Table of Contents
The term Alcoholism has lost much of its meaning. It lacks scientific precision and is of little relevance. The term ALCOHOL DEPENDENCE is preferred and has been used by the World Health organisation.
Alcohol dependence results in behavioural responses that include :
A compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects. The drinker feels unable to resist the urge to continue drinking as the same amount of his favourite drink does not give him the same psychological effect as before. This is due to tolerance as the body speed up elimination of alcohol and inactivate its effects through the liver and other physiological effects.
To avoid the discomfort of absence of alcohol, the drinker seeks another drink. Tolerance may develop and the person may consume greater amounts to achieve the same psychic state. A person may be dependent on alcohol alone or other drugs.
The continuous alcohol use may lead to physical complications such as liver cirrhosis, seizures or inflamed stomach (gastritis) and psychiatric problems such as delirium tremens, alcoholic psychosis and dementia.
The phrase that a person is "having a problem with drinking" is more acceptable in the early stages of helping the alcohol dependent person. Basically it implies that drinking is out of control either continuously or intermittently. As a result of this the person either causes damage to themselves or other people. This damage may be physical such as the damaging effect of alcohol on his own body or aggression and abuse of others when drunk. The damage may be psychological as the person becomes depressed or suicidal under the influence of alcohol. Socially, alcohol problems cause loss of jobs, domestic aggression and abuse or loss of friends and broken homes.
This implies that there is a physical dependence. Withdrawal of alcohol produces physical symptoms and craving.
This can be defined in terms of drink levels which may cause harm and are above recommended levels.
This can be defined in terms of volume of equivalent absolute alcohol, but it has been customary to use the term UNIT which is approximately equal to 10 mls of absolute alcohol.
^ Beverage ^ Amount ^ Units | BEER | 1 pint | 2 units | STRONG LAGER | 1 pint | 3 units | WINES | 1 bottle - 90 ml | 6 units | WINES | glass - 15 ml | 1- 1.5 units | FORTIFIED WINES | 1 bottle - 125 ml | 15 unit | Sherry, Port, etc.| 1 large glass- 16ml | 2 units | | 1 small glass- 8 ml | 1 unit | SPIRITS Whiskey, Gin, Vodka, Brandy | 1 small glass- 8 ml | 30 units
The Royal College of Physicians, General Practitioners and Psychiatrists have agreed recommended levels.
'''Men should not drink more than 21 Units per week and women not more than 14 Units.'''
A further recommendation is that every person should have at least two drink free days per week.
Where men drink over 50 Units and women over 35 over any period of time there is definite evidence of physical damage. Women achieve higher blood alcohol levels per Unit of alcohol because on average they weigh 20% less than men and their total body fluid is less. There may also be increased tissue susceptibility in women.
Alcohol is rapidly absorbed from an empty stomach reaching peak levels in half an hour. Food delays absorption and flattens the absolute curve. 10 mls (1 Unit) of alcohol can cause a rise in blood alcohol levels between 15 and 20 mgs per 100 ml.
Alcohol is removed from blood and excreted at the rate of about 15 mgs per hour
Average alcohol blood level in mg/100ml # (number of units * absolute alcohol in gm in each unit) - (time in hours * 15mg)
e.g. 12 pints of lager in 4 hours : 1215mg - 415mg # 300 mg/100ml
Alcohol is basically a CNS depressant. Depression of higher functions like inhibitions are the first factors affected giving a sense of inflated self-confidence.
Motor performance is affected very early and has been demonstrated to affect driving skills at levels as low as 30 mgs per 100 ml.
^ Test type ^ England, Wales and Northern Ireland ^ Scotland |Micrograms per 100 millilitres of breath | 35 | 22 | Milligrammes per 100 millilitres of blood | 80 | 50 | Milligrammes per 100 millilitres of urine| 107 | 67
Formerly a number of indirect methods were used to find out how many people were drinking and how much. Such things as mortality statistics from cirrhosis of the liver, and per capita consumption of alcohol were used in complicated calculations. More recently with more open discussion about alcohol consumption surveys gave a more accurate picture of what people drank. In the United Kingdom about 90% of the adult population drink alcohol. The majority in a sensible and enjoyable way or think they do so until proved otherwise by comparing with wider norms. There is evidence that about 30 % of the male population drink more than they ought to over prolonged periods and 20% of men drink more over short periods (the "wild oat" phase of drinking). In women under 10% drink too much over prolonged periods and 20% drink too much over short periods. Clearly with high numbers like that treatment must be from an educational standpoint. Fortunately only relatively few of these will need treatment in the specialist sense.
Surveys have also shown there is a wide variation in drinking patterns throughout the country. This is also reflected in those who are seeking treatment. Nevertheless estimates have been made that between 0.5% and 3% of the population need treatment in the specialist sense. The male to female ratio has been falling and currently stands at about one male to two females. Surveys in general hospitals show that in excess of 20% of hospital beds are taken up with alcohol related diseases.
It has been clear for some time that alcoholism runs in families but it has not been clear if this is genetic or a result of family behaviour patterns. Twin studies have shown that there is a probable genetic factor and specific genetic studies seem to be presenting promising results.
There has been a long search for personality factors. No alcoholic personality has been successfully defined and demonstrated. It is tempting to blame a dependent personality but the evidence is lacking. It is clear that many personality disorders have drinking problems.
There is clear evidence that some races have higher incidence of alcoholism than others. The Irish in whatever country they are living have often been compared with the Jewish community. In certain religions alcohol is taboo but this does not stop drinking problems from arising. It is clear that price, in terms of relative cost, availability and social acceptability of drinking are strong aetological factors. It is clear that certain occupations drink more heavily than others. For example:
a. Those who work with alcohol, e.g. barmen and waiters. b. Those who entertain with alcohol, e.g. company executives, commercial travellers. c. Thosw working in heavy industry, e.g. miners and steelworkers. d. Those working unsocial hours, e.g. armed services, police, night workers, doctors.
Alcohol can produce depression. Most of those depressive factors are through the result of the direct action of alcohol on the body or the problems that have been produced in that patient's life. Some who are depressed may drink excessively as an attempt to relieve their depressive symptoms. The same may be said for anxieties and phobias. We are now seeing higher numbers of schizophrenics who are drinking heavily complicating their condition. The relationship between the personality disorder and heavy drinking has already been mentioned. Alcohol does not only cause sexual problems but there are a whole gamut of sexual problems from dysfunction to paraphilia and frank deviant sexual behaviour that may associated with heavy drinking. Women and, to a lesser extent, men who were sexually abused in childhood may develop sexual problems and drink excessively in order to have some sort of sexual relationships or suppress their desires.
These are short questionnaires which are designed to identify people with a drinking problem by inviting them to answer a series of questions. The most well known are:
M.A.S.T. (Michigan Alcohol Screening Jest)
CAGE C # Cutting down was tried (tried before to cut down his drinking but failed) A # Annoyed by criticism of others for drinking (upset by comments of family about his drinking) G # Guilt feeling over drinking (Feels he drinks too much) E # "Eye opener", i.e. morning drinking is usual. (drinks first thing in the morning)
These questionnaires may have their uses but are no substitute for a good alcohol history.
This can be done with a history of smoking and other social activities. It must be done without embarrassment and in detail first establishing if the patient drinks at all and when this is, so that it is possible to construct a mini-drinking diary for each week so that Units can be added up for each part of the day and for a typical week. Bout drinkers have to be questioned about frequency of drinking bouts and the amount they drink.
M.C.V. (Mean Corpuscular Volume) is increased Abnormal liver function tests [Gamma G.T (Gamma glutamyl transpeptidase) is high due to liver cell damage] Blood alcohol levels help to screen patients and can be used in diagnosis.
Heavy drinkers tend to be unhealthy in a number of non-specific ways, by neglecting their health. Thus they tend to have weight problems and its associated disorders, their diet is poor, smoking is heavy with higher incidences of respiratory and cardio-vascular disease. Life expectation is shortened in this way, to say nothing of specific alcohol related diseases and increased susceptibility to accident and violent attacks.
The majority of alcoholics do not need detoxification, the weekly bout drinker has experience of withdrawal on a regular basis. It is only when there is definite evidence of dependence that detoxification is needed. Outpatient and home detoxification are possible in the majority of cases seen in primary care, but the following basic requirements are needed
Medication must be prescribed on a diminishing scale regime. This must be tailored for the patients needs.
Close supervision is essential, to ensure that instructions are obeyed, and problems are quickly observed and dealt with.
There should be an assessment of physical complications, and reasonable confidence that these will not arise, e.g. epileptic fits.
There should also be an absence of co-presenting psychiatric symptoms, e.g. depression and the danger of suicide attempts.
There should be no clouding of consciousness, confusion or evidence of brain damage.
there should be adequate social support, i.e. somebody with whom the patient has had a healthy relationship at home to supervise him taking medication and report complications. Thus out patient or home detoxification is not ideally suited to those living with fellow drinkers, in an antagonistic relationship, on their own or in bed and breakfast accommodation.
The ideal detoxification medication should sedate without suppressing respiration, have anticonvulsant properties, and not be addictive. There is no drug that fulfils all these properties and many substances have been tried. Long acting benzodiazepines e.g. diazepam and chlordiazepoxide are used. Mild cases may only need five days treatment, but more severe cases may need 10 or more days. Chlormethiazole should not usually be given for home detoxification, but still remains a useful drug.
Development of an individual treatment strategy based on assessment
Primary care which may include brief intervention.
Stabilisation of what has been achieved in primary care.
long-term support to maintain what was achieved.
Relapse prevention. .
Consider the need of residential care.
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