Table of Contents

Alcoholism

Alcoholism and Alcohol Dependence

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 SYNDROME

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.

Withdrawal 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 PROBLEM DRINKER

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.

ALCOHOL ADDICTION

This implies that there is a physical dependence. Withdrawal of alcohol produces physical symptoms and craving.

HEAVY DRINKING

This can be defined in terms of drink levels which may cause harm and are above recommended levels.

AMOUNTS OF ALCOHOL CONSUMED

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.

ALCOHOL CONTENT OF SOME DRINKS

  • 1 pint # 250 ml
  • 1 wine bottle # 90 ml
  • 1 glass # 15 ml
  • 1 small glass # 8 ml
  • 1 spirit bottle # 125 ml

^ 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.

BLOOD ALCOHOL LEVELS

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

EPIDEMIOLOGY

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.

AETIOLOGY

GENETIC FACTOR

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.

PERSONALITY

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.

CULTURAL AND ENVIRONMENTAL FACTOR

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.

PSYCHIATRIC DISORDERS.

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.

DIAGNOSIS

SCREENING TESTS (QUESTIONNAIRES)

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:

  1. M.A.S.T. (Michigan Alcohol Screening Jest)

  2. 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.

TAKING AN 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.

LABORATORY SCREENING TESTS

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.

ALCOHOL RELATED DISABILITIES

A) Physical Disabilities

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.

  • Blood Disorders :
    • Alcoholism is the most common cause of macrocytosis (increase in the size of red blood cells measured as raised MCV [mean cell volume) and in the absence of other specific causes is almost diagnostic of alcoholism. Thrombocytopenia (reduced number of blood platlets) and anaemia may also occur.
  • Liver Disease :
    • Acoholic hepatitis progresses into fatty infiltration (both of these are reversible if drinking is stopped), but prolonged heavy drinking can lead to alcoholic cirrhosis with signs of liver disease, acute hepato-encenhalopathy (brain is affected due to failure of the liver to remove bodt toxins) and hepatoma (liver tumour) may be terminal events. Diagnosis of each stage is made on clinical and biochemical grounds.
  • Gastritis :
    • This is a common complication of alcohol abuse and can lead to acute gastric erosion. The incidence Peptic ulceration is doubled in alcoholics.
  • Pancreatitis - both acute and chronic may be associated with alcoholism.
  • Neurological Disorders :
    • The most common is epilepsy of late onset (over 25 years of age). This may be the result of alcoholic withdrawal or can be due to brain damage.
  • Peripheral neuropathy is probably due to thiamine deficiency (Dry Beriberi) and to some extent may be dependent on the nutritious state of the patient.
    • Both Wernicke's Encephalopathy with evidence of cranial nerve damage and Korsakoff'syndrome with evidence of global brain dysfunction may accrue together.
    • Over time with abstinence from alcohol and high doses of thiamine some cases may well gradually recover while others remain static and permanently disabled. Cerebellar degeneration may be seen in chronic alcoholism.
    1. Heart Disease.
    2. Alcoholic cardiomyopathy is probably the other part of thiamine deficiency (Wet Beriberi). Arrhythmias may also be more commonly seen in heavy drinkers.

B) Psychological Disorders

  • Anxiety
    • Anxiety may not only be a cause to start driniking heavily. The consumption of alcohol to a certain extent may cover anxiety symptoms resulting in an increased consumption of alcohol to alleviate anxiety. As the effects of alcohol begins to wear off so more pronounced rebound anxiety becomes apparent. Alcohol may also be associated with phobic disorders, especially phobia where attempts have been made to suppress the specific anxiety with alcohol.
  • Depression
    • Alcohol is a CNS depressant and can in itself produce depressing effects. This says nothing of the social problems, deterioration in relationships and general ill-health that can produce reactive depressing effects. Depression and anxiety may be seen in the wives of alcoholics.
  • Attempted Suicide and Suicide
    • 16% of females who attempt suicide are heavy drinkers but of males who commit suicide 40% are heavy drinkers. 25% of alcoholics below the age of 40 make suicide attempts. Alcoholics have a high suicide rate (80 times the general population). One third to one half of all suicides go through a heavy drinking phase before killing themselves.
  • Schizophrenia
    • A type of schizophrenia may be precipitated and seen only when a patient is in a heavy drinking bout. More schizophrenics are now being seen with drinking problems and it is estimated that 17% of male schizohrenics have drinking 'problems.
  • Personality Deterioration
    • Many alcoholics have personality problems before their drinking becomes heavy. It is difficult to qualify how much is due to alcoholism.
  • Morbid jealousy
    • Alcohol is one of the chief precipitants of this disorder.
  • Delirium Tremens
    • This is really a toxic confusional state which can occur after hours of withdrawal from alcohol. It is characterised by visual hallucinations, delusions and may be accompanied by gross autonomic disturbance, including tachycardia, hypertension and even pyrexia. There may be hypoglycaemia and electrolyte disturbance including hypomagnesaemia. Potassium depletion is dangerous in dehydration. All this may be seen in a patient with marked anxiety, tremor and confusion. Delirium Tremens is a dangerous condition and mortalities of 20-30% used to be reported before good supportive treatment was given. There is always the danger that the confusional state is partly due to a respiratory or urinar tract infection, other infections are also possible. Diagnosis of that physical condition and its management is made much more difficult due to the patients confused and restless state.
  • Amnesia (Palimpsests)
    • This may just be due to high blood alcohol levels which cause impairment of consciousness but prolonged periods of amnesia may accrue which may cover a whole drinking bout and do not reflect persistently high blood alcohol levels. Other mechanisms are clearly responsible. Alcoholics call these episodes "black outs" but there must be a distinction from an amnesic episode and an epileptic fit. Alcoholic Amnesia is no defence in law but frequent attempts will be made by patients and even their solicitors to angle a psychiatric court report in this direction.
  • Intellectual impairment
    • There is now both psychological and CT Scan evidence that alcoholism can produce reduced cognitive capacity. There is a remarkable improvement in some patients with prolonged abstinence.
  • Sexual Problems
    • Classically, alcoholism produces erectile dysfunction in males and once this is fully developed may not improve with abstinence. This is to be distinguished from inability to get a good erection with drink - "brewers droop".
    • Alcohol may remove sexual inhibitions and can initially improve sexual performance of both males and females but as a long term effect causes problems in both sexes.

C) Social Problems

  • Family Problems
    • There is no doubt that alcoholism has a disastrous effect on marriage. Up to 10% of alcoholics are divorced or separated Up to 25% are not married by the age of 40. Marital violence is frequently precipitated by heavy drinking. Violence and neglect of children may also be seen in heavy drinking families. Threatened divorce is a frequent reason for seeking treatment.
  • Employment Problems
    • Heavy drinking is one of the principle causes of work absenteeism. Resignation or dismissal is a frequent sequel. A descending spiral of work record may be seen with inferior jobs being accepted. Dismissal, or threat of dismissal, is a frequent reason for seeking treatment.
  • Financial Problems
    • It is amazing the amount of money alcoholics can get through and the debts they can run up, to say nothing of the family deprivation this causes.
  • Accommodation Problems
    • This readily follows dismissal from work, family problems, separation and financial difficulties. Alternatively, alcoholics may be seen living in a family situation where they have completely lost their respect, dignity and role where only financial restraints and stubbornness prevents them leaving. More alcoholics are now being seen who live in bed and breakfast accommodation. The last stage is to be of no fixed abode and homeless.
  • Problems with the law
    • The percentage of alcoholics presenting with a criminal record varies with the type of clientele. Most cases are alcohol related like drunk and disorderly. There is a high degree of recidivism. Violent offences are frequently associated with heavy drinking. This goes right through the spectrum of offences, including murder.

THE TREATMENT OF ALCOHOLISM

STAGES IN THE TREATMENT OF ALCOHOLISM

Acute Intervention

  1. Emergency treatment (often medical or detoxification.

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

  1. Medication must be prescribed on a diminishing scale regime. This must be tailored for the patients needs.

  2. Close supervision is essential, to ensure that instructions are obeyed, and problems are quickly observed and dealt with.

  3. There should be an assessment of physical complications, and reasonable confidence that these will not arise, e.g. epileptic fits.

  4. There should also be an absence of co-presenting psychiatric symptoms, e.g. depression and the danger of suicide attempts.

  5. There should be no clouding of consciousness, confusion or evidence of brain damage.

  6. 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.

  1. Assessment of alcohol related problems. (Physical, Psychological and Social)

Rehabilitation

  1. Development of an individual treatment strategy based on assessment

  2. Primary care which may include brief intervention.

  3. Stabilisation of what has been achieved in primary care.

Maintenance

  1. long-term support to maintain what was achieved.

  2. Relapse prevention. .

  3. Consider the need of residential care.


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