoms begin within 5 to 10 h of decreasing ethanol intake (addicted patients are likely to awaken in the morning with some signs of withdrawal), peak in intensity on day 2 or 3, and improve by day 4 or 5. Anxiety, insomnia, and mild levels of autonomic dysfunction may persist for 6 months or more as a protracted abstinence syndrome, which may contribute to the tendency to return to drinking.
Only 5 percent or fewer of alcoholics in withdrawal show severe symptoms such as delirium tremens (DTs), a state of confusion sometimes accompanied by visual, tactile, or auditory hallucinations. The likelihood of developing severe withdrawal symptoms increases with concomitant infections or medical problems, a prior history of withdrawal seizures or DTs, and higher quantity and frequency of drinking. These symptoms disappear as the mental state becomes clearer over a period of several days and are distinct from a temporary alcohol-induced psychotic disorder, which usually occurs with a clear sensorium as described earlier in this chapter.
A small percentage of alcoholics also demonstrate one or two generalized seizures ("rum fits"), usually within 48 h of stopping drinking. These are rarely focal in nature (unless there is underlying neuropathology), and electroencephalographic abnormalities are mild and usually return to normal within several days. There is no evidence that withdrawal seizures represent "latent" epilepsy.
The first and most important step is to perform a thorough physical examination in all alcoholics who are considering stopping drinking. It is necessary to evaluate organ systems likely to be impaired, including a search for evidence of liver failure, gastrointestinal bleeding, cardiac arrhythmia, and glucose or electrolyte imbalance.
The second step in treating withdrawal for even the typical well-nourished alcoholic is to give patients adequate nutrition and rest. All patients should be given oral multiple B vitamins, including 50 to 100 mg of thiamine daily for a week or more. Most patients enter withdrawal with normal levels of body water or mild overhydration, and intravenous fluids should be avoided unless there is evidence of hypotension or a history of recent excessive bleeding, vomiting, or diarrhea. Usually medications can be administered orally.
The third step in treatment is to recognize that the CNS symptoms were caused by rapid removal of the brain-depressant effects of ethanol. Symptoms can be alleviated by administering another CNS depressant and gradually decreasing the levels of the drug over a 3- to 5-day period. While many CNS depressants are effective, the benzodiazepines have the highest margin of safety and are, therefore, the preferred class of drugs in the treatment of alcohol withdrawal. Benzodiazepines with short half-lives are especially useful for patients with serious liver impairment or evidence of preexisting encephalopathy or brain damage. On the other hand, short-half-life benzodiazepines, e.g., oxazepam or lorazepam, result in rapidly changing drug blood levels; administration every 4 h is required to avoid abrupt fluctuations in blood levels that may increase the risk for seizures. Therefore, most clinicians use drugs with longer half-lives, such as diazepam or chlordiazepoxide. The goal is to administer enough drug on day 1 to alleviate most of the symptoms of withdrawal (e.g., the tremor and elevated pulse), and then to decrease the dose by 20 percent on successive days over a period of 3 to 5 days. The approach is flexible; the dose is increased if signs of withdrawal escalate, and the medication is withheld if the patient is sleeping or shows signs of increasing orthostatic hypotension. The average patient requires 25 to 50 mg of chlordiazepoxide or 10 mg of diazepam given orally every 4 to 6 h on the first day.
The most effective treatment of delirium tremens remains controversial. Most clinicians use benzodiazepines, but despite as much as 300 mg or more per day of chlordiazepoxide, a patient might still remain awake and agitated. Since it is probable that the confused, agitated state will persist for 3 to 5 days regardless of the pharmacologic intervention used, drugs are given to control behavior rather than to change the course of the syndrome. Antipsychotic medications such as thioridazine or haloperidol are sometimes used, although they must be prescribed with care because they might lower the seizure threshold. The antipsychotic drugs have no place in the treatment of mild withdrawal symptoms.
The generalized seizures rarely require aggressive pharmacologic intervention beyond that given to the usual patient undergoing withdrawal, i.e., adequate doses of benzodiazepines. There is little evidence that phenytoin is effective in drug-withdrawal seizures, and the risk of seizures usually has passed by the time effective drug levels are reached. The rare patient with status epilepticus can be treated initially with intravenous diazepam. If anticonvulsants are used for alcohol-withdrawal seizures, they should be stopped within 5 to 7 days unless a cause for a persisting seizure disorder is documented.
While alcohol withdrawal is often treated in a hospital, efforts at reducing costs have resulted in experimentation with outpatient detoxification for alcoholics with mild abstinence syndromes. This outpatient approach is appropriate for patients in good physical condition who demonstrate mild signs of withdrawal despite low blood alcohol concentrations and for those without prior history of DTs or withdrawal seizures. Such individuals still require careful physical examination, evaluation of blood tests, and treatment with vitamin supplementation. Benzodiazepines can be given in a 1- to 2-day supply to be administered to the patient by a spouse or other family member four times a day. Patients are asked to return daily for evaluation of vital signs, and to come to the emergency room if signs and symptoms of withdrawal escalate
After completing alcoholic rehabilitation, 60 percent or more of middle-class alcoholics maintain abstinence for at least a year, and many for a lifetime. There is no single best way to rehabilitate the alcoholic, and therapeutic approaches center on general supports that meet commonsense guidelines. Considering the lack of evidence for the superiority of any specific treatment type, it is best to keep interventions as simple, safe, and inexpensive as possible.
Maneuvers in rehabilitation fall into two general categories. First are attempts to help the alcoholic achieve and maintain a high level of motivation toward abstinence. These include educating the patient about alcoholism and teaching the family and/or friends to stop protecting the alcoholic from the problems caused by alcohol. The second series of maneuvers helps the patient to readjust to life without alcohol and to reestablish a functional lifestyle through personal counseling, vocational rehabilitation, family support, and sexual counseling.
There is no convincing evidence that inpatient rehabilitation is always more effective for the average alcoholic than is outpatient care. The decision to hospitalize can be made if (1) the patient has medical problems that are difficult to treat outside a hospital; (2) depression, confusion, or psychosis interferes with outpatient care; (3) the patient has such a severe life crisis that it is difficult to get his or her attention as an outpatient; (4) outpatient treatment has failed; or (5) the patient lives too far from the treatment center. If inpatient care is needed, free-standing treatment programs, units that are divisions of general hospitals, and those in psychiatric hospitals are all equally effective. The characteristics of the patient predict outcome more than any specific attribute of the program.
Whether the treatment begins in an inpatient or an outpatient setting, subsequent outpatient contact should be maintained for a minimum of 6 months and preferably a full year after abstinence is achieved. Counseling with an individual physician or through groups focuses on day-to-day living--emphasizing areas of improved functioning in the absence of alcohol (i.e., why it is a good idea to continue to abstain) and helping the patient to deal with free time without alcohol, develop a nondrinking peer group, and handle stresses on the job without alcohol.
The physician serves an important role in identifying the alcoholic, treating associated medical or psychiatric syndromes, overseeing detoxification, referring the patient to rehabilitation programs, and providing counseling. The physician also must regulate the use of medications during alcoholism rehabilitation. Once acute detoxification is complete (an average of 3 to 5 days), there is no place for hypnotics or antianxiety drugs in the treatment of most alcoholics. The patient has already demonstrated an inability to moderate the use of one brain depressant, alcohol, and is at considerable risk for abusing sleeping pills or antianxiety drugs. Anxiety and insomnia can be treated with behavior modification such as relaxation training, meditation, and exercise or through increased activity in hobbies or religion. For example, regarding insomnia, patients should be reassured that insomnia is normal after alcohol withdrawal and will improve over the subsequent weeks and months. They should then follow a rigid bedtime and awakening schedule and avoid any naps or the use of caffeine in the evenings. The sleep pattern will improve rapidly.
One medication that has been used in alcohol rehabilitation is disulfiram, usually given as 250 mg/d. This drug inhibits aldehyde dehydrogenase, causing very high levels of acetaldehyde to accumulate after alcohol is consumed. The disulfiram-ethanol reaction includes tremor, hypertension or hypotension, nausea and sometimes severe vomiting, and diarrhea. Disulfiram must not be given to persons for whom such a reaction could be dangerous, including patients with portal hypertension, diabetes mellitus, heart disease, or a history of stroke. Unfortunately, there is little convincing evidence from carefully controlled studies that disulfiram is significantly more effective than than placebo. As result, this drug should not be routinely prescribed.
Two medications, naltrexone and acamprosate, are reported to either decrease the amount of alcohol consumed or to shorten the period during which alcohol is used if a relapse occurs. While the mechanisms of action are not understood and the number of subjects on whom data are available is limited for naltrexone, both drugs may have a role in the future in alcohol rehabilitation. In a small uncontrolled 10-week study of 29 patients, naltrexone (50 mg/day) combined with counseling by a primary care provider appeared to reduce drinking behaviors However, more data are required before routine clinical use can be justified.
Finally, an inexpensive, readily available, and dedicated additional support for all alcoholics is available in almost every community. Alcoholics Anonymous is a self-help group of recovering alcoholics (men and women who have stopped drinking, perhaps many years ago) that offers an effective model of abstinence, provides a sober peer group, and makes crisis intervention available when the urge to drink escalates. No matter what type of rehabilitation program is planned, the alcoholic should be offered the option of joining Alcoholics Anonymous.
© 1999 Last updated on March, the 14th, 1999.
En son 14, Mart, 2000'de yenilendi
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