Michael I. Fingerhood
Along with cardiovascular disease and cancer, alcoholism ranks among the top three causes of death and disability in the United States. However, the majority of alcoholics in the United States do not receive treatment for their alcoholism. Additionally, many people have early alcoholism and could recover successfully if diagnosed and treated.
Until recently, alcoholism was widely regarded as a hopeless condition with a poor prognosis for recovery. Yet alcoholism is one of the most treatable of all medical and psychiatric conditions, with a high long-term success rate when a disease model of alcoholism is used in diagnosis and treatment.
Definition of Alcoholism
A useful, broad definition of alcoholism is recurring trouble associated with drinking alcohol. The trouble may occur in one or more of several domains, including interpersonal (e.g., valued relationships, especially within the family), educational, legal, financial, medical, and occupational. Although there are many exceptions, trouble caused by alcoholism usually occurs in that order of progression, so that one's health and job are last to be affected. The trouble may include the physiologic manifestations of dependence or addiction: tolerance (the need for increased amounts of a substance to achieve intoxication or desired effect) and withdrawal symptoms. Characteristics of
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alcoholism include inability to control one's use of alcohol (always present), drinking alone, avoiding situations where alcohol is not available, drinking before going to a party, and continuing to drink alcohol despite occupational, psychosocial, legal or physical problems caused by drinking.
Consensus Definition
In 1992, a multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine issued its definition of alcoholism: “Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic” (1). Unlike previously issued definitions, this one specifically included denial as a key component of the definition of alcoholism.
Alcoholism is classified by the American Psychiatric Association under the broad rubric Substance-Related Use Disorders (2). In its subclassification for these disorders, the American Psychiatric Association has generic criteria for substance abuse (abnormal use, with unwanted consequences) and substance dependence (more intensive abuse patterns or physiologic manifestations of addiction). Chapter 29lists the criteria for these two subclassifications. The National Institute on Alcohol Abuse and Alcoholism defines “at-risk drinking” as more than 14 drinks per week or more than 4 drinks per occasion for men and more than 7 drinks per week or more than 3 drinks per occasion for women (3). Recently, the terms “alcohol use disorder,” “problem drinking,” “hazardous drinking,” and “unhealthy alcohol use” have also been used in the literature. These terms aim to include individuals who do not meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for alcohol abuse or dependence, but may be at increased risk for alcohol-related problems or have had problems such as a driving while intoxicated (DWI). Many of these individuals do not need alcohol treatment, but may benefit from primary care intervention to prevent further consequences from drinking.
Causes
The causes of alcoholism are multifactorial and poorly understood (4,5). A predisposition to alcoholism appears to be inherited by at least half of all alcoholic patients, and there is some evidence that inherited factors are associated with the inability to control use of alcohol (6). Social conditioning, enabling behavior by others close to the individual (see Co-alcoholism), and being a child in a dysfunctional family are important nongenetic factors. For some alcoholic men, another mental disorder (especially antisocial personality disorder, primary abuse of other substances, or an affective disorder) may play a role. For alcoholic women, preexisting mental illness, especially a phobic disorder or major depression, may play a role. Additionally, for elderly alcoholics whose problem began after 50 years of age, the losses and isolation that accompany aging are often associated with the onset of problem drinking (see Special Populations).
Alcoholic Beverages: Content and Metabolism
Alcoholic beverages can be divided into nondistilled (wine and beer) and distilled varieties. The concentration of alcohol (ethanol) in wine ranges from 10% to 22% by volume and is 12% to 14% in most wines. Beer usually contains 4% to 5% alcohol by volume, but beers fermented in the bottle contain a higher percentage of alcohol. The distilled alcoholic beverages—whiskey, brandy, rum, gin, and vodka—contain a higher percentage of alcohol. Alcoholic fermentation ceases when the concentration of alcohol exceeds 15% by volume; consequently, to manufacture more potent beverages, distillation or fortification is necessary. In the United States, “proof” is double the percentage of alcohol by volume; for instance, 90 proof whiskeys contain 45% alcohol by volume. One drink of distilled alcohol (1 fluid oz), one glass of wine (4 oz), and one beer (12 oz) all contain approximately 12 grams of alcohol.
In a 154-pound (70-kg) person, on an empty stomach, one drink of distilled alcohol (usually 1 fluid oz or 30 mL) produces a peak blood alcohol level (BAL) of approximately 25 mg/dL within 30 minutes after ingestion. Approximately 15 mg/dL is metabolized per hour. For example, the alcohol in 120 mL of whiskey would take about 6 hours to be metabolized. The rate of metabolism is higher (in the range of 20 to 25 mg/dL/hour) in an individual with alcohol dependence. A BAL of 100 mg/dL is equivalent to 0.08%, in the units commonly used by law enforcement to indicate driving impairment. To reach a BAL of 300 mg/dL, a 70-kg person typically has to consume 14 to 20 drinks over a few hours.
Epidemiology
Prevalence
In 2003, an estimated 119 million Americans (half of all Americans older than age 12 years) were current drinkers, with 16.1 million Americans (6.8% of population) classified as heavy drinkers (5 or more drinks on the same occasion on at least 5 out of the 30 past days) (7). Additionally,
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13.6% of the population drove under the influence at least once in the 12 months previous to the survey. Binge drinking (consuming 5 or more drinks on 1 occasion) has steadily increased in the United States with an estimated 1.5 billion episodes in 2001 (8). Rates of binge drinking are highest for young adults (age 18 to 25 years), with resultant high rates of motor vehicle accidents in this population.
Mortality and Morbidity
Prospective studies show that alcoholic patients have two to four times higher death rates and much higher rates of medical and psychosocial morbidity than do matched controls (9). The most common causes of early death in alcoholics are cirrhosis of the liver, cancers of the respiratory and gastrointestinal (GI) tracts, accidents, suicide, and ischemic heart disease. Most alcoholics smoke and, in fact, lung cancer is the most common cancer diagnosed in alcoholics (10). Importantly, alcoholic men who achieve long-term abstinence do not differ from nonalcoholic men in mortality rate (11). However, relapse is significantly related to mortality.
Natural History of Alcoholism
The natural history of alcoholism in men has been delineated in retrospective and prospective studies. In Jellinek's retrospective study of alcoholic men (4), the majority of subjects identified multiple phases in the progression of their disease: (a) an initial phase, lasting months to years, in which they used alcohol to relieve tension and developed tolerance to alcohol; (b) a phase in which they experienced blackouts (amnesia for drinking-associated events), increasing preoccupation with getting alcohol, and profound loss of control over use of alcohol; (c) a phase in which there were overt psychological and behavioral consequences (rationalization, grandiosity, aggressive behavior, remorse, efforts to abstain); and (d) a stage characterized by chronic intoxication and serious deterioration of health and psychosocial functioning. In Valliant's more recent prospective study (5), this multiphase course of alcoholism characterized three quarters of men who became alcoholic. Most of the remaining men exhibited abnormal drinking patterns, usually rituals to constrain the uncontrolled drinking that they themselves recognized as abnormal, and had less alcohol-related trouble with family, job, and health. Importantly, in these and other studies of the course of alcoholism, it has been found that periodic abstinence or moderation of use is typical. Although anecdotal information suggests that occasionally a person with what appears to be alcoholism can return to normal drinking, this is very uncommon and is not clinically useful to consider.
Manifestations of Alcoholism
Alcoholism is a protean disease, and it is probably the most common great masquerader today. Table 28.1 lists medical, psychosocial, legal, and other manifestations often associated with alcoholism. Manifestations are ranked in the table according to their strength as diagnostic features, ranging from those that are diagnostic of alcoholism to those that should make one at least consider alcoholism. A number of the most important manifestations of alcoholism are discussed here.
Legal Problems
A history or record of DWI highly suggests alcoholism. In one study of 2,358 consecutive people with DWIs, 63.8% of first-time offenders were found to be alcoholic (12). Of those with two DWI arrests, more than 90% were alcoholic, and of those with three, essentially all were alcoholic. A prison record is also strongly suggestive, because most prison inmates have a history of alcoholism or other chemical dependence. Child and spouse or partner abuse is also highly associated with alcoholism.
Behavioral, Psychiatric, and Neurologic Problems
Accidents and trauma, including burns, are often associated with alcoholism; in the majority of patients with severe trauma, alcohol or other psychoactive drug use can be detected. Among patients with symptoms of chronic mental illness, especially symptoms of depression and anxiety, alcoholism is common. Usually alcoholism is the primary problem in these patients, and treatment of mental symptoms is not successful until the alcoholism is treated.
Alcohol Intoxication
The obvious acute consequence of alcoholism is alcohol intoxication, which usually presents no diagnostic problem. Because this condition is so common, diagnostic errors are made when it is forgotten that “drunken” behavior—often with evidence of recent alcohol use—may be caused by a host of conditions, such as infection, metabolic disturbance, neurologic disease, or other drug toxicity. Because alcoholics are especially prone to many disorders that may be manifested as deranged behavior, they should be examined systematically before a diagnosis of simple drunkenness is made.
Alcohol intoxication may be characterized by one or more of the following: relaxation and sedation, euphoria, impaired coordination, loudness, lowered inhibitions, poor memory and judgment, labile mood, slurred speech, nausea, vomiting, and obtundation (Table 28.2). An initial period of excitement and euphoria is often
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followed by depression and sleep, or possibly coma. The duration and magnitude of the intoxication depend on the amount and the rapidity with which the alcohol was drunk and whether the patient drank on an empty stomach (enhancing the rate of absorption). Tolerance is also a significant factor, because an alcoholic may acquire the capacity to increase the rate of alcohol metabolism. Moreover, alcoholics characteristically develop substantial central tolerance, so that they appear fairly sober at BALs of 150 mg/dL or more. Most nonalcoholic people become intoxicated at levels between 100 and 200 mg/dL, and some at levels as low as 30 mg/dL. Levels greater than 400 mg/dL can be lethal, with death usually resulting from depressed respiration or from aspiration of vomitus.
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TABLE 28.1 Medical, Psychiatric, Legal, and Other Findings Suggestive (unmarked to *) to Highly Suggestive (** to ***) or Diagnostic (****) of Alcoholism |
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Blackouts
Blackouts—amnesia for events that occurred during a period of intoxication—are common. However, 10% to 25% of alcoholics do not have memory blackouts, and some normal drinkers have experienced blackouts after drinking.
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TABLE 28.2 Expected Effects According to Blood Alcohol Level for a Person without Tolerance to Alcohol |
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Alcohol Idiosyncratic Intoxication
Alcohol idiosyncratic intoxication (pathologic intoxication) is an uncommon syndrome characterized by an extreme, often aggressive or violent reaction to drinking alcohol, which is often followed by amnesia for the episode. The behavior is atypical of the person when not drinking. The duration of this condition is brief (hours), and the person returns to his or her normal state as the BAL falls. Temporal lobe epilepsy, sedative-hypnotic use, and malingering should be ruled out.
Alcohol Amnestic Disorder (Korsakoff Psychosis)
Alcohol amnestic disorder (Korsakoff psychosis) is characterized chiefly by short-term memory impairment
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associated with some loss of long-term memory, in the absence of clouded consciousness (or delirium) or general loss of intellectual abilities (dementia). (For definitions and detailed discussions of delirium and dementia, see Chapter 26.) Patients with less advanced forms of this disorder may be substantially impaired, but they may appear superficially to be normal, particularly because they often attempt to minimize their impairment and to confabulate in order to fill in memory gaps.
The amnestic disorder often follows an episode of Wernicke encephalopathy, a syndrome of global confusion, ataxia, and impaired eye movement, caused by thiamine deficiency, which may occur suddenly or gradually over several days. Parenteral thiamine given during an acute episode of Wernicke encephalopathy may prevent the amnestic syndrome. With abstention from alcohol and good nutrition for several months, some patients recover entirely from the alcohol amnestic syndrome. However, many remain grossly impaired and require institutional care.
Dementia Associated with Alcoholism
When more generalized intellectual impairment develops after years of heavy drinking, the diagnosis of dementia associated with alcoholism is appropriate. An estimated 70% of actively drinking chronic alcoholics have some cognitive impairment, as measured by psychological testing. Perhaps 10% of these have dementia that is sufficiently apparent and noticeable without psychological testing. Because even detoxified alcoholics are likely to show some cognitive impairment for a period after cessation of drinking, this diagnosis should not be made unless dementia persists for at least 1 month after drinking has stopped. Other causes of dementia must be excluded (see Chapter 26). All alcoholics with any signs of dementia should be treated with high-dosage thiamine (100 mg/day) and long-term multivitamin therapy. Some improve over months to years of abstinence.
Other Medical Complications
The various deficiency states involved in a diet composed largely of nutritionally empty alcoholic calories (7 calories per gram), as well as the direct toxic actions of alcohol itself, have been implicated in the pathogenesis of many of the medical consequences of alcoholism. These disorders are legion, sparing no body system, and most are related to the quantity and duration of alcohol consumption. Among the more common medical complications of alcoholism are gastritis; fatty liver, hepatitis, or cirrhosis; pancreatitis; cerebellar ataxia; gout; peripheral neuropathy; rhabdomyolysis; hematologic abnormalities (elevated mean corpuscular volume of red blood cells, anemia, thrombocytopenia); hypoglycemia; ketoacidosis; electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, and hypophosphatemia); pulmonary infections suggesting aspiration or impaired defenses (tuberculosis and pneumonia); cancers of the liver, respiratory, and GI tract; atrial fibrillation; cardiomyopathy; hypertension; and trauma. Chronic hypertension is a very common manifestation of alcoholism. Because it often remits within weeks after discontinuation alcohol, it may be the most common reversible cause of hypertension (see Chapter 67).
Because it is both serious and preventable, the fetal alcohol syndrome (FAS) deserves special mention. It is manifested by morphologic abnormalities, low birth weight, and developmental and cognitive impairment. This syndrome is a consequence of alcohol ingestion by the mother during pregnancy. The risk of minor abnormalities (e.g., low birth weight) begins with the consumption of one drink per day; this risk increases with increasingly larger amounts of alcohol consumption. It is prudent to advise women not to drink any alcohol during pregnancy.
Medical Consequences: A Summary View
Almost all of the medical consequences of alcoholism tend to have certain common characteristics:
If the patient continues to consume alcohol, damage involving major organs progresses slowly over the course of a few years, often ending in organ failure. The organs affected by alcohol and the rate of decline in function of these organs varies greatly among patients. Severity of damage is loosely correlated with dosage of alcohol. For the liver, damage is more common in women at any level of alcohol consumption (see Special Populations).
Progression of organic damage occurs no matter what medical or psychological intervention the patient receives, as long as drinking continues. If the patient stops drinking, many of the pathophysiologic processes caused by alcohol reverse rapidly, such as those in the blood and bone marrow (cytopenias), those in the small intestine (malabsorption), hypertension, and fluid and electrolyte imbalance. Other processes do not reverse rapidly with abstinence, but they usually do not progress and often improve over weeks and months. Alcoholic hepatitis, chronic pancreatitis, and cognitive deficits are conditions that tend to improve more gradually.
Screening for and Diagnosing Alcoholism
Overview
Except when a patient presents with overt behavioral or medical evidence of alcoholism (see Table 28.1), the diagnosis of alcoholism requires skillful interviewing and
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careful evaluation of other information. Such an approach is needed for most alcoholics, whose disease is a private problem experienced by them and those who are close to them. In addition to unwanted psychosocial and physiologic consequences of alcoholism, two cardinal features inevitably emerge when one is obtaining information from an alcoholic or others who know the alcoholic: evidence of inability to control the use of alcohol and denial that a significant problem exists.
Persons who are recognized in the early stages of alcoholism may be helped by brief interventions as described in a separate section at the end of this chapter.
Loss of Control
Continuous inability to control the use of alcohol is not always present in alcoholics. Indeed, many can go for periods of a few hours (e.g., at a social gathering) to a few months with apparently normal drinking. Therefore, the absence of overt loss of control for a period of time does not rule out alcoholism. In such patients, the loss of control returns eventually. Additionally, some alcoholic patients describe rituals to constrain their intake because of previous trouble with control (e.g., never having a first drink until after dinner). Nonalcoholic people do not describe drinking in these ways, and such information usually indicates that there is a serious problem. Control of alcohol consumption is always an issue for the alcoholic.
Denial
Denial (i.e., the direct or implied message that there is no problem) is present in almost all actively drinking alcoholics. Denial behavior may be caused by one or more of the following mechanisms: (a) conscious lying (one of the least common mechanisms); (b) classic denial (an adaptive coping response to avoid the shame, lowered self-esteem, and distressing inability to overcome the drinking problem that are experienced by most alcoholics); (c) memory blackout caused by drinking; (d) euphoric recall (the patient remembers only the good times experienced when drinking); (e) the fact that no one points out problems related to drinking; (f) wishful thinking; (g) denial on the part of the family and other close people, including helping professionals; (h) ignorance of what an alcoholic is; (i) toxic effects on information processing and memory; and (j) stigma related to the term alcoholic.
Denial presents in some of the following ways: rationalizations (e.g., “I drink because my work is more than anyone should try to do”), glibness and humor, hostility (“I came to you about my blood pressure and I would appreciate it if we could stay out of my personal life”), comparison of oneself with a “real problem drinker” (“Now see here, I have a lovely family, a job that I enjoy…I have nothing in common with those poor guys who have lost it; those are your alcoholics”), reticence to discuss drinking, and the assertion that other physicians or family members do not perceive a problem with alcohol. An alcoholic patient's denial responses are usually the result of years of complex adapting to dependence on alcohol. This helps explain why these responses may seem to be refractory and may cause much frustration during screening and diagnostic interviewing and during efforts to get the patient to accept the diagnosis and agree to treatment.
Screening for Alcoholism
Because alcoholism is common and because the evidence for it is usually private information that patients do not volunteer, all patients should be screened for this problem. The goal of screening, and of further inquiry when there are positive responses to screening, is to be confident that one has ruled out alcoholism, has detected definite alcoholism, or must continue to consider alcoholism as a possible diagnosis.
There are a number of ways to screen for the cardinal features of alcoholism. The approach outlined in Fig. 28.1 incorporates the four so-called CAGE questions into the interview (13). In this approach, exploratory inquiry about the use of alcoholic beverages follows inquiries about less sensitive habit information, and the inquiry begins with an open-ended question that prompts patients to respond with more than a simple Yes or No or with a quantitative reply (e.g., “a few beers”). In patients who report any current or recent use of alcohol and in those with discomfort, glibness, voluntary reporting of heavy use, or other information suggesting alcoholism (Table 28.1), including that from the patient's medical history, there is increased likelihood that a problem exists (14). In the absence of such clues, all patients who report alcohol use should still complete the followup questions listed in Fig. 28.1 or other questions that focus on similar content.
The approach in Fig. 28.1 is designed to uncover specific data that point to the diagnosis of alcoholism. Lengthier than the CAGE, the Michigan Alcoholism Screening Test (MAST) is a 24-question standardized instrument that has been used extensively for alcoholism screening (Table 28.3) (15). The questions in the MAST may be helpful when one is attempting to uncover occult alcoholism. The questions are best used to gather additional information within the flow of obtaining a history related to drinking, complementing and adding information to positive CAGE answers. Another screening tool, the 10-item Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization (WHO), focuses on alcohol consumption and as such can be regarded as a screening tool for problem drinking (Table 28.4) (16,17). The CAGE questions (Fig. 28.1) have the advantage of being simple to incorporate into an office interview, being phrased in a nonthreatening way, and focusing on several
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features that are present in most patients with alcoholism:
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FIGURE 28.1. A recommended approach to the use of interviewing to screen all patients for alcoholism and problems with alcohol in the family. |
Studies of the CAGE questions have shown that they are sensitive (70% to 90% of alcoholics respond positively to one or more of the questions, and most have at least two positive responses) and specific (80% to 95% of nonalcoholic people respond negatively to all four questions) (18). An additional tool similar to the CAGE, the TWEAK (Table 28.5) was developed and validated for assessing alcohol misuse in pregnant women and may outperform the CAGE in women (19).
The test characteristics of the CAGE questions are superior to those of laboratory tests—gamma-glutamyl transpeptidase (GGT), other liver function tests, and mean corpuscular volume (MCV)—that are often measured in patients with alcoholism (20). However, abnormalities in these specific tests may be helpful in supporting persistent inquiry and in confrontation of the patient with suspected alcoholism.
Screening questions that focus on one common consequence of alcoholism, trauma, may be sensitive—especially the question, “Have you ever been injured after drinking?” A positive response to this question, or a history of unexplained repeated trauma or traffic accidents, may be important in patients whose CAGE responses are equivocal and in those who have few of the social contacts that are implied in the CAGE questions. The latter group includes antisocial younger drinkers, older people, and others who commonly become isolated.
Importantly, the approach in Fig. 28.1 does not include direct inquiry about quantity or frequency of alcohol use. Although quantitative inquiry may be helpful for identifying a patient who is ready to discuss problems associated with drinking, its disadvantages are that it does not focus on inability to control use or on adverse consequences of drinking, there is no gold standard for the cutoff quantity below or above which one can confidently exclude or diagnose alcoholism, and problem drinkers usually underreport the amount and frequency of their drinking.
Diagnosis of Alcoholism
The confident diagnosis of alcoholism requires nonjudgmental exploration of any positive information obtained in screening. This may include asking for clarification (“Can you tell me more about the last time you decided to cut back a bit?” or “Exactly what does she say to annoy you?” and gentle confrontation (“That must have made you feel pretty bad—sounds like the drinking had a lot to do with it”) (21).
At times, a planned interview with a family member or close friend, by telephone or in person, may be needed to make a confident diagnosis of alcoholism. This entails requesting the patient's permission to discuss his or her drinking with another person. Questions to another person regarding the patient's drinking patterns and consequences of the drinking (asking the same questions contained in the CAGE and MAST instruments, such as, “Has your husband ever felt that he ought to cut down on his drinking?”) usually yield abundant evidence for alcoholism when the
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problem is present. An exception may be the relatives of an elderly alcoholic who have little contact with the patient or have tacitly agreed to ignore or deny a frustrating, seemingly hopeless situation. In this instance, educating the family about the disease concept of alcoholism may be necessary before they are willing to describe the patterns and consequences of the patient's drinking.
Through contact initiated by one or more family members, information will be produced that supports the diagnosis of alcoholism. Family members should be encouraged to tell the patient that they have contacted his or her doctor to describe these concerns. Ways in which the family can influence the treatment of the patient and can get help for themselves are described in section on Co-Alcoholism.
In summary, except for the presence of the diagnostic manifestations of alcoholism (Table 28.1), there is no simple way to diagnose alcoholism. When the problem is not overt, skillful interviewing of the patient and evaluation of multiple pieces of information are needed to make this diagnosis. This process may be accomplished at one or two visits or over weeks to months.
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TABLE 28.4 Alcohol Use Disorders Identification Test (AUDIT) Questionnairea |
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General Principles of Treatment
Definition of Successful Treatment
Alcoholism is a highly treatable disease. Successful treatment depends largely on the skills of those who motivate the alcoholic patient to accept the diagnosis, to undergo detoxification, and to enter and adhere to a long-term treatment process. Treatment success can be defined as the achievement of abstinence or progressively longer periods of abstinence from alcohol (and other drugs), with improved life functioning for patients and their families. (A case example is shown in Fig. 28.2.) Factors
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associated with good and poor outcomes after treatment are summarized later (see Prognosis with Treatment). The appropriate terms for describing an alcoholic in recovery are recovered alcoholic (a public or polite term) or recovering alcoholic (a personal or clinical term). The terms ex-, reformed, former, or cured alcoholic are inappropriate. Despite reports that some alcoholics can learn controlled drinking, this goal of treatment has been shown in studies to be unrealistic for most alcoholics and should be avoided.
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TABLE 28.5 The TWEAK Questionnaire |
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FIGURE 28.2. Drinking–sober profile of a 53-year-old factory supervisor who had been abusing alcohol for 15 years. The achievement of longer and longer periods of abstinence is typical of the process of recovery from alcoholism. Hatched areas, drinking; clear areas, abstinence; Tx, came in for treatment after having dropped out of treatment. |
Avoiding a Psychoanalytic Approach
It has been shown repeatedly that treating alcoholics as though their abnormal drinking behavior is secondary to underlying psychopathology is usually unsuccessful and often counter-therapeutic. Insight-oriented or in-depth psychotherapy early in the treatment of alcoholism is therefore contraindicated. By contrast, supportive and directive psychotherapy, using the treatment methods outlined here and focused on the alcoholism as a primary disease, is usually effective in helping the alcoholic patient reach a successful recovery.
Breaking Down Denial and Motivating the Patient
Denial is the major obstacle to having a patient accept the diagnosis of alcoholism and agree to treatment. Three motivational techniques are fundamental for breaking down denial in patients and, if necessary, in their family members: confrontation, showing empathy, and offering hope. These techniques are equally important in one-on-one interviews and in the other paths to treatment that are described later.Confrontation is telling the person what one observes, including that one has diagnosed the disease alcoholism. The patient usually denies the diagnosis and may even get angry. However, with persistent and nonjudgmental confrontation, most patients eventually admit that they have a problem with alcohol. It is important in a confrontation not to argue with the patient but simply to restate the facts.
Statements that convey empathy and offer hope are important in allaying the person's denial, anxiety, anger, and shame. They should be interspersed with confrontational statements. Empathy is conveyed by stating that one recognizes the patient's feelings (“I can see that this is upsetting you”) and by conveying concern (“I am very concerned about you”). Offering hope is crucial. The patient must hear, repeatedly, that there is a way out and that there is relief from the misery and bewilderment of the condition. The way out is through abstinence from alcohol and other psychoactive drugs—one day at a time—and regular use of group treatment, which includes self-help groups and group therapy.
Motivation of the patient is an ongoing process. In a model described by Prochaska and DiClemente (Fig. 28.3), one must first facilitate the patient to move from the state of precontemplation to contemplation. The patient must seriously be ready for change (determination), musttake action (detoxification and treatment) and, finally, must work toward long-term sobriety (maintenance). Unfortunately, because alcoholism is a chronic disease, relapse is a likely part of the cycle (22).
After a confident diagnosis of alcoholism has been made, the objectives of care are to have the patient accept the diagnosis and agree to treatment. Specific aspects of this process are described here, beginning with one-on-one confrontation of the patient.
Confrontation
Using the motivational techniques described previously, one can often persuade an alcoholic patient to accept
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treatment. Several actions are critical in the confrontation of the patient:
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FIGURE 28.3. A stage model of the process of change. (Adapted from Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychother Theory Res Pract 1982;19:276. Reprinted with permission from Miller WR, Jackson KA. Practical psychology for pastors. Englewood Cliffs, NJ: Prentice-Hall, 1985:130 .) |
Figure 28.4 summarizes a recommended approach that includes each of these actions. This approach may be incorporated into the interview at a single visit or into interviews at multiple visits. The term drinking problem may be used early in the discussion, before the patient's feelings regarding alcoholism are known. Even in the most denying and uncooperative patient, naming the diagnosis is useful because it plants a seed that is likely to grow, given time and motivation. One must be directive in confronting a patient with alcoholism. It is important, however, to include questions that give the patient some sense of control during this rather one-sided interaction (see items 3, 5, 7, and 10 in Fig. 28.4). Because most alcoholic patients have negative emotional responses, either overt or private, to being told their diagnosis, it should be assumed that they would not register much of what one says and that brevity, repetition, and directness are essential. Repeated statements of concern, optimism, and support for the person are as important as statements of fact about the disease. Such statements help patients while they are hearing a diagnosis that inevitably brings shame and help convince them that they have a disease for which they are not to blame. To ensure that patients do not conclude that they cannot avoid further drinking because they have a disease, one should tell them that it is their responsibility to seek treatment.
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FIGURE 28.4. A recommended approach for one-on-one confrontation of the patient in whom alcoholism has been diagnosed. |
The first goal of treatment is abstinence from alcohol and other psychoactive drugs. However, it is never sufficient simply to tell the patient to stop drinking. Early in treatment, the patient must accept help in the difficult process of recovery. This help is multidimensional. In addition to regular follow-up by a supportive physician who believes
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the patient can recover, the most important elements are a plan for detoxification, Alcoholics Anonymous or group therapy, and family involvement (see Nonpharmacologic Treatment After Detoxification). Inpatient treatment in a specialized alcoholism treatment facility may be needed. Each of the possible treatment options should be explained to the patient and the family. If the clinician is not familiar with these, an alcoholism counselor should be asked to explain them to the patient. If the patient is in a crisis and not enough time is available during the first visit, a return appointment should be scheduled within a few days or the patient should be immediately referred to a reliable treatment program.
Formal Intervention
All too often, alcoholics with concerned families do not respond to efforts to motivate them to accept treatment. In this situation, the family should be told about the option of using a formal intervention. This consists of a meeting at which people closest to the alcoholic (immediate family members, concerned friends, employer, or other important people) create a crisis that motivates the alcoholic to accept treatment.
The intervention team is composed of as many people as possible who are emotionally important to the alcoholic. Before the actual intervention, this team meets to talk about the alcoholism, to come together in their thinking, and to agree that their purpose is to show the patient in unmistakable terms that there is a problem and that he or she needs treatment. The process is initiated by having each participant put in writing specific dramatic instances of drinking-related incidents that led to anger, fear, disappointment, sadness, embarrassment, or other distress for the team member. The team then rehearses confronting the alcoholic. Each person learns to begin with an expression of concern for the alcoholic, to describe the disturbing event and how it made that person feel, and to name specific measures they will take if the patient does not agree to treatment (e.g., loss of job, no further visits by grandchildren). As part of a formal intervention, arrangements may be made in advance to have the person admitted for alcoholism treatment. Financing of treatment, packing clothes, arranging for absence from work, and other details must all be worked out by the team ahead of time.
Motivating through Employee Assistance Programs
Increasingly, employers have recognized the economic and human costs of alcoholism and have developed employee assistance programs to motivate and assist alcoholics into treatment. Employers threaten to terminate employees who have deteriorating job performance due to alcoholism unless they get treatment and remain in treatment. Physicians asked to write work excuses can often work with employee assistance programs to coerce the denying alcoholic to get appropriate treatment for alcoholism. This approach uses the strong motivation to keep a job as leverage for getting treatment and following through to recovery—leverage the physician alone may not have on the patient. The problem of the impaired professional and the use of measures similar to employee assistance programs are discussed in a later section.
Detoxification
The majority of alcoholics can be detoxified from alcohol by outpatient procedures (23). With the cost of treatment now a major consideration, the decision between inpatient and outpatient detoxification should be based mostly on medical history and severity of alcohol withdrawal symptoms.
Alcohol Withdrawal Symptoms
The diagnosis of alcohol withdrawal requires a history of recent heavy drinking followed by reduced intake or cessation of use, the absence of other conditions that could cause symptoms mimicking withdrawal, and one or more of the four major manifestations of alcohol withdrawal (tremors, seizures, hallucinosis, and delirium tremens) (24). These occur also in other conditions, ranging from withdrawal from other sedative-hypnotic drugs to meningitis (see list of causes of delirium in Chapter 26).
Tremulousness usually begins 8 to 12 hours after the patient's last drink and peaks in 24 to 36 hours. Withdrawal seizures occur within 8 to 24 hours. Withdrawal seizures may occur independent of other manifestations of alcohol withdrawal. Both seizures and tremulousness can occur before the BAL has reached zero.
The alcohol hallucination is almost never the mythical pink elephant. Rather, it is usually one of moving insects, small animals, or threatening voices. In a series of 50 consecutive patients, 58% of their hallucinations were purely visual, 16% were purely auditory, and 26% were mixed (25). In certain patients these hallucinations may not be all negative; that is, the patient becomes used to them and is no longer frightened. Hallucinations may begin up to several days after the patient stops or markedly reduces alcohol use (usually in the first 48 hours). Typically, alcoholic hallucinosis lasts from minutes to days (usually less than 1 week) but in a very small percentage of patients hallucinosis continues for weeks to months or, rarely, as a continuous symptom.
Delirium tremens is a late manifestation of withdrawal, occurring from 48 hours (most common interval) to 14 days (uncommon) after cessation of drinking (26). It may begin after the patient has shown signs of improvement from the early manifestations of withdrawal. Any of the
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symptoms of delirium, described in Chapter 26, may signal the onset of delirium tremens.
At least half of ambulatory alcoholic patients who stop drinking develop none of the four major manifestations of withdrawal. Additional minor symptoms are common. Anorexia, nausea, and sometimes vomiting are present in varying degrees. Tachycardia, systolic hypertension, and paroxysmal diaphoresis also are common. Generalized weakness may be prominent, and tinnitus, hyperacusis, itching, muscle cramps, and mood and sleep disorders are sometimes experienced. The patient often is hyperalert, startles easily, and has difficulty concentrating and usually craves alcohol or other drugs to quiet symptoms.
Selection of Patients for Inpatient versus Outpatient Detoxification
There are a number of indications for referring a withdrawing alcoholic patient for inpatient detoxification (Table 28.6). Inpatient detoxification provides careful 24-hour monitoring and treatment of withdrawal symptoms, evaluation of inter-current medical problems, and removal of patients from the environment that has facilitated their drinking. If medically stable, patients participate in groups (usually Alcoholics Anonymous) and receive individual counseling.
For mildly symptomatic patients with a stable home environment and supportive family and friends, outpatient detoxification supervised at daily visits to a treatment program or physician's office is as effective as inpatient detoxification. Patients may contract to attend an Alcoholics Anonymous meeting daily with a friend or family member. For moderately sick patients, the choice of outpatient versus inpatient detoxification should be based on what programs are available. Some outpatient detoxification programs are intensive, requiring patients to spend entire days being monitored, with patients receiving medication as needed and participating in group counseling but going home to sleep. Other outpatient detoxification programs consist only of brief daily visits.
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TABLE 28.6 Indications for Referring a Withdrawing Alcoholic for Inpatient Detoxification |
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Use of Drugs in Detoxification
A useful tool for making decisions about pharmacologic treatment in the withdrawing alcoholic is the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) (Table 28.7) (27). Pharmacologic therapy is not indicated for a score less than 10. For scores of 10 to 20, clinical judgment should determine the need for pharmacologic treatment. For scores greater than 20, treatment with drugs is indicated and should be administered on either an outpatient or an inpatient basis. For scores of 20 to 40, the assessment can be repeated after administration of a dose of medication; patients without improvement need more intensive monitoring as inpatients. Notably, pulse and blood pressure are not part of the CIWA scale. Although elevations of blood pressure and pulse do occur in alcohol withdrawal, the other signs and symptoms are more reliable in the assessment of severity of withdrawal. Therefore, one should not make a decision about whether to prescribe drugs for alcohol withdrawal based solely on blood pressure and pulse measurements.
Detoxification with the use of orally administered psychoactive drugs appears to be most effective when it is combined with the nonpharmacologic techniques described in the next section and when treatment is given early. The safest and most effective drugs for this purpose are the benzodiazepine sedative-hypnotics (28). All of the benzodiazepines are effective. Diazepam has the advantages of having a rapid onset of action, a longer half-life, and a lower cost. Its long half-life permits loading on the first day; that is, 5 to 10 mg every 1 to 4 hours until severe symptoms dissipate, which will reduce or perhaps eliminate the need for further dosing on subsequent days. Lorazepam (Ativan) does not require hepatic metabolism and is safer in patients with severe liver disease (e.g., prolonged prothrombin time [PT]). Patient response to a dose of benzodiazepine is unpredictable and is not necessarily related to the amount of drinking. Ideally, patients should be monitored for response after initial dosing to make an assessment of indicated dosage and dosing interval. Dosing should be titrated to effect. Essential to management is early recognition of withdrawal, early treatment, frequent monitoring, and continual treatment. Given the decision to use sedative drugs in the detoxification process, one can choose low or high dosages (Table 28.8). Low dosages of sedative-hypnotic drugs may be tried first for most patients. The advantage of low-dose treatment is that the
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patient remains more alert. High dosages of these drugs may be indicated when the low dosage does not suppress or prevent symptoms within the first few hours.
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TABLE 28.8 Characteristics of Benzodiazepines Used Orally in the Treatment of Alcohol Withdrawal |
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The aim of drug treatment is to alleviate the most bothersome symptoms and signs of withdrawal. Symptom-driven therapy, compared to fixed schedule therapy, has been shown to decrease treatment duration and the amount of benzodiazepine used (29). Benzodiazepines should be given in such a manner that withdrawal symptoms are improved without oversedation of the patient. If the patient is being treated as an outpatient, each day's medication should be entrusted to a family member or friend who will be staying with the patient. Most patients need to be medicated for only 24 to 72 hours. Antihypertensive drugs (most notably clonidine and β-blockers) have been used for management of alcohol withdrawal. These drugs effectively alleviate the sympathetic markers of withdrawal (hypertension and tachycardia) but do little for the more severe aspects of withdrawal (seizures and hallucinosis). For this reason, if a patient is so symptomatic that the use of drugs is deemed appropriate, a benzodiazepine should be the drug of choice. Carbamazepine may also be effective in treating patients with mild alcohol withdrawal (30). The prevention of withdrawal seizures is discussed later.
Detoxification without Drugs
Candidates for nonpharmacologic outpatient detoxification should be ambulatory and, except for their chronic alcoholism and acute withdrawal, should be otherwise free from serious chronic illness or acute problems. The primary aim in nonpharmacologic detoxification is to provide a nonthreatening, positive environment for the patient. The patient should be kept ambulatory when possible and given a regular diet. Except when asleep or resting comfortably, the patient should be encouraged to perform purposeful activities, such as carrying out small duties or attending introductory group education and therapy sessions.
Nonpharmacologic therapy can be just as effective as drug therapy in the detoxification of ambulatory patients in uncomplicated cases (31). The advantages of nonpharmacologic detoxification, compared to traditional detoxification with drugs, are that it can be done largely by nonmedical personnel, it is less expensive, and the patient is more likely to remain alert and, consequently, able to participate in treatment. The only routine medication should be vitamins (100 mg of thiamine, 1 mg of folate, and a multivitamin daily). These vitamins should be continued for the first month or more of recovery.
Many communities have established alcoholism facilities that provide a sheltered, supportive environment to care for alcoholics, using a social model for detoxification. Patients are screened and evaluated to detect any obvious medical problems before or shortly after being admitted. Should complications arise, backup hospital/medical support is available. The length of stay varies in each program, from 3 days to more than 30 days. Most social setting programs use Alcoholics Anonymous extensively, and many of the larger programs use techniques used in other alcoholism treatment centers. These centers can be either day treatment or residential facilities.
For detoxification at home without the use of drugs, a reliable family member or other person should be present to observe the patient for at least 2 full days. The physician supervising such detoxification should be in touch with the patient or the family member daily during the 2 to 4 days required for detoxification. The following is a checklist for home detoxification:
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Prevention of Withdrawal Seizures
There is no consensus about whether phenytoin (Dilantin) should be included in the detoxification of patients with a history of withdrawal seizures. It has been shown that phenytoin at a dosage of 300 mg/day for 5 days can prevent most withdrawal seizures, even though therapeutic plasma levels of phenytoin are not reached (32). However, in another study, when patients received an intravenous load of phenytoin or placebo within 6 hours after a first alcohol withdrawal seizure, phenytoin provided no benefit in preventing further seizures (33).
There is evidence that a high-dosage benzodiazepine regimen for withdrawal can prevent seizures (34). Therefore, patients who are significantly symptomatic and are receiving sufficient pharmacologic therapy with a benzodiazepine do not require phenytoin. However, patients who are only mildly symptomatic and have a history of a withdrawal seizure should receive prophylactic phenytoin if they are not going to be treated with a benzodiazepine. This recommendation is based on the fact that a seizure may occur without the presence of any other manifestations of alcohol withdrawal (35).
Nonpharmacologic Treatment after Detoxification
Overview
Treatment consists of motivating the patient, initiating a treatment plan, and providing regular followup. The clinician who initially motivates an alcoholic to accept treatment may elect not to coordinate the overall treatment but to provide a referral elsewhere. For this important referral, one should select a specialist or a program with demonstrated expertise in helping alcoholics recover.
In selecting skilled help, one should look for several characteristics. Effective programs are abstinence-oriented; use Alcoholics Anonymous or group therapy as a mainstay of treatments; avoid the use of psychoactive drugs in long-term treatment; refer the spouse to Al-Anon or family therapy; provide close followup; and avoid insight-oriented psychotherapy, unless indicated later in the course of recovery. The physician who makes the referral should reinforce participation in the treatment program whenever the patient returns for followup.
Alcoholics Anonymous and Group Therapy
Alcoholics and other chemical-dependent people seem to recover best in group treatment settings. Groups effectively break down the denial process and heal the associated guilt and shame through a combination of identification, nonjudgmental acceptance, confrontation, and support. Every alcoholic should be strongly encouraged to attend Alcoholics Anonymous regularly. Studies show that regular Alcoholics Anonymous attendance is strongly correlated with long-term recovery and improved functioning (36). Patients who continue to attend Alcoholics Anonymous after inpatient treatment have improved outcomes (37).
Many patients are reluctant to attend Alcoholics Anonymous or a therapy group. Therefore, when referring a patient, it is important to convey that one is familiar with these programs and has confidence in them. Immediate action, taken while the patient is in the office, may consist of having the patient contact a family member or friend who is active in Alcoholics Anonymous, telephoning the local Alcoholics Anonymous office and having the patient request a contact to take him or her to a convenient Alcoholics Anonymous meeting, or telephoning an alcoholism treatment program and arranging an intake appointment for the patient. The best way for physicians to learn about these programs is to attend one or more Alcoholics Anonymous meetings and, if available, open group therapy meetings. To locate such meetings, one can call the local Alcoholics Anonymous office or look on the Internet at http://www.alcoholics-anonymous.org. Table 28.9 summarizes the Alcoholics Anonymous process.
Psychotherapy
It is commonly thought that all alcoholic patients have a primary and causative underlying psychological problem. If treatment of this condition is successful, the alcoholism is expected to resolve because it is considered to be chiefly a manifestation of the underlying psychological problem. Although this approach may seem theoretically valid, this therapeutic strategy rarely works unless there happens to be a coexisting psychosis. Patients with alcoholism cannot gain insight into aspects of their lives successfully until they have maintained sobriety. Early psychotherapy may impede maintenance of sobriety and trigger relapse. Even in patients with coexisting psychosis, the alcoholism must also be treated. After rapport is established, therefore, the initial effort in psychotherapy should be to work with the patient toward abstinence and regular participation in group treatment.
Ongoing supportive care by the provider, as described in Chapter 20, is useful for reinforcing the patient's understanding of the disease and the recovery process; for monitoring the patient's functioning in important life areas, such as family, job, and interpersonal relations; and for assisting the patient in change and growth.
Discussions with the Spouse or Closest Family Members
As part of the early treatment of an alcoholic patient, the situation should be discussed with the spouse or person
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closest to the patient. Such discussions (which should be conducted without breaking the patient's confidentiality) serve to ensure that the family agrees with the goal of abstinence; explore the spouse's own drinking pattern; discern any special problems occurring in any of the close family members, and educate the spouse about the enabling process. If the family does not change and grow, usually through regular attendance at Al-Anon meetings, it will be more difficult for the patient to recover. Family treatment and the Al-Anon process are described later (see Co-alcoholism).
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TABLE 28.9 The Process of Alcoholics Anonymous |
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Pharmacologic Treatment of Alcohol Dependence
Disulfiram (Antabuse)
Although disulfiram has not been shown to increase duration of sobriety (38), the use of disulfiram to prevent drinking should be considered for some patients. Patients must be in active recovery, including Alcoholics Anonymous and individual or group therapy. Disulfiram should not be used as the focus of treatment but as an adjunct. Because disulfiram is taken daily, it is a constant reminder that one cannot drink safely. For the patient on disulfiram, the decision not to drink has to be made only once a day.
Alcohol is initially oxidized by the hepatic enzyme alcohol dehydrogenase to acetaldehyde, and disulfiram inhibits acetaldehyde oxidation by interfering with aldehyde dehydrogenase. This effect may persist for up to 2 weeks after cessation of disulfiram. The symptoms of the alcohol–disulfiram reaction are related to elevated acetaldehyde; they are usually proportional to the amounts of disulfiram and alcohol ingested. Some people have typical symptoms after drinking as little as 7 mL of alcohol (about half of a drink). A very small percentage of patients seem to be able to drink despite taking disulfiram with no significant symptoms.
The common symptoms of the alcohol–disulfiram reaction usually begins within 10 minutes and includes flushing, throbbing in the head and neck, headaches, anxiety, general discomfort, sweating, and respiratory difficulty. The reaction typically lasts between 30 minutes and several hours.
Patients who are motivated to succeed in recovery and who have experienced relapse or dread the likelihood of relapse are candidates for disulfiram. Table 28.10 summarizes a practical plan that can be used in office practice. This supervised approach is similar in its demands on patients and physicians to the initiation and management of long-term treatment. Patients should carry an identification card that identifies them as taking disulfiram.
Contraindications for the use of disulfiram include a history of hypertension, diabetes, emphysema, seizures, significant liver or renal disease, coronary artery disease (CAD), hypothyroidism, pregnancy, or a history of drinking while taking disulfiram. If alcohol-related liver disease is present, prescribing of disulfiram should be delayed until the levels of serum aspartate aminotransferase (AST) and serum alanine aminotransferase (ALT), two serum markers of liver disease, are less than three times the normal range. Cough syrups and foods (e.g., salad dressings) that name alcohol as an ingredient should be avoided.
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TABLE 28.10 The Suggested Approach to Supervised Use of Disulfiram |
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Naltrexone
Naltrexone (ReVia) is a second drug that is potentially useful as an adjunct to a formal treatment program for individuals with alcohol dependence (39,40). Unlike disulfiram, patients do not get sick if they drink while taking naltrexone. Naltrexone has been shown to reduce alcohol craving and as a result may be particularly useful in preventing relapse in motivated patients (38,41). When patients relapse they tend to drink smaller amounts. There is no data supporting naltrexone assisting in long-term abstinence, as most studies have been small and have followed patients for only 3 to 6 months. A large multicenter study of alcoholic veterans did not find a benefit from using naltrexone over 1 year (42). A recent Cochrane review of the use of naltrexone for alcoholism concluded that the evidence supports the use of naltrexone as a “short-term treatment for alcoholism”(43). Long-acting parenteral depot forms of naltrexone for use in alcohol dependence are available in Europe.
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Naltrexone is an opiate antagonist and therefore cannot be prescribed to patients who are taking opiate analgesics. Furthermore, patients maintained on naltrexone will not obtain pain relief if prescribed an opiate. Naltrexone is well tolerated, with nausea as its main side effect. Naltrexone can be used in combination with disulfiram. Although there is no clear evidence of hepatotoxicity, the makers of naltrexone advise monitoring of liver function tests (initially at monthly intervals and then less frequently). If naltrexone is tolerated and is successful in aiding abstinence, the recommended initial course of treatment is 3 months. Naltrexone does not cause physical dependence and can be stopped at any time without withdrawal symptoms. If a patient is going to have elective surgery, naltrexone should be stopped at least 72 hours beforehand to allow the use of opiate analgesia.
Acamprosate
Acamprosate (Campral, calcium acetyl homotaurinate), the newest drug approved for treatment of alcoholism, was approved for use in the United States in 2004. Compliance is difficult, as acamprosate must be taken as 666 mg (two pills) three times a day. Most studies of acamprosate examine its effectiveness in individuals who have just completed detoxification. Studies of benefit are mixed, but a recent meta-analysis of acamprosate concluded that it is an effective adjuvant therapy for alcoholism and can significantly improve abstinence (44). A study of the combined use of acamprosate and naltrexone for preventing relapse had a high dropout rate limiting the interpretation of its findings (45).
A decision to stop disulfiram, naltrexone, or acamprosate is best made jointly by the physician, the spouse or other close person, the Alcoholics Anonymous sponsor, and the patient. It should be based on the strength of the patient's recovery. Important guidelines in this decision are active Alcoholics Anonymous or group-therapy participation, coping with crises without recourse to drinking, improved family relationships, dissolution of denial, social ease (diminution in social anxiety), growth in self-esteem, and prolonged abstinence.
Psychoactive Drugs
Although many alcoholics have symptoms such as anxiety, insomnia, and tremors that might be helped by sedatives, in actuality these drugs usually interfere with successful recovery. Anxiolytic drugs may have a role in acute detoxification, and major tranquilizers, antidepressants, and lithium have usefulness in treating, respectively, the schizophrenic, the severe protracted depressive, and the manic-depressive alcoholic (as long as these patients are being treated concomitantly for alcoholism). Apart from these situations, psychoactive drugs should not be prescribed for alcoholics. There are many reasons for this recommendation: (a) all sedatives are cross-tolerant with alcohol and thus have a built-in escalation factor; (b) combining sedatives with alcohol is often dangerously synergistic; (c) inability to control consumption, a cardinal feature of alcoholism, occurs with prescribed sedative drugs; (d) memory blackouts may also occur with other sedatives and minor tranquilizers; (e) patients may alter the prescription to obtain excessive quantities of these drugs; (f) prescribing these drugs reinforces psychoactive substance use as a coping mechanism and impairs development of the patient's own coping mechanisms; and (g) the drugs interfere with learning to relate to others in a healthy manner.
FollowUp: Prevention and Management of Relapse
Next to dealing with denial and motivating the patient, followup is the most difficult part of treatment. One reason is that when an alcoholic recovers there may be an early honeymoon period during which the patient feels and looks so good that one is lulled into believing that regular follow-up is unnecessary. However, because it takes 2 to 3 years of appropriate treatment before recovery can be secure, regular followup is indicated.
During the first 6 weeks after stopping drinking, patients need much support and direction, for this is the time when they are most likely to relapse. At least weekly patient contacts are indicated for this time, with a gradually decreasing frequency thereafter. Some of these contacts may be by telephone. Other high-risk times for relapse include special days and occasions, such as vacations, holidays, business trips, birthdays, and anniversaries, and crises, such as separation, divorce, death of a close person, or illness in the family. Other relapse danger times are when a patient stops taking pharmacologic therapy or stops attending Alcoholics Anonymous or group therapy meetings.
“Dry drunks” are often part of the natural history of recovery. This is the name given by recovering alcoholics to the negative emotions and behaviors reminiscent of those that occurred when the patient was drinking. Dry drunks may last from a few hours to several weeks or even months. Treatment is by recognition, education, and alteration of the diet and other current life habits. Dry drunks are often associated with eating poorly. Regular, well-balanced meals should be recommended, and caffeine intake, including coffee, tea, colas, and chocolate, should be markedly decreased or discontinued. Increased attendance at Alcoholics Anonymous or group therapy meetings at this time is very important. Moderation in the patient's work and recreational activities and rest should be advised.
The relapse process generally begins long before the person drinks. It often progresses in the following sequence:
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reactivation of denial, progressive isolation and defensiveness, building a crisis to justify symptom progression, immobilization, confusion and overreaction, depression, loss of control over behavior, recognition of loss of control, and finally relapse to drinking.
Although it should not be telegraphed to the patient, relapse is part of the natural history of successful recovery for most alcoholics, and one should not become discouraged if it happens (Fig. 28.3). Instead, one should immediately recruit the patient back into treatment using the same motivational techniques used initially. Relapse is a time for both patient and therapist to learn about their mistakes and to correct them by strengthening treatment.
Inpatient Rehabilitation
Although controlled studies differ regarding the advantage of inpatient rehabilitation versus outpatient treatment, inpatient rehabilitation for 2 to 6 weeks may be especially helpful for selected patients (46). It is always planned for in advance when a formal intervention is used (see Formal Intervention). Other indications for inpatient rehabilitation are strong denial, especially if it persists in outpatient treatment; unsuccessful or too slow recovery despite adequate outpatient treatment; weak or unavailable support systems; danger to self or others; severe medical, psychiatric, or other problems related to the alcoholism; and patient's desire for inpatient treatment.
Although treatment goals among inpatient rehabilitation programs vary, some of the major goals include breaking down denial, educating about alcoholism, providing an introduction to group treatment (self-help groups and group therapy), learning how to ask for help, learning how to communicate directly and honestly, learning how to enjoy life while abstinent, beginning family restoration, and developing a specific, appropriate, and structured long-term recovery program.
Prognosis with Treatment
A number of factors, described here, are associated with a good or poor prognosis for recovery. Even factors traditionally thought to be major barriers to treatment success—a skid row lifestyle or being an unattached young adult—do not always preclude successful recovery.
Factors Associated with a Good Prognosis
The first of the factors associated with a good prognosis is clinician commitment to facilitating patient motivation. Most patients are only marginally motivated to get well. Patients are ambivalent: A part of them wants to get well, and another part of them wants to continue drinking and stay sick (patients usually do not know what is wrong with them because no one has told them of the diagnosis in an effective way). Such patients have a good chance of getting into recovery if their physician is committed to the treatment of their alcoholism and consistently use the motivational techniques described previously.
The presence of a crisis situation is also a positive prognostic factor if the crisis is used as a motivational tool. The crisis may be the threat of a job loss, family separation or divorce, a DWI charge, a health-related crisis, an organized formal intervention or some other dramatic event. The physician actually precipitates a crisis when the confrontation approach is used (Fig. 28.4). As in that approach, it is critical to act promptly if a situational crisis is to be used effectively to motivate the patient to accept treatment. If exploitation of this crisis does not work, at least a seed has been planted that may eventually yield results. A third factor associated with a good prognosis is appropriate treatment for at least 2 years. Many alcoholics who begin treatment either believe they can do it on their own or return to drinking and drop out of treatment. To recover effectively, most alcoholics need to be with people who are recovering successfully. This favorable environment is found most easily in self-help groups such as Alcoholics Anonymous and in group therapy. Therefore, if patients show any indication of dropping out of treatment, it is important to promptly persuade them against this move.
The prognosis is also better if family, job, health, and cognitive function are intact. The status of family, job, health, and cognitive function usually correlates with how far alcoholism has advanced. Making a diagnosis early in the course of the alcoholism generally portends a better prognosis because each of these aspects of the patient's life tends to be more intact early in the illness. Also, in early illness the patient's and family members’ denial systems and other defense systems tend not to be as strong. If one or more members of the patient's family are receiving treatment for co-alcoholism (see Co-Alcoholism), the prognosis for the patient usually is better.
Additional factors that increase the likelihood of long-relapse occurs and the acceptance by patient and physician of a recovery model that views alcoholism as a physical, mental, and spiritual illness.
Factors Associated with a Poor Prognosis
If the patient has no perceived threat of loss from continued drinking, the prognosis for recovery is generally worse. Factors that may worsen prognosis include: pharmacologic treatment alone, psychoanalytically oriented psychotherapy in the first year of alcoholism treatment, controlled drinking treatment, use of sedatives in long-term
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management, inpatient or outpatient treatment that does not treat alcoholism as a primary illness, and treatment that is too short in duration.
Although many patients who have a continued self-destructive bent do not tend to recover, some do. Often, intensive inpatient alcoholism treatment for 2 months or longer can be helpful for such patients. However, economic restraints most often limit this option. Cognitive impairment or psychosis often makes treatment difficult. However, the presence of these factors alone does not preclude a full attempt at treatment. With abstinence there is often surprising improvement over time.
Acceptance of a derelict status by the patient makes the prognosis virtually hopeless. However, it can be helpful to screen for a potentially reversible derelict status by looking at prior career and duration of dereliction. For example, a person who up until 2 years ago was in a productive profession or trade and is now on skid row has potential for recovery. By contrast, a person who has had no constructive activities for many years usually has less chance for reaching a successful long-term recovery. Patients who have powerful enablers to deny, cover up, and protect them from the consequences of drinking or drug using (see Co-alcoholism) are less likely to make a successful recovery.
Special Populations
Alcoholism in Older Persons
It is estimated that alcoholism is present in 3 to 4 million Americans older than 60 years of age, with prevalence estimates of 2% to 10%. Most elderly alcoholics have not been diagnosed, and even fewer are in treatment (47). This is true despite the fact that the elderly alcoholic is more likely than a younger alcoholic to have seen a physician recently.
The diagnosis of alcoholism can be more difficult in the elderly because they are less likely to face job loss, legal problems, marital problems, or fear of premature death. However, any change in functional status can be an important clue. The CAGE questionnaire, discussed previously, has been validated in a cohort of 323 elderly patients in an outpatient medical practice of an urban university teaching hospital. The sensitivity and specificity were 86% and 78%, respectively, for a score of 1 and 70% and 91%, respectively, for a score of 2. In this population, scores of 2, 3, and 4 yielded positive predictive values of 79%, 82%, and 94%, respectively (48). The CAGE may not be effective in detecting elderly binge drinkers who are at high risk of falling (49). As an adjunct, a geriatric version of the MAST has been developed (Table 28.11) (50).
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TABLE 28.11 Michigan Alcoholism Screening Test—Geriatric Version (MAST-G) |
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Older patients with alcoholism tend to fall into two groups: those with early onset and those with late onset. Two thirds of patients fall into the early onset group. These are patients who have had ongoing alcoholism but may have avoided some of the usual sequelae. They are often hidden, functional alcoholics who, as they lose mobility or cognitive abilities, become unable to function normally. The late-onset patients are likely to have had a recent stressor (i.e., loss of spouse, retirement, a new impairment in activities of daily living). Occasionally, late-onset alcoholism occurs in a previous teetotaler (51). Compared with younger alcoholic patients, the elderly are more likely to be separated, divorced, or widowed and live alone.
Older people are more sensitive to the acute effects of alcohol, with amplification of preexisting deficits. Dysphoria predominates over euphoria. Additionally, there is more likely to be interaction with prescribed drugs.
Once an older patient is confronted and agrees to treatment, there are some aspects of treatment specific to the elderly. The elderly patient who experiences significant alcohol withdrawal is best monitored in an inpatient setting. For patients with mild withdrawal treated at home, family or friends should stay with the patient for at least the first week of abstinence. In addition, home health care, if available, should be considered (see Chapter 9). Once the patient is medically stable, treatment toward continued abstinence should be initiated. Treatment must be specifically tailored for the elderly. Because of decreased mobility and an inability to drive, patients may find Alcoholics Anonymous meetings more difficult to reach. Meetings during the day must be found for elderly patients who are afraid to go out at night. The elderly tend to be more comfortable in smaller groups. These can often be found in meetings that run in a senior center. The senior center can also be a source of activities to fill the new void of free time formerly spent drinking.
Because older adults are often taking many medications and are more likely to have other chronic medical illnesses, disulfiram should generally be avoided. Many elderly alcoholics would benefit from a 30-day stay at an inpatient treatment center. Some centers have recovery programs specifically for the elderly alcoholic. Access to this type of treatment is usually related to insurance status and cost.
Alcoholism in Women
Alcoholism is more likely to go unrecognized in women than in men, yet suicide, trauma, and liver disease are more common in female than in male alcoholics (52,53). Women are also more likely to develop alcohol dependence after a lesser duration of drinking. An additional concern is the pregnancy-related complication of fetal alcohol syndrome, mentioned previously. Alcoholism decreases a woman's average life expectancy by 15 years (54). More than 50 case-controlled studies and 7 meta-analyses have shown a direct relationship between alcohol consumption and breast cancer (55).
Women tend to drink more subtly and covertly. In part, this is related to society's considering drinking in public, especially in a tavern or bar, less acceptable in women than in men. Women often drink at home and those who are unmarried, divorced, or unemployed drink more. Alcoholic women are also more likely to have alcoholic spouses.
The techniques discussed previously should be used to screen, diagnose, and confront women with alcoholism. There are some particular obstacles to treatment. Women are more likely to need provision of childcare while they are in treatment. In addition, alcoholic women tend to have less spousal support than alcoholic men do. There are treatment programs aimed specifically toward women, including women-only meetings of Alcoholics Anonymous. Alcoholic women, who make up only about 30% of Alcoholics Anonymous participants, should generally seek other women to be their sponsors.
The Impaired Physician or Other Professional
The prevalence among physicians of alcoholism and other chemical dependencies is probably similar to that for the general population (56). Each year, a substantial number of physicians are lost to the profession because of chemical dependence or other treatable illnesses, and many more practice despite being seriously troubled or impaired. Numerous professional organizations have implemented programs to address impairment in colleagues, including organizations of physicians, nurses, dentists, pharmacists, psychologists, social workers, lawyers, and others.
Definitions
Impaired professionals may be defined as those who are troubled by personal difficulties to the extent that they cannot (a) offer reasonable patient care, (b) effectively help others through interpersonal skills, or (c) maintain skills by continuing education. Impairment is also characterized by denial. Intervention with appropriate treatment as soon as alcoholism is recognized is a major goal of the impaired physician movement.
Recognition and Management
The manifestations, symptoms, or signs of impairment from alcoholism or other chemical dependence among professionals are the same as those seen in nonprofessionals. When one is concerned about impairment in a colleague, it is advisable to contact one or more close associates of that colleague to confirm the impairment. Likely reasons for the impairment may be uncovered by this discreet inquiry, and often alcoholism or another chemical
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dependency is the underlying problem. Persuasion of an impaired physician to accept the existence of a problem and agree to rehabilitation can be attempted by a concerned colleague. Such efforts are likely to be met with intense denial. A second approach is to use the state's physician rehabilitation committee. Each state medical society has a committee and maintains telephone access for confidential reporting of impaired physicians. Subcommittees undertake verification of the problem, followed by confrontation of the troubled physician, similar to the formal intervention technique described earlier in this chapter. The goal of this process is to rehabilitate the physician, usually through intensive treatment in a residential facility.
Brief Intervention for Nondependent Drinkers
Brief interventions are time-limited sessions provided by primary care providers that focus on reducing alcohol use in the nondependent drinker. Many targeted people may be in the early stages of alcoholism, having not yet lost control of their drinking. The brief intervention procedures used in studies vary, but none involve more than six contacts. No outside referrals are made, but written materials are often helpful. Typical followup sessions are usually 15 minutes long. Brief interventions have been found to be effective in reducing alcohol consumption (or achieving treatment referral) in problem drinkers in the primary care setting (57,58). Even a single brief 5- to 10-minute intervention may have impact (59). This further illustrates the importance of addressing alcohol use in all patients, even those who are not alcoholic, because problem drinking, independent of alcohol dependence, plays an enormous role in contributing to trauma, especially automobile accidents.
The brief intervention process consists of assessing alcohol use, giving feedback, contracting and goal setting, arriving at a strategy for behavior modification, and providing a plan for followup. There must be an emphasis on personal responsibility for change and clear advice to change. Therapeutic empathy describes the recommended counseling style. Typically, the goal of brief intervention is not abstinence. Therefore, patients must receive followup assessments to confirm that they are problem drinkers and not alcoholics.
The approach to brief intervention parallels the approach previously mentioned for confronting the patient with alcoholism. Six essential elements should be included: (a) feedback of personal risk (patient-focused review of the evidence for existing or potential risk related to drinking), (b) emphasis on personal responsibility for change (empowering the patient to take control of the decision for change), (c) clearadvice for change (“Based on all we have discussed, you need to make a change”), (d) offering a menu of alternative options (“Here's some ways you can make a change”), (e) therapeutic empathy as an innate part of the intervention (“I know this may be difficult”), and (f) enhancement of patient self-efficacy (“This is not hopeless; with change, things will get better for you”). The mnemonic FRAMES may help remember the six elements. Chapter 4 describes in detail the concepts that underlie these behavior modification techniques.
Co-alcoholism (Co-dependence)
Co-alcoholism can be defined as ill health or maladaptive, problematic, or dysfunctional behavior that is associated with living with, working with, treating, or otherwise being close to a person with alcoholism. Co-alcoholism is a specific example of the more general phenomenon of codependence (i.e., suffering or dysfunction associated with or caused by focusing on the needs or behaviors of others). Children who grow up in a family dominated by alcoholism can experience varied long-term behavioral and psychologic effects, and may benefit from group or individual therapy, either as children or adults (Adult Children of Alcoholics).
Co-alcoholism affects not only individuals and families but also helping professionals, communities, businesses, other institutions, and even whole societies. Its signs and symptoms range from passive acceptance and absence of overt problems to the following range of manifestations:
In People Close to an Alcoholic
In Helping Professionals
In Society at Large
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Co-Alcoholism in the Individual
The following is a typical case history of co-alcoholism in an individual.
Case Study
A 38-year-old married woman presented with recurring episodes of upper abdominal pain of about 4 years’ duration. During that time she had been evaluated by two internists and had been hospitalized once. After extensive evaluations, the working diagnosis was functional abdominal pain. She was treated with antispasmodics and sedatives but there was no substantial improvement. The pain occurred almost every day. On a followup visit 6 months later, the patient said that a friend had suggested that she attend the self-help group Al-Anon because her husband's drinking had been bothering her for at least 5 years. The patient reported that after she attended 12 Al-Anon meetings over 3 months, her abdominal pain gradually abated. On followup 2 years later, she had continued to attend Al-Anon and the symptoms had not recurred. In the meantime, the patient's husband had continued to drink.
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This case study illustrates a common manifestation of co-alcoholism: a psychosomatic illness that resolved after the patient recognized an alcohol problem in the family and attended Al-Anon regularly.
Recognition and Treatment of the Co-Alcoholic Patient
When a patient has unexplained somatic or psychological symptoms, it is helpful to ask whether the patient has ever been concerned about the drinking (or drug use) of anyone close to him or her. If the answer is Yes, the patient should be asked to describe the problem. If the patient is vague or doubtful, one can administer some or all of the questions in the Family Drinking Survey shown in Table 28.12. One can also ask the possible co-alcoholic to answer CAGE questions (Fig. 28.1) or the questions on the MAST (Table 28.3) as though they were addressed to, and answered honestly by, the potentially alcoholic person to whom he or she is close. A positive score on one of these is a strong indication of co-alcoholism.
Initially, the psychological and behavioral adjustments of the co-alcoholic are normal responses to an abnormal situation. However, these adaptive responses eventually lead to the person's becoming dysfunctional. Co-alcoholism, like alcoholism, is chronic and progressive; it is characterized by denial, ill health, and/or maladaptive behavior and by a lack of knowledge about alcoholism.
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TABLE 28.13 The Al-Anon Process |
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The major strategies in treating a patient with co-alcoholism are remarkably similar to those for treating the alcoholic:
Co-Alcoholism in the Helping Professions
Co-alcoholism includes behavior on the part of professionals that enables alcoholics to remain enmeshed in their disease. Enabling behavior often coexists with otherwise excellent clinical skills. Some questions (Table 28.14) are useful for identifying the various ways in which enabling may occur in the context of medical practice. Societal norms (including one's own approach to the use of alcohol or other drugs), plus a lack of awareness of modern
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approaches to diagnosis, motivation, and treatment of the alcoholic, are probably the major reasons for co-alcoholism in helping professionals. Several steps are recommended for the professional who wishes to cease being an enabler:
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TABLE 28.14 Questions to Identify Enabling Behaviors in Health Professionalsa |
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Domestic Violence
Domestic violence is present in all demographic and socioeconomic strata. It is especially prevalent in women whose partners abuse alcohol or other drugs and in women who themselves abuse substances. It is estimated that 75% of wives of alcoholics have been threatened and 45% have been assaulted by their alcoholic partners (60). Domestic violence has been defined by the American Medical Association (AMA) (see http://www.hopkinsbayview.org/PAMreferences) as an ongoing debilitating experience of physical, psychological, or sexual abuse in the home, associated with increased isolation from the outside world and limited personal freedom and accessibility to resources.
In the United States, it is estimated that 2 million women are victims of domestic violence each year and that more than 12 million will be abused at some time during their lives. Most of these women never seek help from health care providers for the consequences of domestic violence. However, studies demonstrate a relationship between domestic violence and medical and psychiatric illness.
Brief screening for domestic violence should be incorporated into the medical interview of all women. Because some women may not initially recognize themselves as victims of domestic violence, questioning should be specific (Table 28.15). The issue should be dealt with sensitively, validating the difficulty most women have in discussing the
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issue. The patient may be reluctant to disclose information because of shame, humiliation, low self-esteem, or fear of retaliation by the perpetrator. Some women may also believe that they deserve the abuse and do not deserve help or that they need to protect their partner, who is often their only source of affection and support. There may also be a belief on the part of the victim that the medical provider will not understand the problem or will not believe her.
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TABLE 28.15 A Recommended Approach to the Use of Interviewing to Screen Patients for Domestic Violence |
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TABLE 28.16 Clinical Signs and Symptoms Suggestive of Domestic Violence |
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In addition to screening, certain patient problems should alert the practitioner to the possibility of domestic violence (Table 28.16). Problems may range from direct evidence of physical trauma (contusions, abrasions, broken bones) to nonspecific complaints of fatigue and difficulty concentrating. The screening information and medical history related to domestic violence must be well documented in the medical record, because they provide evidence that may be used in a legal case. The record should include detailed descriptions of any injuries and, if possible, photographs of injuries sustained.
Once evidence of abuse is obtained, one must validate the seriousness of the situation to the patient. This must occur even if the patient is not yet ready to leave the abusive spouse. In addition, the immediate safety of the woman should be assessed. Unfortunately, the level of severity of past violence may not be a predictor of the severity of future violence. If safety is in question, the woman (and her children) should be advised to stay with family or friends, or at a shelter that specializes in caring for abused women and their families. Medical attention may also be needed for abused children in the household.
Often, the patient resists taking action. One should continue to show concern and work to motivate the patient toward change. Once the patient has agreed to take action, local community resources that can provide support, safety, and advocacy must be accessed. The National Domestic Violence Hotline (1-800-799-7233) is a 24-hour service that helps women find a safe place to stay in their community. At times, psychiatric or substance abuse referral may also be appropriate.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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