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Alcohol Use, Abuse and Rehabilitation

By Dr. Kedar Karki

Definition : Alcoholism is an illness marked by consumption of alcoholic beverages at a level that interferes with physical or mental health, and social, family or occupational responsibilities. People with alcohol dependence consume the most severe amount of alcohol to achieve intoxication or the desired effect, and exhibit withdrawal symptoms when alcohol is discontinued or intake is decreased. They also spend a great deal of time drinking alcohol and obtaining it. Alcohol abusers are "problem drinkers". That is they may have legal problems, such as drinking and driving or binge drinking (drinking six or more drinks on one occasion). People who are dependent on or abuse alcohol return to its use despite evidence of physical or psychological problems, though those with dependence have more severe problems and a greater compulsion to drink. The alternative name for alcohol dependence is the alcohol abuse.

Causes And Risks

Alcoholism is a type of drug addiction. There is both physical and psychological dependence associated with this addiction. Physical dependence reveals itself through withdrawal symptoms when alcohol intake is interrupted, tolerance to the effects of alcohol, and evidence of alcohol-associated illnesses. Alcohol affects the central nervous system as a depressant, resulting in a decrease of activity, anxiety, tension, and inhibitions. Even a few drinks can result in behavioral changes, a slowing in motor performance, and a decrease in the ability to think clearly. Concentration and judgment become impaired. In excessive amounts, intoxication may result.

Alcohol also affects other body systems. Irritation of the gastrointestinal tract can occur with erosion of the lining of the esophagus and stomach causing nausea and vomiting, and possibly even bleeding. Vitamins are not absorbed properly, which can lead to nutritional deficiencies with the long-term use of alcohol. Lever disease, called alcoholic hepatitis, may also cause cardiomyopathy. Sexual dysfunction can also occur, causing erectile dysfunction in men and cessation of menstruation in women. Alcohol affects the nervous system and can result in neuropathy and dementia. Chronic alcohol use also increases the risk of cancer of the larynx, esophagus, liver, and colon. Alcohol consumption during pregnancy can cause severe birth defects. The most serious is fetal alcohol syndrome, which may result in mental retardation and behavior problems; a milder form of the condition, which can still cause lifelong impairment is called fetal alcohol affects.

The social consequences of problem drinking and alcohol dependence can be as serious as the medical problems. People who abuse or are dependent on alcohol have a higher incidence of unemployment, domestic violence, and problems with the law. About half of all traffic fatalities are related to alcohol use.

The development of dependence on alcohol may occur over a period of years, following a relatively consistent pattern of progression. At first, a tolerance of alcohol develops. This results in a person being able to consume a greater quantity of alcohol before its adverse effects are noticed. Memory lapse ("black outs") relating to drinking episodes may follow tolerance. Then people may lose control over drinking and find it difficult or impossible to stop if they try. The most severe drinking behavior includes prolonged binges of drinking with associated mental or physical complications. Some people are able to gain control over their dependence in earlier phases before a total lack of control occurs- the problem is no one knows which heavy drinkers will be able to regain control and which will not.

Withdrawal symptoms develop because the brain has physically adapted to the presence of alcohol and cannot function adequately in the absence of the drug. Symptoms of withdrawal may include elevated temperature, increased blood pressure, rapid heart rate, restlessness, anxiety psychosis, seizures, and really even death.

There is no known common cause of alcoholism; however, several factors may play a role on its development. A person who has an alcoholic parent is more likely to become an alcoholic than a person without alcoholism in the immediate family. Research suggests that certain genes may increase the risk of alcoholism but which genes or how they exert their influence is controversial. Psychological factors may include a need for relief of anxiety, ongoing depression, unresolved conflict within relationships, or low self esteem. Social facilities include availability of alcohol, social acceptance of the use of alcohol, peer pressure, and stressful lifestyles.

The incidence of alcohol intake and related problems is increasing. Data from many sources indicate that about 15% of the population in the United States are "problem drinkers", and approximately 5% to 10% of male drinkers and 3% to 5% of female drinkers could be diagnosed as alcohol dependent (12.5 million people).

Prevention

Educational programs and medical advice about alcohol abuse have been successful in decreasing alcohol abuse and its associated problems. Alcohol dependency requires more intensive management. It is advised that women have no more than one drink per day and men no more than two drinks per day. One drink is defined as a 12-ounce bottle of beer; a 5-ounce glass of wine; or a 1 ?-ounce shot of liquor.

The following questions are used by the National Institute on Alcohol Abuse and Alcoholism to screen for alcohol abuse/dependence:

· Have you felt that you should cut down on your drinking?

· Do you ever drive when drinking?

· Is someone on your family concerned about your drinking?

· Have you ever had any blackouts after drinking?

· Have you ever been absent from work or lost a job because of drinking?

· Do you have to drink more than before to achieve intoxication or the desired effect (to screen for tolerance)?

Some of the symptoms associated with alcoholism include

· Solitary drinking

· Making excuses to drink

· Need for daily or frequent use of alcohol for adequate function

· Lack of control over drinking, with inability to discontinue or reduce alcohol intake

· Episodes of violence associated with drinking

· Secretive behavior to hide alcohol related behavior

· Hostility when confronted about drinking

· Neglect of food intake

· Neglect of physical appearance

· Nausea and vomiting

· Shaking in the morning

· Abdominal pain

· Numbness and tingling

· Confusion

Note: Symptoms may vary

Alcohol withdrawal symptoms may vary from mild to severe

· Rapid heart rate and sweating

· Restlessness or agitation

· Loss of appetite, nausea or vomiting

· Confusion or hallucinations

· Tremors and seizures

Signs And Tests

All physicians should ask their patients about their drinking. A history may be obtained from family if the affected person is unwilling or unable to answer questions. A physical examination is performed to identify physical problems related to alcohol use.

· A toxicology screen or blood alcohol level confirms recent alcohol ingestion (which does no necessarily confirm alcoholism).

· Liver function tests can be elevated. GGPT (glutaryl transaminase) is often elevated more than other liver function tests.

· Corpuscular volume or size of the red blood cell.

· Sometimes serum magnesium, uric acid, total protein, and folate tests are abnormal.

Treatment

Many people with alcohol problems don't recognize when their drinking gets out of hand.

In the past, treatment provider believed that alcoholics should be "confronted" about "denial" of their drinking problems, but now research has shown that compassionate and empathetic counseling is more effective.

Three general steps are involved once the disorder has been diagnosed: detoxification, intervention, and rehabilitation. Research finds that traditional confrontational where family members or the employer surprises the alcoholic and threaten consequences if treatment is not begun is *not* effective. Studies find that more people enter treatment if their family members or employers are honest with them about their conches and gradually help them to see for themselves that drinking is a problem by showing it is preventing them from reaching their own goals.

Once the problem has been recognized, total abstinence from alcohol is required for those who are dependent; for those who are "Problem drinkers," moderation may be successful. Since many alcoholics initially refuse to believe that their drinking is out of control, a trial of moderation can often be an effective way to deal with the problem—if it succeeds, the problem is solved; if not, the person is usually ready to try abstinence. Because alcoholism affects the people closely related to the alcoholic person, treatment for family members through counseling is often necessary.

Detoxification is the first phase of treatment. Alcohol can be withdrawn under a controlled, supervised setting. Tranquilizers and sedatives are often prescribed to control alcohol withdrawal symptoms. Detoxification usually takes 4 to 7 days. Examination for other medical problems is necessary, for example, live and blood-clotting problems are common. Acute withdrawal symptom of alcohol may occur, such as delirium tremens, which could be fatal. Depression or other underlying mood disorders should be treated. Often, alcohol abuse develops from efforts to self-treating illness.

Alcohol recovery or rehabilitation programs supports the affected person after detoxification to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation caters are recovering alcoholics who serve as role models. Programs can be either inpatient, with the patient residing in the facility during the treatment, or outpatient, with the patient attending the program while they reside at home.

Medications are sometimes prescribed to prevent relapses. These medications should not be given during pregnancy.

Prognosis

Alcoholism is a major social, economic, and public health problem. Alcohol is involved in more than half of all accidental deaths and almost half of all traffic fatalities. A high percentage of suicide involves the use of alcohol in combination with other substances. Additional deaths are related to the long-term medical complications associated with the disease. Only 15% of those with alcohol dependence seek treatment for this disease. Relapse after treatment is common so it is important to maintain support systems in order to cope with any slips.

Complications

* Acute pancreatitis and chronic pancretitis

* Alcoholic cardiomyopathy

* Alcoholic neuropathy

* Bleeding esophageal varices

* Cerebellar degeneration

* Cirrhosis of the liver

* Complicated alcohol abstinence (delirium terms )

* Depression

* Erectile dysfunction

* Fetal alcohol syndrome in the offspring of alcoholic women

* High blood pressure

* Increased incidence of cancer

* Insomnia

* Nutritional deficiencies

* Suicide

* Wrinkle- Korsakoff syndrome

Use of Alcohol

1. Drinks less than two glasses of alcohol daily, and does not exceed a three drink peek on any drinking occasion.

2. Over time the same amount of alcohol needed to get high.

3. Drinking does not interfere with work, social life, hobbies or health. Punctuality in work and alcohol. Deadlines met. No convictions for drunken driving. No related health problems. Recognizes alcohol as a potent drug. Knows family history and any increased risks.

4. Ability to stop drinking for periods of time to let the body recover, detoxify and avoid dependence. Have healthy role models and protective cultural rituals.

5. No hangovers or withdrawal symptoms.

6. Drinks for positive reason, to celebrate, share and communicate not to relieve pain, forget problems or overcome fears.

(Dr. Karki is M.V. St. Preventive Medicine. He is currently based in New Delhi)