100 Q&A About Alcoholism & Drug Addiction (100 Questions & Answers about)

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100 Questions & Answers About Alcoholism Charles Herrick, MD New York Medical College

Charlotte A. Herrick, PhD, RN Professor Emeritas School of Nursing University of North Carolina Greensboro, North Carolina

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World Headquarters Jones and Bartlett Publishers 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 [email protected] www.jbpub.com

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Jones and Bartlett’s books and products are available through most bookstores and online booksellers. To contact Jones and Bartlett Publishers directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jbpub.com. Substantial discounts on bulk quantities of Jones and Bartlett’s publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones and Bartlett via the above contact information or send an email to [email protected]. Copyright © 2007 by Jones and Bartlett Publishers, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. Library of Congress Cataloging-in-Publication Data Herrick, Charles. 100 questions and answers about alcoholism / Charles Herrick and Charlotte A. Herrick. p. cm. ISBN-13: 978-0-7637-3918-8 ISBN-10: 0-7637-3918-9 1. Alcoholism—Miscellanea. 2. Alcoholism—Popular works. I. Herrick, Charlotte A. (Charlotte Anne), 1933- II. Title. III. Title: One hundred questions and answers about alcoholism. RC565.H3735 2007 616.86’1—dc22 2006035895 2404 Production Credits Executive Publisher: Christopher Davis Associate Editor: Kathy Richardson Production Director: Amy Rose Production Editor: Renée Sekerak Production Assistant: Amy Browning Manufacturing Buyer: Therese Connell Cover Design: Anne Spencer Composition: Northeast Compositors, Inc. Cover Images: (from left to right) © Photodisc, © LiquidLibrary, © Photos.com, © Photodisc Printing and Binding: Malloy, Inc. Cover Printing: Malloy, Inc. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products described. Treatments and side effects described in this book may not be applicable to all patients; likewise, some patients may require a dose or experience a side effect that is not described herein. The reader should confer with his or her own physician regarding specific treatments and side effects. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. The drug information presented has been derived from reference sources, recently published data, and pharmaceutical research data. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Printed in the United States of America 10 09 08 07 06 10 9 8 7 6 5 4 3 2 1

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Contents

Introduction

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Acknowledgments

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Part 1: The Basics

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Questions 1–12 discuss fundamental questions about alcohol, including: • What is alcohol? • Is alcohol a drug? • When and how was alcohol discovered?

Part 2: Diagnosis

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Questions 13–19 discuss the recognition and diagnosis of alcoholism, including: • What is the DSM-IV? • What is alcohol dependency? • What is alcohol abuse?

Part 3: Risk, Prevention, and Epidemiology

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Questions 20-33 discuss factors contributing to alcoholism, such as: • What is the prevalence of alcohol use and alcoholism? • What other risk factors are associated with alcoholism? • How can I prevent my kids from drug and alcohol abuse?

Part 4: Treatment

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Questions 34-60 detail treatment options, including: • Who is qualified to diagnose and treat alcoholism? • What is AA, and how does it work? • What is ASAM, and what are the criteria for placement in a particular program?

Part 5: Associated Conditions

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Questions 61-74 address concerns about other medical conditions associated with alcoholism, for example: • What are the medical consequences of alcoholism? • Can alcoholism cause dementia? • Are there other neurological effects of alcoholism?

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Part 6: Special Populations

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Questions 75-89 explain the effect alcohol has on different populations, such as: • My baby was born with fetal alcohol syndrome. What is that, and what does it mean for my baby? • How do I know whether my child is just experimenting with alcohol and drugs or has a real problem with them? • How are men and women different in their response to alcohol?

Part 7: Surviving Alcoholism

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Questions 90-100 focus on survival, personal rights, and resources, including: • Will I ever be able to drink again? • I was arrested for a DUI. What should I do? • What are my rights to privacy?

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Appendix

257

Glossary

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Index

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Introduction

Perhaps no medical topic arouses more confusion, dismay, and passion in both the public and the medical profession than alcoholism. Although alcohol is often associated with joy and celebration, ritual, and reverence, alcoholism is associated with sorrow and moral failing, disease, and death. No other disease entity can be conceived as having such extreme attributes. This is particularly evident in our country since its inception, where attitudes toward alcohol consumption have swung back and forth from liberal use to strict prohibition. The debates that stirred the American Revolution occurred more often in taverns than churches. Witness the most recent popular movie Sideways, in which wine brought out the best and worst of two friends, arousing aesthetic appreciation, love, passion, anger, and betrayal, but ultimately humor. Wine was never blamed, and sales of pinot noir increased dramatically. Contrast that movie with an earlier one, Leaving Las Vegas, that also garnered critical acclaim but with less popular appeal. It portrayed a man who was inevitably successful in drinking himself to death. At one extreme, alcohol represented bacchanalian reverence, and at the other, it represented a living hell. We currently live in a culture that has little tolerance for risk; thus, drugs such as Vioxx and Ephedra are banned from the market because of their perceived dangers. This perception of risk is based on emotion, however, not on fact. Society’s decision to ban certain substances while allowing others to be freely available has little to do with the dangers inherent in any particular substance, and it has more to do with the emotional outcry that a particular substance engenders. For example, consider the seemingly benign over-thecounter medication acetaminophen, or Tylenol. Tylenol was first introduced in 1956. About 150 acetaminophen-related deaths are

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Alcohol is the single most unique intoxicant because it is a legal, nonprescription, and culturally sanctioned substance that causes more devastating effects to human lives than any other known drug, whether available by prescription or over the counter or on the street.

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reported every year in the United States alone. Add to that the associated morbidity and mortality from those requiring liver transplants from Tylenol overdoses, and the numbers become even greater. Contrast that with Ephedra, a once hugely popular drug for weight loss and bodybuilding that has been linked to a grand total of 155 deaths. The deaths from Vioxx are more difficult to calculate because these deaths are primarily from patients already suffering from cardiovascular disease and not from the direct effects of the drug itself. The estimates suggest up to 27,000 deaths since its introduction in 1999. The outrage leading to its removal had more to do with the company’s refusal to acknowledge the risks than the risks themselves. Alcohol, however, is responsible for approximately 85,000 deaths annually from injuries or diseases directly related to the use or abuse of alcohol. Thus, people often judge the risks and benefits of a particular substance based more on cultural, religious, and moral beliefs than on scientific fact. Alcohol is a prime example (see Part 3 for more information about risk). Alcohol is the single most unique intoxicant because it is a legal, nonprescription, and culturally sanctioned substance that causes more devastating effects to human lives than any other known drug, whether available by prescription or over the counter or on the street. Prohibition, the one attempt in American history to prohibit alcohol use, was a miserable failure, with the cure being worse than the illness. Although it successfully cut the deaths from cirrhosis in half, it came at the cost of increased crime and social unrest. Ingesting anything—medicine, an illegal drug, or even food—is an act that entails a degree of risk.

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Introduction

Therefore, people should understand the risks and the alternatives before ingesting anything. Informed consent is both a legal and an ethical responsibility of healthcare providers to ensure that their patients are knowledgeable about the drugs they are ingesting, including over-the-counter medications, herbal remedies, street drugs, food, and alcohol (see Question 99 for a more detailed discussion of informed consent). This book on alcohol and alcoholism provides necessary information for readers to make informed decisions. Examining the topic of alcohol and addiction will also provide readers with information about the influence of alcohol on their own personal well-being. Although the focus of this book is on alcohol and alcoholism, many of the questions and answers pertain to other addictive substances and behaviors as well, and thus, this book may offer some useful insight into the nature of addiction on a more general level. We live in a time when there is a belief that scientific facts will ultimately help in legislating morality. The culture wars, whether they are fighting over health care, the environment, or other social issues, muster their troops of “scientific experts” when calling on the “facts” to forge political, legal, and moral policy. This is no more evident than the “war on drugs,” in which both sides argue persuasively for the need to continue or abandon current policies. Although the institution of medicine has accepted the concept of alcoholism as a disease, the larger culture with its personal values and beliefs, which includes healthcare providers themselves, continues to debate the issue, with many still viewing alcoholism as a moral failing. This book examines the facts of alcoholism. The following controversial perspective about

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alcoholism is discussed: Is it a disease or a moral failing? Hopefully a path may be developed in order to find the way out of this no-man’s land, where emotions, rather than reason, have left a field littered with the broken lives of those who this horrible affliction has devastated. Because of the controversy of alcoholism as a disease or a moral failing, this book explores the controversy at length so that the reader can be properly informed about the issues and thus be better prepared to understand them in a way that is empowering rather than confusing. Susan’s comment: We celebrated when Ben recently had his 30th birthday. Nearly 6 years ago, while driving, he lost control of the car. The person behind him was very alert, stopped quickly, and found him slumped over the wheel and foaming at the mouth. When the ambulance arrived, Ben was awake but didn’t remember what had happened. After many hours and a battery of tests in the emergency room, a place that would become very familiar in the coming years, the doctor explained the diagnosis of an alcohol withdrawal seizure. My reply, as well as his sister’s, was “thank you, but I was interested in a medical report, not social work.” According to Dr. Herrick, his psychiatrist and co-author of this book, Ben is a “malignant alcoholic” who is still alive—30 hospital trips and 7 rehabs later.

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Acknowledgments

This book is dedicated to my family, particularly my wife, who allowed me the time and provided me with invaluable assistance in completing this book. I would also like to thank my children, who had to put up with my preoccupation with this book for so many weekends. It is also dedicated to the many patients that I have had the privilege to treat. I am constantly surprised and impressed by their persistence in the face of adversity. Finally, my hope is that this book may prove useful to not only patients and their families, but to physicians and other healthcare providers who continue to struggle with understanding this unusual disease. Charles Herrick, MD I want to express the honor and pleasure that I have experienced by co-editing a book with my son, Charles Herrick. I am a proud mother! I want to thank my husband, Bob Herrick, and Chuck’s father for his support and patience in helping us to see this project to fruition. Most of all I would like to thank Ana Cristina Herrick, Chuck’s wife, for being the liaison between the co-authors. She coordinated our efforts, provided editorial comments and contributed creative ideas to explore the issues. She was the “lynch pin” who made it come together! Charlotte A. Herrick, PhD, RN

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PART I

The Basics What is alcohol?

Is alcohol a drug?

When and how was alcohol discovered?

More . . .

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1. What is alcohol? Alcohol an organic chemical that consists of carbon, oxygen, and hydrogen.

All alcoholic beverages contain predominantly water, secondarily alcohol, and finally, depending on the initial substance used in the fermentation process, a variety of other organic chemicals that give each particular beverage its unique color and flavor.

2

Alcohol is a simple organic chemical that consists of carbon, oxygen, and hydrogen. Organic chemicals all contain carbon, hydrogen, and oxygen as their essential makeup and typically come from organisms, but there are many synthetic products that make our lives more convenient. Plastic, oil, and the general makeup of the human body are all organic chemicals. Alcohol, which yeast (a type of fungus) produces, is essentially a waste product from its consumption of sugar. All alcoholic beverages contain predominantly water, secondarily alcohol, and finally, depending on the initial substance used in the fermentation process, a variety of other organic chemicals that give each particular beverage its unique color and flavor. Fermentation can lead to only an alcohol content of 10% to 15% because any concentration over that will kill the yeast. To increase the alcohol concentration beyond 15%, one needs to boil it off from the water—hence the development of distilled spirits.

2. Is alcohol a drug? When considering whether alcohol is a food or a drug one must ask what is the meaning of the term “drug?” Most people view a drug as a mind-altering chemical, illegally obtained and consumed and potentially dangerous (e.g., heroin, cocaine, methamphetamine, marijuana, and LSD). Drugs have a pejorative connotation. Alternatively, any particular pill that a physician might prescribe is viewed as a medication. The connotation of medication is “health giving” or “healing.” Thus, antibiotics, antidepressants, antihypertensives, analgesics, and chemotherapeutic agents are thought of as

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The Basics

medications and not drugs. Cancer chemotherapeutic agents are prescribed to kill cancer cells. These agents, however, do not know the difference between a cancer cell and a normal cell. Fortunately, cancer cells grow faster than most normal cells, and these agents kill the faster growing cells more than the slower growing cells. Otherwise, they are rather indiscriminate killers, which is why they have terrible side effects and are quite dangerous. They are some of the most toxic substances known to humans; however, they are not thought of as drugs or poisons. Instead, they are considered to be medications that have the power to heal. Historically, Americans have not considered alcohol, caffeine, and tobacco to be drugs or medications. Consequently, they are viewed socially and legally differently from drugs or medications. In fact, such categorical distinctions between a drug, a medication, and a socially acceptable substance are purely a product of culture and have nothing to do with the properties inherent in any of these particular substances. All of the categories that these substances fall under have the potential for mind-altering effects. The clinical term for mind altering is literally psychotropic. Even antibiotics have been known to cause mind-altering effects; however, some substances have known predictable, psychotropic effects and are sought specifically for that purpose.

Historically, Americans have not considered alcohol, caffeine, and tobacco to be drugs or medications. Consequently, they are viewed socially and legally differently from drugs or medications.

The cultural construction of substances provides the link between the pejorative term “drug” and its psychotropic effects, which is the reason for the public’s misunderstanding about psychiatric medications. The assumptions are as follows: All drugs are psychotropic. All drugs

Psychotropic a drug that has an effect on the psychic functions of the brain, behavior, or experience.

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are addictive. All psychiatric medications are psychotropic; therefore, all psychotropic medications used in psychiatry to treat mental illness are addictive. This statement is false (see Question 14 for another description with respect to the definition of dependence). If you were to examine the etymological root of medications or drugs (as they should be synonymously regarded), you would be rather shocked. The term “pharmakos,” from which the words pharmacy and pharmaceutical are derived, was originally used to identify the human sacrifice that was offered to “cure” societal ills. With time, the word pharmakos increasingly became associated with the various poisons that were ingested by the pharmakos as part of the sacrifice and eventual “cure.” These poisons, when ingested, then had a dual role—to kill (the pharmakos) and to cure (society). Now that modern medicine has the ability to understand disease processes and the mechanisms of drug actions, “pharmakos” has unwittingly been liberated from the pejorative term “poison.” Prescription medications kill more individuals in America every year than poisons and street drugs combined. Thus, in the end, alcohol is like any of the pharmakos used past and present. It is a medicine, a drug, and a food. Which particular category alcohol falls into is as much a matter of the person using it as it is society’s perception of that person and the substance of alcohol.

3. When and how was alcohol discovered? Alcohol was likely first discovered in early human history during the hunter/gatherer days. It was first found in fruit and honey that had been left standing too long. Mead, made from honey, was most likely the first alcoholic drink. Beer did not develop until there was suffi-

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cient grain that could be harvested with the rise of agriculture. Wine came about around 6,000 BC. More concentrated alcohol did not develop until the advent of distillation. Beer and mead remained the drink of peasants, as their primary nutritional and economic resource was grain, whereas wine required cultivation of grapes, a much more expensive and intensive process, taken over primarily by the Catholic Church, which had the money and resources to cultivate it. Thus, wine was the drink of the religious and the elite. Fermented sources of alcohol remained the only sources of alcohol for 9,000 years, until the development of distillation by Arab alchemists (alcohol comes from the Arabic “al kohl,” meaning any material’s “basic essence”). Distillation works because alcohol has a lower boiling point than water and can be boiled off before water boils. It is recaptured in another container, providing a more concentrated mix of the substance. Distillation did not reach the West until the Middle Ages. Around this time, Europe was faced with the Black Death, and Europeans’ survival led to a continent-wide problem, with alcohol as both an escape from misery and a celebration for those who survived. Consequently, there was a dramatic increase in alcohol use and a parallel increase in problems associated with its use. It was not until the 17th century with the advent of other beverages such as tea, coffee, and cocoa that led to a reduction in alcohol consumption. Even as late as the latter part of the 19th century, however, a safe supply of water was nonexistent, and thus, alcohol remained a safe form of fluid intake relative to water. It was the confluence of the germ theory leading to safe water production, religious revivalism, and the application of medical concepts to chronic alcohol dependence that ultimately led to the view of

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alcohol as being evil. The following question addresses these issues at greater length.

4. Why do humans use alcohol?

One of the most intriguing phenomena is the almost universal production and consumption of alcohol. What possible advantage would there be to humans to consume alcohol over humans who do not? Drunken monkey hypothesis an evolutionary theory as to why having a taste for alcohol may convey some survival advantage by allowing animals to choose fruit that is the ripest.

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For anyone who has had a drink and enjoyed the experience, the question seems ridiculous. For anyone who has suffered the ill effects of alcohol either directly or through the sufferings of a loved one, the answer seems beyond comprehension. To bridge the extremes of use and abuse, there are three reasons why humans use alcohol. First, there may be an evolutionary reason that humans use alcohol. Second, there were health reasons for alcohol consumption, particularly in Western Europe. Finally, many people use alcohol to experience its psychotropic effects.

Evolution Evolution attempts to explain how and why certain traits in human nature exist. One of the most intriguing phenomena is the almost universal production and consumption of alcohol. What possible advantage would there be to humans to consume alcohol over humans who do not? This question has resulted in the development of a hypothesis known as the “drunken monkey hypothesis” (Stephens & Dudley, 2004). It is based on a number of facts that when linked together suggest a possible explanation to support a survival advantage for the consumption of alcohol. The hypothesis begins with our ancestors, the primates. A large portion of a primate’s diet consists of fruit. Where competition for fruit is great, the ability to locate ripe fruit quickly has a selective advantage. As fruit ripens, the yeasts on it convert the sugars to alcohol. The amount of alcohol on the fruit is related to how ripe the fruit is. Locating fruit by the smell of

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Although this remains a controversial hypothesis, it has its appeal. First, alcohol content has been measured in some fruits, and scientists have found that unripe fruit contains no alcohol, whereas overripe fruit contains about 4% alcohol. A monkey preferentially selects fruit with an alcohol content of about 1% at its peak of ripeness. Other species also seem to locate fruit based on alcohol content, including the fruit fly Drosophila, and a variety of birds, butterflies, and fruit bats.

Health Benefits Additional evidence includes the fact that apparently alcohol, in moderation, conveys some health benefits to our species as well as others (see Question 28). Fruit flies, for example, live longer and have more offspring when exposed to intermediate amounts of alcohol compared with no alcohol or high amounts of alcohol. If alcohol had only negative health benefits, the selective advantage for its taste and smell may not have developed. Other evidence includes that the genes for alcohol metabolism, notably alcohol dehydrogenase and aldehyde dehydrogenase, vary widely within the human species, being less prevalent in East Asians. Without these enzymes, the consumption of alcohol is an

The Basics

alcohol is the quickest method for locating ripe fruit. Therefore, having a keen sense of smell and taste for alcohol would aid in the acquisition of the fruit. Monkeys, as well as other fruit-eating animals, have the ability to identify ripe fruits based on the smell of alcohol dispersed by the fruit downwind. Although humankind gave up fruit as a major source of nutrition eons ago, humans share a substantial portion of their genetic ancestry with primates. The current problems with alcohol may be a modern fallout of an initially important survival advantage to having a taste for alcohol.

Drosophila a type of fruit fly that is commonly used to test genetic influences to various physical and behavioral traits. Alcohol dehydrogenase an enzyme that is a biological catalyst that accelerates the breakdown of alcohol into aldehyde, responsible for many of the negative effects of alcohol. Aldehyde dehydrogenase an enzyme that accelerates the breakdown of aldehyde into acetic acid, a nontoxic chemical that is easily eliminated from the body. Enzyme a biological molecule that catalyzes or accelerates a chemical reaction. Most enzymes are proteins.

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intensely unpleasant experience, and thus, those individuals avoid it. This genetic variation in taste for alcohol suggests that such genes are selective depending on the environment. Where these genes are more prevalent, the rates of alcoholism increase (see Question 20).

Aqua vitae latin for “the water of life.” Potable drinkable water.

The attempt to alter one’s conscious state is universal and appears almost instinctual, seen first in small children taking pleasure in spinning around or hyperventilating.

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Alcohol is unique among intoxicants in that throughout its early history it was viewed as lifesaving. For most of the past 10 millennia, alcohol was probably the most common daily beverage and was a necessary source of fluids and calories. In a world of contaminated and dangerous water supplies, alcohol earned the title granted it in the Middle Ages: “aqua vitae,” or the water of life. Alcohol was primarily consumed in the West as an alternative to water because potable water was scarce. Alternatively, in the East, the practice of tea drinking allowed for potable water, and the fact that 50% of Asians lack the enzyme to metabolize alcohol properly contributed to the more limited use of alcohol in their culture (see also Question 22, Table 6). Additionally, the analgesic and euphoric aspects of alcohol were well known. Proverbs mentions alcohol as a means of relieving pain and suffering. Finally, alcohol provided a buffer against fatigue so that one could avoid the boredom and drudgery of long marches or backbreaking labor in the fields.

Psychotropic Effects Intoxicant use has a long history. The attempt to alter one’s conscious state is universal and appears almost instinctual, seen first in small children taking pleasure in spinning around or hyperventilating. It is seen in every society and in every epoch. The move from a “natural high” associated with various physical activi-

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ties, especially sex, to a chemical substance causing such a state is a short distance. Drug use has a place in all cultures and has been and continues to be associated with religious rituals and spiritual awakening. This has most likely occurred for a couple of reasons. First, it allows for a particular culture to control the use and thus mitigate any harmful effects that may occur from misuse or overuse. Second, altered states of consciousness are sought in order to obtain knowledge of the divine or the deeper, hidden truths about life and the world. Certain drugs are purported to offer a metaphysical and epistemological window into the meaning of life. Alcohol is frequently associated with divine heavenly rest. The Eucharist confers immortality, and the Koran depicts a paradise flowing with wine. They all demonstrate a desire to penetrate the ineffable and to comprehend the universe. The Old Testament and the Talmud make ample references to the virtues of alcohol and that intoxication is a way of relieving oneself from the struggles of life. Today, alcohol plays a much different role in our lives. Although it continues to remain part of ritual and religion, its use is more commonly viewed as a form of relaxation and entertainment. Alcohol is increasingly the social lubricant that allows people to be less anxious at social gatherings and enhances the enjoyment of one another’s company. It also stimulates the appetite and enhances the taste of food.

Mitigate to soften or become less harsh.

Metaphysical relating to a reality not investigated by the natural sciences or perceptible to the normal senses. Epistemological the study of the nature and grounds of knowledge especially with reference to its limits and validity.

5. How do chemicals work in the brain? We begin with a short introduction to how the brain works in general and how chemicals interact with neurons to alter communication between nerve cells. This

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Gray matter the part of the brain that contains the nerve cell bodies, including the cell nucleus and its metabolic machinery. White matter tracts in the brain that consist of sheaths (called myelin) covering long nerve fibers. Neuron a nerve cell made up of a cell body with extensions called dendrites and the axon.

will help you to understand how the brain responds to the ingestion of alcohol. The brain is a complex organ that is comprised of gray matter and white matter. Gray matter consists of the cell bodies of neurons and other support cells. White matter consists of long tracts of axons, like telephone lines, that run between the neurons. Figure 1 shows the brain and its general divisions, and Figure 2 shows a single neuron. Different areas of the brain have somewhat different functions. For example, the motor cortex controls voluntary movements of the body, and the sensory cortex processes information to the senses. Different areas of the brain communicate with other areas nearby as well as more distantly. Information starts in the gray matter and travels via the axons of the neurons, making up the white matter in the brain.

Motor cortex

Pars opercularis

Somatosensory cortex

Sensory associative cortex Visual associative cortex

Broca’s area Visual cortex

Primary Auditory cortex Wernicke’s area

Figure 1 Brain and general divisions. From brainconnection.com. Used with permission. Copyright © 1999 Scientific Learning Corporation. All rights reserved.

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CELL BODY Dendrites

Nucleus

Synapses

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Myelin sheath AXON

Schwann cell Node of Ranvier Synaptic terminals

Figure 2 Single neuron. From brainconnection.com. Used with permission. Copyright © 1999 Scientific Learning Corporation. All rights reserved.

Neurons and Neurotransmitters The brain contains billions of neurons that interact with each other electrochemically. This means that when a nerve is stimulated, a series of chemical events occurs that in turn creates an electrical impulse. The resulting impulse propagates down the nerve length known as the axon and causes a release of chemicals called neurotransmitters into a space between the stimulated nerve and the nerve that it wishes to communicate with, known as the synaptic cleft (see Figure 3). The neurotransmitters interact with receptors on the second nerve, either stimulating or inhibiting them. The interaction between the neurotransmitters and receptors can be likened to a key interacting with a lock, where the neurotransmitter or “key” engages the receptor or “lock,” causing it to “open.” This “opening” is really a series of chemical changes within the second nerve that ultimately either causes that nerve to “fire”

Motor cortex an area on the outer part of the brain that is responsible for voluntary motor control. Sensory cortex an area on the outer part of the brain that is responsible for organizing sensory input into a coherent perception at the level of consciousness. Axon that part of the neuron or nerve cell that is a long tube conducting signals away from the cell body.

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Electrochemical the means by which a nerve conducts signals through the body and axon. This causes a release of chemicals.

or not to “fire.” Brain activity is the result of an orchestrated series of nerves firing or not firing in binary fashion. It is much like a computer where very complicated processes begin as a series of 1’s or 0’s (on or off, fire or do not fire).

Neurotransmitters chemical released by nerves that communicate with other nerves causing electrochemical changes in those nerves to continue to propagate a signal.

After the nerve fires, releasing neurotransmitters into the synaptic cleft, the neurotransmitters must be removed from the area in order to turn the signal off. There are two ways that these chemicals can be removed in order to turn the signal off. The first is by destroying the chemical through the use of another chemical known as an enzyme with that specific purpose in mind. The second is by pumping the chemical back up into the nerve that released it by using another special chemical known as a transporter or transport pump. The process of pumping chemicals back into the nerve is known as reuptake (see Figure 3). It is important to understand these basic principals of neurophysiology because all psychoactive compounds, whether neurotransmitters, hormones, medications, addictive drugs, or alcohol, involve one or more of these mechanisms. The differences between their effects stem from the particular receptor and neurotransmitter with which it interacts. Alcohol works in the brain in a manner similar to other chemicals, as a “key” that fits into a specific “lock” that opens a door for further communication. Alcohol, unlike many other drugs of abuse, however, is not a magic bullet targeting a specific area of the brain and a specific neurotransmitter or receptor system. Alcohol works on both the motor and sensory components of the brain and has multiple neurotransmitter effects, although it does have a receptor that appears to be specifically designed for it. These effects

Synaptic cleft the gap between nerves where neurotransmitters are released that allow nerves to communicate with one another. Receptors specific areas of protein on a neuron that are configured to respond only to specific neurotransmitters. Transporter also known as a transport pump. Transporters are made up of proteins that act as “vacuum cleaners,” taking up leftover neurotransmitters from the synaptic cleft and transporting them back into the nerve cell that originally released them.

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Voltage-gated Ca++ channels

Neurotransmitter re-uptake pump

Post-synaptic density

Neurotransmitter receptors

Axon Terminal

The Basics

Synaptic vescicle

Neurotransmitters

Presynaptic

Synaptic Cleft Post synaptic

Figure 3 Synaptic Cleft. www.wikipedia.com.

are not unique to alcohol. Opiates have opiate receptors, and marijuana has marijuana receptors, which means that the body produces chemicals with similar activity as their ingested cousin, alcohol.

6. How does alcohol affect the brain? The exact cause of intoxication at the cellular level is not clearly known. It appears that although alcohol has a wide-ranging effect on the brain, certain brain regions are preferentially more sensitive to alcohol, and certain neurotransmitter systems are involved. The neurotransmitters affected by alcohol include gammaaminobutyric acid (also known as GABA), glutamate, serotonin, dopamine, and the endogenous opiates. These neurotransmitters are involved in various aspects of alcohol’s short- and long-term effects on the brain that include both intoxication but also withdrawal and possibly addiction. Some neurotransmitters are excitatory—that is, they increase the firing rate of nerve cells that would normally fire at a lower rate

Transport pump see transporter. Reuptake the process by which neurotransmitters return to the presynaptic cells after being released into the synaptic cleft and attaching receptors on the postsynaptic cells. GABA gamma-aminobutyric acid, the brains major inhibitory neurotransmitter. This neurotransmitter dampens all brain activity.

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Glutamate the brain’s major excitatory neurotransmitter. This neurotransmitter activates all brain activity. Serotonin one of the brains major neurotransmitters. Dopamine one of the brain’s major neurotransmitters. Endogenous opiates opioids that develop or originate within the body. Anticonvulsant a drug that prevents seizures from occurring. Barbiturates a class of drugs that effect GABA to prevent seizures from occurring. They are used for anxiety disorder until the discovery of benzodiazepines, which were found to be much safer in. Phenobarbital a barbiturate currently used as an anticonvulsant.

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with a given environmental input—whereas some are inhibitory, or decrease the firing rate of nerve cells in response to a given environmental input. GABA is the brain’s major inhibitory neurotransmitter. The function of GABA is to inhibit or dampen overall brain activity. Thus, general arousal is dampened, leading to decreased motor tension and anxiety and increased sedation and sleep. GABA also has anticonvulsant activity, which prevents seizures. Alcohol causes GABA to be more potent in the cerebral cortex by altering the GABA receptor in such a way as to make it more attractive to GABA. Most current prescription sedatives (antianxiety inducing) and hypnotics (sleep inducing), such as diazepam and lorazepam, or zolpidem, are medications that act on this neurotransmitter system in a similar manner as alcohol. Barbiturates such as phenobarbital also act on GABA receptors. Additionally, anticonvulsant medications such as valproic acid, gabapentin, and lamotrigine increase GABA activity, though by a different mechanism than the sedative hypnotics. Experimental drugs have been used on laboratory rats that actually block the behavioral manifestations of alcohol intoxication, including sedation and loss of coordination. The lack of signs and symptoms of alcohol use probably occurs because these experimental drugs bind to the GABA receptor blocking alcohol’s ability to also bind at the same site. Glutamate is the brain’s primary activating neurotransmitter and is another neurotransmitter system that alcohol affects, but it is opposite from GABA. Glutamate has a primary role in learning and memory functions

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Serotonin, a third neurotransmitter, is implicated in alcohol’s intoxicating effects. Serotonin plays a role in anxiety, mood, sleep, appetite, and sexual function. Drugs that acutely boost serotonin can cause an alcohol-like high. The hallucinogens, such as LSD, mescaline, and psilocybin, impact the serotonin neurotransmitter system, thus inducing hallucinations and euphoria and also impairing other cognitive functions. Evidence demonstrates that acute alcohol administration increases serotonin activity in the brain as well as impacts various

Valproic acid an anticonvulsant medication that acts on GABA and is FDA approved for use in bipolar disorder (manic depression). Gabapentin (Neurontin) an anticonvulsant medication that may be used as an adjunct treatment with other drugs for seizures for adults and children over 12 years old. Lamotrigine generic name for Lamictal–an anticonvulsant. Excitotoxicity the pathological process by which neurons are damaged and killed by the overactivation of receptors for the excitatory neurotransmitter glutamate. NMDA (N-methylD-aspartic acid) an amino acid derivative acting as a specific agonist at the NMDA receptor. Norepinephrine a neurotransmitter in the brain as well as a stress hormone released by the adrenal glands.

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The Basics

through the alteration of neuronal growth. It can also play a role in nerve cell death when its levels are too high through a process known as excitotoxicity. It also appears to have a role in the development of psychosis and seizures. Glutamate’s effectiveness is reduced by alcohol’s damping effect on its major receptor known as the NMDA receptor (for N-methyl-D-aspartate, the chemical that specifically attaches to that particular glutamate receptor). Acute alcohol use also inhibits the release of glutamate, which in turn impacts on the release of several other neurotransmitters downstream, including dopamine, norepinephrine, and acetylcholine. Chronic alcohol use, on the other hand, potentiates or increases the brain’s sensitivity to glutamate. This occurs through a process known as upregulation, where the brain is like a thermostat producing more NMDA receptors in order to compensate for alcohol’s dampening effects. Upregulation may relate to the effects of tolerance, which means that increasing amounts of alcohol are needed in order to increase GABA further and dampen glutamate. This may also explain withdrawal symptoms, where sudden increases in glutamate activity may account for nerve toxicity leading to hyperactivity, psychosis, and seizures.

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Acetylcholine the first neurotransmitter discovered. Potentiates to make more active or effective, to augment, and to make more potent. Sensitivity probability of a positive test among patients with a particular disease. Hallucinogen a classification of drugs that produces hallucinations, euphoria, an altered body image, distorted or sharpened visual and auditory perceptions, confusion, loss of motor coordination, and impaired judgment and memory. Ondansetron generic name for Zofran, an antiemetic drug that acts on specific serotonin receptors. Antiemetic a drug known for its antinausea and antivomiting qualities.

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serotonin receptors, increasing the activity of some receptors while decreasing the activity of others. On the other hand, chronic administration of alcohol leads to a decrease in serotonin activity in the brain and causes upregulation of some serotonin receptors that may contribute to the development of some of the symptoms of tolerance and withdrawal when alcohol is abruptly stopped. Particularly symptoms of anxiety, dysphoria, and insomnia often increase. Serotonin may also be responsible for the nausea that people experience from alcohol. Ondansetron, a serotonin receptor blocker, is used as an antiemetic in cancer chemotherapy and may have similar beneficial affects in alcoholism. It appears that the antidepressant medications known as selective serotonin reuptake inhibitors (e.g., fluoxetine) increase serotonin in the brain and decrease drinking behavior in rats who have been selectively bred for alcohol preference and found to have low serotonin. This effect has also been found in humans, although its effects are so modest that they are not clinically useful. Serotonin can also affect other neurotransmitter systems. Serotonin can increase GABA activity, which may contribute to memory loss and cognitive impairment. Serotonin also stimulates the release of dopamine, which also effects attention, concentration, memory, mood, and psychosis. Opiates, also known as narcotic analgesics, are most commonly thought of as pain medications that are associated with addiction. In the 1970s, it was discovered that opiates attach to very specific opiate receptors in the body and brain that cause analgesia or pain relief. Why would the body have such receptors if it did not also make its own chemicals that fit those receptors? From the findings of this research came the discovery of endogenous opiates known as enkephalins and endorphins. These chemicals cause similar effects on the

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Selective serotonin reuptake inhibitors (SSRI) a class of antidepressant/ antianxiety medication that works by blocking the serotonin transporter. Fluoxetine the generic name for Prozac, which is a selective serotonin reuptake inhibitor (SSRI). Opiate a type of opioid.

Dopamine is a major neurotransmitter associated with the brain’s reward system (Figure 4), but it also plays a

Cingulate gyrus

Anterior nucleus of thalamus

Thalamus Para-olfactory area Fornix

Mamillary bodies of hypothalamus

Hypothalamus Hippocampus Uncus Amygdala

Para-hippocampal gyrus

Figure 4 Limbic areas involved with mood and reward. From brainconnection.com. Used with permission. Copyright © 1999 Scientific Learning Corporation. All rights reserved.

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The Basics

body as the opiates that are ingested. Alcohol appears to increase an endogenous opiate known as betaendorphin. Research has demonstrated that mice specifically bred for the lack of a particular opiate receptor have no interest in alcohol. When chemicals are administered that block the beta-endorphin receptor, rendering it dysfunctional, mice decrease their alcohol consumption similarly to those who do not have the receptor to begin with. This research has led to the development of specific treatments (see Questions 49 and 50). It is now recognized that opiate receptors are found on known dopamine pathways in the brain, which suggests that enkephalins and endorphins, when attached to these receptors, also play a role in the release of dopamine.

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Narcotic analgesic an opioid used to control pain. Enkephalins an endogenous opioid made up of amino acids. They are produced in the brain and have an affinity for opiate receptor sites, acting similarly to analgesics and opiates. Endorphins short for endogenous morphine. See enkephalin or endogenous opiate. Vertigo dizziness, as in the room is spinning around. This is a brain effect as opposed to lightheadedness or feeling faint, which is due to low blood pressure. Mellanby effect impairment from alcohol is greater at a given blood alcohol level when the amount of alcohol in the blood is increasing as opposed to decreasing. This also explains the differences in feeling “hung over” as opposed to “buzzed” at the same alcohol level depending on a falling or rising level.

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role in attention and concentration, involuntary movements, and hallucinations. Alcohol boosts dopamine in the brain, leading to euphoria and possibly contributing to addiction. Increasing scientific evidence suggests that all drugs of abuse, including nicotine, boost dopamine to one degree or another; however, in experimental studies with laboratory animals, selectively knocking out these specific dopamine pathways affects the quality of alcohol administration but not the various reinforcers that prompt the animal to continue to self-administrator. Table 1 lists the various neurotransmitters and alcohol’s effect on the various neurotransmitter systems. The intoxicating effect of alcohol generally correlates with the amount of alcohol in the blood. In persons who are not alcoholic, blood alcohol concentrations of 25 mg per deciliter indicate mild intoxication manifested by alterations in mood, thought, and motor control. At levels above 100 mg per deciliter, signs of vertigo, double vision, slurred speech, and unsteady gait increase. The legal limit was 100 mg per deciliter, but most states have adopted the more conservative limit of 80 mg per deciliter to meet the guidelines for federal highway funding; however, studies demonstrate that levels even as low as 47 mg per deciliter are associated with an increased risk of involvement in motor vehicle accidents. Blood alcohol levels of 500 mg per deciliter or greater may lead to respiratory arrest and death. Several modifying variables can influence the outcomes. At the same concentration, a rising blood level of alcohol causes greater intoxication than a falling blood level. This is known as the Mellanby effect. Chronic alcohol use can lead to tolerance so that intoxication occurs at much higher levels than

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Table 1 Alcohol’s Effects on Neurotransmitter Systems

Experience

Transmitter/Receptor

Euphoria/pleasure Anxiolysis/ataxia Sedation/amnesia Nausea Neuroadaptation Stress Withdrawal

Dopamine, Opioids ↑GABA ↑GABA + ↓NMDA 5HT3 NMDA, 5HT CRF GABA, NMDA (↑Ca, ↓Mg)

The Basics

• Effects on the dopamine system –Increase dopamine in mesocorticolimbic system –Reinforcing, rewarding effects • Effects on the opioid peptide system –Activation of opioid peptide system –Reinforcing and rewarding effects (Mu) –Aversion (Kappa) –Craving • Effects on NMDA glutamate system –Blockage of NMDA receptor (allosteric effect) –Sedative/hypnotic effects –Neuroadaptation –Withdrawal • Effects on the serotonin system –Neuroadaptation aversion –Depression, anxiety • Effects on stress hormones –Stress response (fight or flight) –Increased epinephrine and norepinephrine

mentioned previously here, and patients with blood alcohol levels of 500 mg per deciliter are commonly seen in emergency rooms without clinically significant respiratory distress.

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7. What is addiction? American Society of Addiction Medicine (ASAM) established in 1989, was the first American medical society to focus on drugs and alcohol. Reinforcers the stimuli that are coupled with a behavior in operant conditioning that are either applied or removed to elicit the desired response.

The American Society of Addiction Medicine (ASAM) defines addiction in the following manner: “Addiction is a disease characterized by continuous or periodic impaired control over the use of drugs or alcohol, preoccupation with drugs or alcohol, continued use of these substances despite adverse consequences related to their use, and distortions in thinking, most notably denial.” Addicts typically begin by experimentation, evolve into regular but controlled use, and ultimately find themselves in periodic episodes of loss of control over the use of alcohol that causes impairment in various areas of their lives, either physically or socially. Despite these negative consequences, they continue to use. The issue of loss of control is a controversial one, as addicts to one degree or another are able to exhibit control over their use with a variety of reinforcers; however, the reinforcers, whether they are negative or positive, have much less impact than alcohol itself in modifying the behavior of an addict. For example, for most people, one physical accident from alcohol use requiring an emergency room visit would be negatively reinforcing—that is, it is enough to modify their drinking behavior to avoid future accidents. For an alcoholic, the visit to the emergency room is merely a pattern of frequent visits. Preoccupation with obtaining and using alcohol refers to the fact that the addictive substance plays a central part in their inner lives, whether or not they are actively using it. Thus, maintaining abstinence is only one element in one’s treatment, as the major struggle continues internally. This internal struggle includes, but is not limited to, denial. Also included are the litany of excuses for continued use, the blaming of oth-

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ers, particularly family members and caregivers, for their failure to maintain abstinence, and the frequently cited identification with some other emotional problem that really needs to be addressed rather than the alcoholism itself. The negative consequences play little if any role in modifying the continued use, which is the final aspect of addiction. From ASAM’s perspective, addiction and dependence can be used interchangeably. The varying concepts of physiological dependence, psychological dependence, and addiction are more thoroughly explored in Question 14. Addictive behaviors may include gambling, sex, drugs, and all of the variations on those themes, which recently include the use of the Internet and involvement with pornography. From that simple definition, it appears that no biological or pathophysiological process must be invoked. The addiction may result from the involvement or the pursuit of an activity, rather than on what direct effect the pursuit of the activity may have on the brain. How can gambling or the Internet have the same effects on the brain as opiates or alcohol? There is no receptor specific for gambling or the Internet like there is for opiates or alcohol. Somehow the behavior and the pursuit of an activity take on a life of their own, to the exclusion of all other responsible activities. If that is the case, then how can addiction be a disease? This is the subject of our next question. Susan’s comment: Unfortunately, Ben’s blood alcohol levels have been more than 400 or 500 several times. He always amazes those who treat him because he is so lucid. Although he exhibits intoxicated behavior, he is not “falling down drunk” and does not exhibit any signs of respiratory distress. One time,

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however, he was in the high 500s and was comatose after arrival at the emergency room. Thankfully, he began to improve immediately with treatment. Although I understand that he needs to be sober before treatment, I always worry that one day we won’t be “crying wolf ” and that something important might be missed with the overall diagnosis of “severe ETOH intoxication.” Thus, I still continue to bring him to the emergency room. Sometimes I get tired of apologizing; however, many trips have been made to the same place for the opposite condition: complications from alcohol withdrawal. There is certainly a marked difference in the attitude of medical personnel at the times when he is clearly sick rather than drunk. Although I sometimes sense that caregivers believe that Ben “deserves” the punishing symptoms of withdrawal, for the most part, they are sympathetic to his plight and mine. Needless to say, I have become acquainted with people on the ER staff, who often say to me when I either bring him myself or follow the ambulance, “I don’t know how you do it.” Most of the time my response consists of two questions. First, I ask, “Do you have children?” When they nod their head, which most do, I simply ask, “Wouldn’t you?” The look of disapproval that is in their eyes seems to give way to a bit more understanding after that. After Ben is stable and while we are awaiting the results of the blood tests, I sometimes go back to my nearby office to fill in my co-workers who have watched this process so many times. Someone says, “Doesn’t he realize what he’s doing to you?” I reply, “First, he’s got to realize what he’s doing to himself.”

8. How is alcoholism a disease? Alcoholism clearly represents problematic behavior; however, before alcoholism can be defined as a dis-

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ease, the concept of disease needs to be understood more completely.

The Basics

The concept fundamentally presumes a causal nature that results in a pathological state. The most common example that everyone can agree on is an infectious disease, where a foreign organism invades the body and causes a specific set of pathological processes to occur in the body that ultimately express themselves as various signs and symptoms. Signs are objective evidence that an outside observer can elicit through a physical examination and/or a set of tests such as blood or urine tests and/or imaging tests. Symptoms are the subjective manifestations of the disease that the individual feels. These include the aches, pains, and various discomforts that the person suffering from the disease feels. The discovery of specific treatments that killed the underlying organisms strengthens the disease concept, thus restoring the individual back to their normal state, free of signs and symptoms of that disease. With technological advances, however, the concept of disease has changed. For example, why do some individuals develop a disease when exposed to a germ, whereas others do not? Genetics, local environmental conditions, and immune systems all became sources of study in understanding why some individuals carrying a particular organism are more prone to develop the disease. Disease is no longer a simple matter of finding a germ and killing it. Cause now entails not just the existence of the germ, but also multiple other factors that interact together with the germ to increase one’s chances of developing a particular disease.

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Genetic and environmental factors also play a role in making alcohol more or less lethal to any one particular individual.

In that respect, alcohol can be viewed in the same manner as the germ theory of disease. It is the foreign substance that is the necessary but not the only factor in the development of alcoholism. Genetic and environmental factors also play a role in making alcohol more or less lethal to any one particular individual. Statistical chances for the development of the disease are well calculated in terms of amount and exposure to alcohol over time. A natural course develops in the development of the disease with repeated exposure over time. There is a consistent set of signs and symptoms that develop in the course of the disease. Physical exam findings and laboratory tests can support the diagnosis. Abstinence is the key to treatment, albeit the biggest obstacle because of the easy availability of the offending substance. If you still believe that this analogy is wrong, consider a counterfactual example of a real disease. Tertiary syphilis causes behavior problems. It took years before the underlying cause was discovered, but it was well understood that it was transmitted through sexual contact. It was the result of “immoral behavior,” and thus, a great deal of stigma was attached to it (as there still is). Before the discovery of penicillin, the psychiatric wards were populated with these patients. Nevertheless, only one third of individuals exposed to syphilis that are untreated develop tertiary syphilis. Thus, two thirds of individuals who were exposed to syphilis escaped both the fatal stages as well as the stigma attached to the infection. Why do some people develop tertiary syphilis while others do not? What factors, either inherent in the individual, the environment, or the organism, cause only a third to develop the fatal form? Certainly it is not a matter of choice, of right living, or of free will. It is, in the end, a matter of luck.

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This example raises the unspoken fact that inherent prejudice exists in ascribing responsibility to individuals for their disease no matter what the disease is. This is especially true today with heart disease and cancer that unhealthy lifestyles and the increase in obesity cause, but even the seemingly most upright and healthy individuals can get sick. It is not unheard of to hear comments about someone who gets sick frequently as weak or “thin skinned,” whereas others who amazingly avoid all illnesses are upright, moral, or positive thinkers. Our culture is rampant in applying moral values to disease and illness. In that regard, alcoholism is merely on a continuum in terms of people’s attitudes and perceptions. Susan’s comment: When my kids were little, I was amazed at how cruel the other kids could be. As Ben and his friends grew, they usually settled things around a keg of beer. Benny enjoyed that intangible thing that we all secretly wanted for our kids— popularity—so there were many parties and a lot of drinking. If the “guys” didn’t get “wasted,” they weren’t cool. In the adult world, however, when it comes to alcoholism, cruelty is universal. People who never turn down a drink themselves can certainly be judgmental. These same people can’t wait to scour the DWIs printed in the paper each day hoping to find someone they know. I wish I thought they were doing so to thank God that they haven’t gotten “pinched.” Instead, they get some sick kind of pleasure out of it and can’t wait to get to work to see whether others have seen it. If it weren’t so true, it would be funny. Also, I often hear discussions regarding the disease versus moral failing concept: “Well, insurance pays for it, so it must be a disease.”

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Proximate cause in evolutionary theory, the initial cause that changes the behavior of a biological system. Pulling one’s hand from a fire is caused by a reflex arc in the nervous system and would be an example of a proximate cause. Ultimate cause in evolutionary theory, the untimate cause for why a particular behavior evolves to serve an evolutionary purpose that has survival value.

Dopamine is the neurotransmitter in the brain that is most associated with reward. Alcohol increases dopamine both indirectly through other neurotransmitters as well as directly on dopamine itself.

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Our health care system has redefined itself as dictated by the insurance companies, whose own newly created language refers to the patient as the “subscriber” and the doctor as the “provider.” The decision of what they cover and deny becomes the final arbiter of a “real” medical condition in many people’s eyes. Insurance coverage provides for this “disease,” so it must be one!

9. What makes alcohol addictive? Several theories exist about why alcohol is addictive. These can be divided into three broad categories: biological, psychological, and social. The biological category consists of both proximate and ultimate causes. Proximate cause refers to the immediate physiological processes involved in how particular substances are more addictive than others. Less proximate causes include the genetic susceptibility toward being more prone to developing addiction. The ultimate cause refers to evolutionary explanations as to why humans developed an attraction to alcohol and why addiction became part of our genetic makeup. The evolutionary explanation on why humans drink alcohol was addressed in Question 4, which entailed the drunken monkey hypothesis. The proximate cause of alcohol’s affect on the brain regarding the various neurotransmitter systems that alcohol impacts was addressed in Question 6. The various neurotransmitter systems seem to converge on dopamine. Like the expression “there are many roads to Rome,” there are many neurotransmitter pathways to dopamine. Dopamine is the neurotransmitter in the brain that is most associated with reward. Alcohol increases dopamine both indirectly through other neurotransmit-

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Learning Theory Psychological and social theories also explain how alcohol is addictive. These theories can be thought of together under one broad category known as psychosocial theory. The most well-known and prominent theory is learning theory. Learning theory includes classical conditioning, operant conditioning, and modeling.

Classical Conditioning Classical conditioning is a form of learning that occurs when a stimulus is paired in time with a reward that causes an automatic response. Pavlov, a Russian physiologist, used dogs as his subjects to demonstrate this basic phenomenon. In Pavlov’s now classic experiment, a bell (stimulus) was paired with food (reward), causing a dog to salivate. After repeated pairings, the food could be removed, and the bell alone would cause a dog to salivate. This automatic response required no conscious learning on the dog’s part.

Bupropion generic for Wellbutrin, marketed as an antidepressant, and Zyban, marketed as a smoking cessation medication. Zyban see bupropion. Psychosocial theory a theory developed in the early 1900s that the cause of mental illness pertains to environmental circumstances. Learning theories pertain to the acquisition of knowledge and skills and modifying behavior to learn new behaviors through behavior modification interventions (positive and negative reinforcement, extinction) and cognitive behavior interventions. Classical conditioning a type of learning that results when a conditioned and unconditioned stimulus are paired together, resulting in a similar response to both stimuli.

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The Basics

ters as well as directly on dopamine itself. Research has demonstrated that dopamine is the neurotransmitter system affected by all drugs of abuse and probably influences all addictive behaviors. One of the most successful medications prescribed for smoking cessation is bupropion, known as Zyban, which increases dopamine in the brain. The genetics of alcohol addiction are covered in Question 21.

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Operant conditioning a type of learning that is concerned with the relationship between voluntary behavior and the environment. Modeling learning through pervasive imitation. Intermittent reinforcement the reinforcement of a behavior (the reward) that occurs some of the time as opposed to continuous reinforcement that occurs every time after the behavior occurs. Extinction elimination of a classically conditioned response by the repeated presentation of the conditioned stimulus without the unconditioned stimulus.

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Operant Conditioning The psychologist B.F. Skinner developed the theory of operant conditioning in the 1950s with the invention of the Skinner box. In operant conditioning, a reward is paired with a specific behavior, such as a rat pressing a lever in order to obtain food or water. The rate and intensity of the lever pressing can be measured against the type of reward offered. The number of lever pressings required can be varied in order to obtain a reward. Varying the numbers of pressings before a reward is given is known as intermittent reinforcement and is the most powerful way to sustain a behavior and hamper the extinction of that particular behavior. The most well-known example of that in everyday life is the slot machine. The length of time extinction occurs after the reward ceases can be measured in order to determine the power of a particular reward and the behavior used in achieving that reward. Offering punishment when a particular behavior is elicited can also modify behavior in order to eliminate it. This model offers one of the most useful ways of testing the power of specifically addictive substances.

Modeling The last psychosocial theory is modeling, which refers to learning by witnessing other’s behaviors. Role models are powerful learning tools. We generally want to copy the behaviors of those we admire. In our society, for better or worse, our role models are celebrities and that is why companies use them to sell their products. If celebrities were not successful at selling various consumer products companies would not hire them and pay them such handsome fees. Advertisers use celebri-

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The Basics

ties as role models to enhance the image of the product. If we find a celebrity we admire using a particular product, that product will become much more attractive to us. If that product is alcohol we will want to use it too. All three of these theories offer insight into behaviors in general and more specifically alcohol addiction. Putting biology and learning theory together, one can begin to see how they conspire to cause addiction. Alcohol is a substance that alters perception, selfregard, and mood, generally in positive ways. These effects are highly reliable in that they always occur with alcohol use and are a function of alcohol’s direct physiological affects. Using alcohol is generally associated with environments and people that are social, engaging, and if not festive, then at least pleasant. Also, when the environment is anxiety provoking, alcohol has the ability to reward the user by reducing his or her anxiety. Consequently, with continued use in a specific environment of choice, the positive effects of alcohol become paired with the environment, making the environment immediately attractive and associated with drinking alcohol. Over time, the number of alternative reinforcers or rewards that can substitute for alcohol decreases, as the immediate reward of ingesting alcohol is more reliably available and reproduced. This pattern of use that is associated with specific environments that support and reinforce such use leads to a “crowding out” of alternative positive rewards that previously competed with alcohol but now require too much effort and planning when compared with drinking. It is well known that individuals in general gravitate toward smaller but sooner rewards over larger but

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later rewards. This is true across all ages and all types of rewards. For example, a well-known study has consistently demonstrated that most young children will choose the immediate reward of a few M&Ms rather than wait a prescribed amount of time for a bag of M&Ms. Likewise, the immediacy of the reward from the use of alcohol overwhelms any delayed gratification that abstinence may bring. Over time, with the development of tolerance, an ever-increasing amount of alcohol must be consumed in order to obtain the desired effect, and the immediate discomfort of withdrawal from alcohol further reinforces its use as a way of avoiding the punishing feelings from nonuse. The strength or weakness of these effects obviously depends on the personality (and/or the genetic makeup) of the individual. It is clear that some individuals are more susceptible to the addictive effects of alcohol than others.

10. What aspects of alcoholism are voluntary or involuntary? The assessment of whether any human behavior is voluntary or involuntary has both ethical and scientific implications. Historically, the study of psychology was originally regarded as a moral science, whereas the behavior of all other nonhuman organisms and inanimate objects was regarded as part of the natural sciences. This division seemed logical because humans act based on conscious voluntary deliberation, whereas all other things appear to act in a more mechanical involuntary manner. To some degree, that general belief and separation remain true today, illustrating science and society’s continuing struggle to separate human behaviors that are a result of natural causes (involuntary) from those that are a result of

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The distinction is easy to make when behavior occurs as a result of a specific pathological process, such as a brain tumor or a seizure, or when someone commits fraud, as the recent Enron trial demonstrated. What if the behavior, such as alcoholism, blurs the boundaries, however? Convincing someone that alcoholism is a disease appears to be, on the surface, a bit of rhetorical spin, especially when voluntary abstinence is the treatment of choice for a problem that argues that the choice to drink is not voluntary in the first place. The transition of an individual from a social drinker to an alcoholic, when there is no overt pathophysiological evidence of a disease, continues to invite a great deal of societal anger. This transition can be complicated and difficult to define because it is based on a pattern of behavior that many people can identify with because they too have had a drink in their lives, and it appeared to be a matter of choice when to stop, hence the notion of moral failing. The courts generally rely on psychological theories of behavior to help them distinguish between behaviors

The Basics

choice (voluntary). As science continues to advance, the line separating these two alternatives is becoming increasingly blurry; however, every society’s ability to function effectively and with a sense of fairness requires such distinctions be made. This is important because if a socially undesirable behavior is regarded as voluntary, then the person behaving in that manner should be held responsible for his or her actions and punished appropriately. If, however, his or her undesirable behavior is involuntary, it should be excused and prompt society to treat the person humanely in a manner that provides care and relief.

Convincing someone that alcoholism is a disease appears to be, on the surface, a bit of rhetorical spin, especially when voluntary abstinence is the treatment of choice for a problem that argues that the choice to drink is not voluntary in the first place.

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Eliciting stimuli plural for eliciting a stimulus. It is a trigger that elicits an involuntary or automatic response.

Alcoholics also have very strong reactions to eliciting stimuli, such as evoking overwhelming cravings when passing a favorite bar, meeting up with a drinking buddy, or having the smell and taste of a particular drink.

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that are voluntary from those that are involuntary. As noted in Question 9, psychological theories of behavior rely on learning theory. The courts define voluntary behavior as behavior that responds to rewards and punishments, whereas involuntary behavior is defined as the result of a response to eliciting stimuli. This makes sense for the simple fact that the courts enforce the law by prescribing punishments to those who break it and thereby (hopefully) providing an incentive to not break the law in the future. This is essentially the difference between operant and classical conditioning in that operant conditioning is thought to be voluntary and classical conditioning involuntary. Alcohol dependence is highly rewarding as well as acting strongly in a manner that generates various eliciting stimuli ultimately prompting automatic responses. Both operant and classical conditioning effects act in concert so that the degree of influence on the behavior as voluntary verses automatic is difficult to determine. Studies repeatedly demonstrate that people with severe addiction problems do respond to rewards and punishments just as people without addiction problems do, but to a significantly lesser degree, especially when those rewards/punishments are competing with the highly rewarding addictive substance. Alcoholics also have very strong reactions to eliciting stimuli, such as evoking overwhelming cravings when passing a favorite bar, meeting up with a drinking buddy, or having the smell and taste of a particular drink. In fact, eliciting stimuli can even provoke such negative reactions as withdrawal symptoms even after someone has been successfully detoxed on an inpatient setting and they enter a place where those withdrawal symptoms began. For example,

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The Basics

to understand these feelings better, imagine going without water for a day or food for a week. The thirst and appetite centers would become so strong as to focus centrally and to prompt you to act in any way that can satisfy your thirst or hunger. This has great survival value, but alcohol has essentially highjacked that part of the brain so that it responds more intensely to alcohol than any other reward or punishment. If we are to answer the question more thoroughly, other factors need to be considered when determining whether any particular alcoholic’s drinking is voluntary. These include a number of issues: (1) The more impaired someone is intellectually, the less voluntary his or her behavior can be. This is why society and the courts generally do not regard the mentally retarded or minors as responsible as normal adults. (2) The more reactive someone’s emotions are to trivial incidents, the less voluntary their actions can be in response to their emotional states. (3) The more the need to relieve pain drives the craving for alcohol, the less voluntary the behavior can be. (4) The more restricted the choices one feels that he or she has, the less freedom he or she has to act otherwise. (5) The more universal the patterns of responses are, the more apt they are part of a process that transcends individual choice. (6) The more detrimental the behavior is to one’s health and survival, the less voluntary it is. (7) Finally, how ingrained and unchanging the behavior is despite attempts to modify the behavior with various consequences, the less voluntary it is. All of these factors play a role in how voluntary one’s alcoholic behavior is. People undoubtedly choose to drink, but no one chooses to be an alcoholic.

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Susan’s comment:

Delirium tremens (DTs) an acute withdrawal syndrome from alcohol that frequently occurs in alcoholics who have a 10-year (or more) history of heavy drinking.

The notion of “eliciting stimuli” is hard to imagine, but I have watched it happen. For example, being in a hospital setting seems to exacerbate Ben’s withdrawal symptoms. After pouring a toxic substance into his body with little to eat for days and subsequently stopping, Ben’s body is completely depleted—like a car running out of gas. Interestingly enough, Ben’s surroundings directly impact the severity of his symptoms. The progressive nature of the disease, along with “kindling” (Question 66), has resulted in his suffering from serious delirium tremens (DTs) (see Questions 63 and 64). This condition, however, has only manifested itself in the hospital setting. During the times that he takes Ativan and withdraws at home, I watch very carefully for signs that he may be headed “off the reservation,” but it doesn’t seem to happen. There may be a lot of reasons for that, but I believe that the hospital setting elicits his anxiety much worse than the home environment.

11. Is alcoholism a disease or just a bad habit?

Dipsomania an uncontrollable urge or craving for alcohol. This is an old expression for an alcoholic.

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Alcoholism has actually had a long history of debate over its exact nature. Although alcoholism was always considered a scourge, Thomas Trotter, a doctor at the turn of the 19th century, was one of the first to relate alcoholism to the increasing numbers of patients in asylums. Doctors working in the asylums were seeing increasing numbers of patients suffering from mental illnesses as a result of alcoholism. Trotter considered the heavy drinker to be ill. Brühl-Cramer, a German doctor, also considered heavy drinking to be a disease and used the term dipsomania to describe the disorder. He went on further to state that the loss of moral

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judgment was a consequence and not the cause of the disease. Lippich (1799–1845), an Austrian doctor who followed 200 drinkers for 4 years, produced the first statistical evidence of the effects of alcohol and established that alcoholics were more prone to illness and had fewer children and shorter lives than the general population. Benjamin Rush, the revolutionary hero, considered the father of American psychiatry, published An Inquiry into the Effects of Ardent Spirits on the Human Mind and Body in 1784. He wrote that alcoholism was due to a loss of the will and that although it may have begun as a matter of choice it eventually became a necessity. E.M. Jellinek, a New England physician, was the first to attempt a classification of alcoholism. He founded the Research Council on Problems of Alcohol in 1937 and undertook the first serious statistical study of the problem in the United States, eventually published in 1942. His study demonstrated the failure of prohibition and showed the complexity and variability of drinking habits within populations across the United States. He was instrumental in getting the World Health Organization (WHO) to accept his definition of alcoholism and to define it as a disease. Jellinek was the first to describe alcoholism as a dependence that interferes with all aspects of one’s life, including a person’s mental health, bodily health, personal relationships, and occupational functioning. Because of that, he felt medical care was necessary. Alcoholism became known as Jellinek’s disease. There has been a long-standing historical tradition that alcoholism is not simply a matter of choice because the

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There has been a longstanding historical tradition that alcoholism is not simply a matter of choice because the consequences of the behavior are so selfdestructive that no one in his or her right mind would ever choose such a course of action.

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consequences of the behavior are so self-destructive that no one in his or her right mind would ever choose such a course of action. The emphasis has been consistently placed on the loss of control that the alcoholic experiences in his or her attempts to stop despite such obviously destructive consequences. This criterion defines the boundary between the normal and the pathological and not the amount or frequency of one’s alcohol consumption. Mounting biological and psychological evidence continues to show that people struggling with alcoholism are different from the normal population. There are many ways to try to understand and dissect the behavior of an alcoholic, and no one doubts that the behavior is abnormal; however, calling alcoholism a disease suggests that it is the result of a specific pathophysiological process, which it clearly is not. Alcoholism is more likely the final end product of varying conditions, but so are obesity, heart disease, and cancer. Many people are quick to criticize the disease concept because the social consequences suggest that if we do not hold alcoholics responsible for their behavior then the “disease” provides an excuse for the lack of control and continued drinking. In fact, no evidence exists showing that people with alcoholism need an excuse to drink. Quite the opposite occurs—calling alcoholism a moral failing, a disease, or a disorder does not change the alcoholic’s self-destructive behavior and the problems associated with that behavior. It only changes the perceptions of people who have reasons to treat alcoholics as either ill or contemptible. As Shakespeare so eloquently wrote, “A rose by any other name smells just as sweet.”

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Susan’s comment:

The Basics

People often deem alcoholism as a lack of self-control, even those who display the same characteristics in other areas. For example, Ben’s older sister has always struggled with her weight, but her brother’s illness/behavior has still been very difficult for her; she is unable to hide her disappointment and anger. This, of course, hurts him, which elicits anger in me. Several months ago, after another of Ben’s relapses on an important occasion, she was very frustrated, leading her to be unkind, pompous, and judgmental. As she was berating her brother, I could feel the anger building in me. I asked her whether she thought that Ben had a lack of self-control. She exclaimed, “ Yes, I certainly do.” I then asked her to explain the difference between his lack of selfcontrol with alcohol and her struggle with weight. Of course, she was furious because I had struck her where it hurt. This is only one example of how alcoholism has the potential to gut family relationships.

12. What causes the disease of alcoholism? The facile answer would be drinking alcohol in excess causes alcoholism, but that begs this question: Why do some people drink to excess, whereas others do not? Why can some people drink larger quantities than others and suffer no ill effects? If alcoholism is a disease (see Question 11), then it should be considered a disease of lifestyle—that is, alcoholism is the consequence of particular cultural and environmental forces playing on one’s biological predisposition. Consequently, multiple causes, rather than one simple cause, must exist. This is true for most medical conditions. The three leading causes of death—heart disease, stroke, and cancer—are all diseases of lifestyle. For

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example, consider the link between smoking and lung cancer. Smoking did not exist in Western culture until the discovery of the New World in the late 15th century. For centuries later it gradually took root as an acceptable and perhaps even healthy habit. It was only in the last 50 to 60 years that doctors began to suspect that it was responsible for the rise in lung cancer. Still, it took many years of statistical analysis before scientists could demonstrate a clear causal link between cigarette smoking and lung cancer. Even this statistical analysis required a cultural shift to accept that fact. Even today, people argue, “My grandmother smoked her entire life and died at the ripe old age of 90 from natural causes. How can cigarettes possibly cause cancer?” The reality is that cigarette smoking is only one piece, albeit a big one, of the causal puzzle that leads to lung cancer. Instead, when physicians talk about cause, they are really talking about various risk factors that influence the odds of developing a particular illness. This is discussed at greater length in Questions 21 and 22. Alcohol use is a necessary but not sufficient cause in the development of alcoholism. A variety of sources inside and outside of a person impact the odds of becoming alcoholic. The biopsychosocial model provides a framework for understanding the multifactorial causes of alcoholism. In this model, considerations are given to biological, psychological, and social factors that influence the odds of developing any particular disease. This model provides a greater understanding of “diseases of lifestyle.” For example, applying the biopsychosocial model to lung cancer demonstrates the biological risk factors of family history, the presence of particular genetic markers, and the direct effects of particular carcinogens acting

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Biologically, alcoholism is associated with changes in various neurotransmitter levels and activity. Additionally, alcoholism frequently runs in families, suggesting a genetic, or heritable, aspect to the illness. Psychologically, certain personality types are more prone to developing alcoholism. People who are antisocial or prone to risk taking are more likely to abuse drugs and alcohol. Also, people who are anxious, particularly in social situations, are susceptible to alcohol abuse and dependence. Socially, alcoholism is linked to stressful life events, usually entailing an overwhelming psychological trauma. Individuals with a posttraumatic stress disorder (PTSD) are more prone to alcoholism. In summary, no one cause of alcoholism exists. It is a multifactorial disorder caused by a genetic predisposition, personality traits, psychological trauma, and environmental factors. Susan’s comment: The “biopsychosocial” model can easily be applied to Ben. Biologically, a very significant family history of alcohol abuse exists on both sides. In addition, Ben suffered a skull fracture in three places as a result of a fall when he was 2.5 years old. Two CAT scans of his brain about 2 years apart in the past 5 years reveal “diffuse cerebral atrophy fairly severe for the patient’s age.” Everyone agrees that there is a

The Basics

on the tissues; psychological risk factors of addictive personality, and/or certain mental illnesses such as schizophrenia, that make an individual more prone to smoking; and the social risk factors of exposure to peers who smoke, the person’s diet and activity level, or exposure to other environmental toxins. All of these factors influence the odds of having lung cancer.

People who are antisocial or prone to risk taking are more likely to abuse drugs and alcohol. Also, people who are anxious, particularly in social situations, are susceptible to alcohol abuse and dependence. Posttraumatic Stress Disorder (PTSD) a mental/emotional disorder that is characterized by persistent distressing symptoms lasting longer than 1 month after exposure to an extremely traumatic event.

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relationship between that event and how severe his disease is. If nothing else, this serves as more evidence that it is “not his fault,” which a mother needs to believe. Psychologically, Ben was diagnosed with moderate to severe ADHD in the fourth grade, but at the time, I was not a believer in a condition that seemed like an excuse for lack of attention and laziness. He was excitable as a small child, and as he grew, that turned into serious anxiety. Socially, Ben’s father lost his business in a very public and humiliating way, a consequence of drinking, about a year after the first withdrawal. Along with that, Ben’s accustomed lifestyle was lost: his own convertible, a waterfront house with a boat, country club membership, etc. In addition, Ben’s dad also had a much-loved girlfriend who died suddenly at around the same time. Currently, the worst source of inner conflict for him is his relationship with his father, who still drinks actively. I have done everything to keep them apart but have failed, and the loyalty of this son to his father is both destructive and unshakable. My remarriage almost 6 years ago has been a huge adjustment for Benny, who was used to having me all to himself.

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PART II

Diagnosis What is the DSM-IV?

What is alcohol dependency?

What is alcohol abuse?

More . . .

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13. What is the DSM-IV? DSM-IV and DSM-IV-TR are the abbreviations for Diagnostic and Statistical Manual of Mental Disorders (IV refers to the 4th edition, and TR stands for text revised). This is considered the standard diagnostic manual for establishing the diagnosis of various mental disorders. In its introduction, a few caveats are outlined. First, the term “mental disorder” implies a distinction from “physical” disorders that is a relic of mind/body dualism. Second, the term “‘mental disorder’ lacks a consistent operational definition that covers all situations.” Third, the categorical approach has limitations in that discrete entities are assumed when in fact there are no absolute boundaries dividing one disorder from another. Fourth, the criteria for each disorder serve as guidelines only and should not be applied in either a “cookbook fashion” or in an “excessively flexible” manner. Finally, the purpose of the manual is primarily to enhance agreement among clinicians and investigators, and it does not imply that any “condition meets legal or other nonmedical criteria for what constitutes mental disease, mental disorder, or mental disability” (see the Introduction and Cautionary Statement of DSM-IV-TR). You should keep these caveats in mind, as it is easy to get caught up in a physician’s diagnosis, believing that it is set in stone, which it is not. As new information is acquired about treatments, the diagnoses and treatment plans are very likely to change. Additionally, it is not uncommon for clinicians to disagree on the diagnosis because of the previously mentioned caveats. After an initial assessment, when reading the various criteria individually, it may be easy to assume accuracy and jump to the conclusion that criteria have identi-

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Any set of psychological symptoms must either impair functioning or cause significant distress in order to qualify as a psychiatric disorder. It is easy to make assumptions and/or come to false conclusions with this last criterion as a guide. What constitutes distress or disability is often a quality-of-life issue. If a Harvard-educated MBA holds a midlevel job in a small company, does that mean that he or she has not risen to an expected potential? Consequently, he or she may be labeled as “disabled” or “distressed” because of the perceived lack of success. If he or she is a daily drinker, was it the drinking that led to his or her lack of progress? Was it simply a lifestyle choice of wanting to leave the rat race? Ultimately, only that individual can answer such questions; however, with the guidance of a good therapist, honest answers may be found. Unfortunately, we live in a culture that increasingly stresses material wealth as the final measure of success. This can and has led to a lot of “distressed” individuals in our society who all too often search for “therapeutic” solutions for their misguided sense of “failure.”

14. What is alcohol dependency? According to the ASAM, addiction and dependency are interchangeable terms (see Question 7). In the mid-1980s, the WHO operationalized the concept of dependence syndrome, adapted by both the DSM and

Diagnosis

fied the condition. Only time and the guidance of a skilled clinician, who is probing and comprehensive in his or her questioning, will help to establish a diagnosis that leads to an effective treatment plan.

According to the ASAM, addiction and dependency are interchangeable terms (see Question 7).

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ICD (International Classification of Diseases this is the World Health Organization’s manual for classifying all diseases, including mental illness and substance abuse.

ICD (International Classification of Diseases) committees. The syndrome refers to a cluster of physiological, behavioral, and cognitive processes. The DSM-IV-TR delineates these processes with the following specific criteria as described in Table 2. Because only three of seven criteria are required to meet the diagnostic requirement for dependence, whereas tolerance and withdrawal are prominently featured, they are not necessary to meet the definition of

Table 2

DSM-IV-TR Criteria for Alcohol Dependence

A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: • There is a need for markedly increased amounts of alcohol to achieve intoxication or desired effect. • There is a markedly diminished effect with continued use of the same amount of alcohol. 2. Withdrawal, as defined by either of the following: • For the characteristic withdrawal syndrome for alcohol, refer to DSM-IV. • Alcohol is taken to relieve or avoid withdrawal symptoms. 3. Alcohol is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire, or there are unsuccessful efforts to cut down or control alcohol use. 5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Source: The American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV-TR, p. 197). Washington, DC: Author.

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Diagnosis

dependency. Therefore, there is the possibility that an individual can be dependent without developing tolerance or withdrawal. There is also the possibility that a person can develop tolerance and withdrawal without actually being dependent. This is an important concept that requires further explanation. Dependency’s distinction from tolerance and withdrawal is one of the greatest sources of confusion with respect to drugs in general and alcohol more specifically. Many prescription and nonprescription medications on the market can cause tolerance and withdrawal syndromes. The most obvious drug that people think about in terms of dependency includes the prescription pain medications called opiates. Everyone who takes these medications on a regular basis will develop some level of tolerance and withdrawal, and therefore, the medications must be tapered in order to avoid withdrawal symptoms. As the criteria demonstrate, the experience of tolerance and withdrawal alone does not mean that a person has developed an addiction or dependency to medication. Many medications that cause tolerance and withdrawal are never thought of as addictive, including some antihypertensive medications, anticonvulsant medications, steroids, and antidepressant medications. Physicians have never regarded any of these as addictive. Alternatively, many street drugs do not cause any measurable physiological changes in the body that could be labeled as tolerance or withdrawal, but nevertheless, these are some of the most highly addictive substances known to humans. This then leads to a humorous irony. When certain medications are prescribed for their psychotropic effects rather than any

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other effects they might have, such as antidepressants and antianxiety agents for depression and anxiety as opposed to migraines or seizures, evidence of tolerance and withdrawal is immediate proof of addiction, despite the fact that no other criteria of dependence are met while using these medications. At the same time, many argue that because some street drugs show no evidence of tolerance or withdrawal, they are absolutely not addictive. Again, as the criteria explicitly state, if the drug does not become a central activity in people’s daily lives (the other five criteria delineated essentially fall under the concept of “loss of control”), then they are not addicted or dependent on the drug. There is, however, another source of unending confusion, which is semantic in nature. Conflating the DSM definition of dependency with the common definition of dependency can only be thought of in a pejorative way. This only further confuses the concept. People depend on all kinds of things that are specific to their individual needs. A diabetic, for example, is dependent on his or her insulin, a paraplegic on his or her wheelchair, and a person with schizophrenia on his or her antipsychotic medication. Under these circumstances, being dependent on something on a daily basis to restore one’s health and allow one to improve his or her ability to function in the world is a good, not bad, thing. Unfortunately, the pejorative term for dependency has led many patients to refuse or stop necessary treatments simply because of the belief that it is an addiction and a sign of weakness or moral failing. Again, the larger culture is at work on this issue, where any form of reliance on anything or anyone outside of oneself is a sign of weakness.

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15. What is alcohol abuse?

Abuse is often diagnosed in individuals who recently began using alcohol. Over time, abuse may progress to dependence; however, some alcohol users abuse alcohol for long periods without developing dependence. The difference between dependence and abuse is most obvious in terms of the issue of tolerance and withdrawal. As was earlier pointed out, however, tolerance and withdrawal are not necessary to the diagnosis of dependence. Using ever-increasing amounts of alcohol

Abuse is the selfadministration of any drug in a culturally disapproved manner that causes adverse consequences.

Table 3 DSM-IV-TR Criteria for Alcohol Abuse • A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) • The symptoms have never met the criteria for substance dependence for this class of substances. Source: American Psychiatric Association. (1994). DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision, p. 199). Washington, DC: Author.

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Diagnosis

Abuse is the self-administration of any drug in a culturally disapproved manner that causes adverse consequences. The National Institute on Alcohol Abuse and Alcoholism defines alcohol abuse as “a maladaptive drinking pattern that repeatedly causes life problems.” The DSM-IV-TR defines alcohol abuse in Table 3.

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Using everincreasing amounts of alcohol and spending everincreasing time in pursuit of alcohol (along with the negative consequences as defined in abuse) are sufficient issues to warrant the diagnosis of dependence.

and spending ever-increasing time in pursuit of alcohol (along with the negative consequences as defined in abuse) are sufficient issues to warrant the diagnosis of dependence. Thus, someone may periodically misuse alcohol in a way that gets him or her into trouble, but his or her use never escalates to the point of dependence.

16. How do you know whether you are an alcoholic? As noted Questions 14 and 15, alcoholism refers to the two DSM-IV-TR categories of alcohol abuse and dependence. The simple answer, therefore, is that if an individual fits either of those categories, then he or she is an alcoholic. The more complex answer takes into consideration the caveats noted in the previous answer about the limitations of the DSM-IV-TR. Should the following criteria be used to define alcoholism: “an inability to fulfill a major role” or “recurrent use despite social or interpersonal problems such as arguments with one’s spouse about the consequences of intoxication”? What does “often” mean? One patient reported that her alcohol counselor compared her high level of functioning despite her “alcoholism” to Winston Churchill’s alcoholism. Her response to the comparison was curt, but to the point, “And where would England be today if he had been forced into a rehab during the war?” It is important to distinguish between quantitative and qualitative differences. A quantitative difference between a regular drinker and an alcoholic suggests a slippery slope downward. The line must be drawn somewhere along that slippery slope between the nor-

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Diagnosis

mal, regular drinker; the heavy but functional drinker; and the abnormal, pathological alcoholic. The qualitative difference between a drinker and an alcoholic suggests that these two different individuals represent distinct types or categories. Nothing in the diagnostic and medical literature actually represents such clear distinctions. Where should the line be drawn between normal blood pressure and hypertension? Between being merely overweight and obese? Between precancerous tissue and cancer? Between heavy drinking and alcoholism? Clearly there are types, according to diagnostic criteria, that everyone can agree on as representing hypertension, obesity, cancer, and alcoholism; however, that still does not capture a large number of people who fall somewhere in between. The line is drawn depending on risk. For example, when looking at hypertension, studies demonstrate that blood pressure higher than 140/90 for people over the age of 18 years has a dramatically increased risk of heart attacks or strokes compared with those with blood pressures that are lower than those numbers. Increased risk is not a guarantee, just a higher probability. How many drinks you consume daily can also be measured against risk but offers no guarantee either. The easiest way to understand this is to think of buying a lotto ticket. Buying two tickets may double your chances of winning, but the odds still remain infinitesimal. Consider the example of a person who drinks three drinks five times a week and on two occasions up to six drinks. Clearly this person’s alcohol use is heavy, but what if this person has never missed work, has never had relationship difficulties, has never had an eye opener, has never shown up to an important engagement intoxicated or endangered himself or herself

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DWI a legal acronym for driving while intoxicated.

To reiterate, alcoholism does not depend on the amount or frequency of alcohol used!

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because of intoxication, but noticed after stopping for a couple of days some mild withdrawal symptoms such as tremors and insomnia. Out of concern, he or she sees the doctor for a physical examination, including laboratory studies, and everything is found to be entirely normal. This person clearly demonstrates tolerance and withdrawal, but this person does not meet the criteria for either alcohol abuse or dependence! Contrast this with a person who drinks only on weekends but drinks to the point of passing out every time and has no idea how much he or she consumes, has had several DWIs, and has been told by the physician that he or she has alcohol-induced liver disease. Despite these consequences, the person can neither control the amount that he or she drinks nor stop drinking. This person has never experienced withdrawal symptoms. Nevertheless, this person does meet the criteria for alcohol dependence! To reiterate, alcoholism does not depend on the amount or frequency of alcohol used! A third scenario includes those people who call themselves alcoholics but have absolutely no objective pathological evidence to support their belief. Their livers are fine. They have never needed hospitalization or detoxification. They have never shown up to work drunk. Nobody has ever witnessed them misusing alcohol. For them, however, they felt that alcohol was playing a role in their life that was leading them down a path toward eventual self-destruction. They somehow understood their vulnerabilities and headed them off at the pass or at least believed strongly enough that that is what they needed to do. Are they really alcoholics who stopped their disease dead in its tracks? Many people who are alcoholic remit spontaneously. They decide one day to stop, and that is the end of it.

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To understand the validity and reliability of screening tools, you must understand that they are measured and compared in terms of sensitivity and specificity. Sensitivity refers to the ability to identify correctly those individuals who are true alcoholics in a population. Specificity refers to the ability to correctly identify those individuals who are clearly not alcoholics. Tests that have high sensitivity and specificity are valid and reliable. No test, not even specific laboratory tests, is 100% sensitive and specific. False positives and negatives exist for every test. That does not make them useless. Keep these concepts in mind when considering the use of the various screening tools used. Several screening tools are available to identify alcoholism. In 1982, the WHO developed the AUDIT, which is an abbreviation for Alcohol Use Disorders Identification Test. It was designed as either a brief structured interview or self-assessment to be incorporated into general health screening or during a general medical history. AUDIT has 92% sensitivity and 94% specificity. This means that it correctly identifies 92 of 100 alcoholics and 94 of 100 nonalcoholics (see Table 4 for the complete screening tool).

Validity the accuracy of the outcome of a test or instrument (i.e., the extent to which a test or instrument measures what it intends to measure). Reliability the ability to reproduce the same outcomes upon repeated testing. Sensitivity probability of a positive test among patients with a particular disease. Specificity probability of a negative test among patients without disease. A very specific test, when positive, rules in disease.

Because many felt that the AUDIT was too time consuming, shorter versions were developed. These shortened versions, known as the AUDIT-PC, AUDIT-C, and FAST, essentially contain the first three or four questions of the AUDIT. Needless to say, they are not

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17. What are the screening tools available for alcoholism, and are they reliable?

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52 Table 4 The AUDIT The Alcohol Use Disorders Identification Test is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

1. How often do you have a drink containing alcohol?

Never

2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have six or more drinks on one occasion?

1 or 2

Monthly or less 3 or 4

2–4 times a month 5 or 6

2–3 times a week 7–9

4 or more times a week 10 or more

Monthly

Weekly

4. How often during the past year have you found that you were not able to stop drinking after you had started? 5. How often during the past year have you failed to do what was normally expected of you because of drinking? 6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the past year have you had a feeling of guilt or remorse after drinking? 8. How often during the past year have you been unable to remember what happened the night before because you had been drinking? 9. Have you or has someone else been injured as a result of your drinking? 10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?

Never

Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly

Monthly

Weekly

Monthly

Weekly

Monthly

Weekly

Monthly

Weekly

Monthly

Weekly

Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily

Scoring: Less than 10 does not require additional medication.

Never

Never Never Never Never

No No

Yes, but not in the past year Yes, but not in the past year

3 Points

4 Points

Yes, during the past year Yes, during the past year

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as valid, and thus, they require the person administering the test to question further when a concern is identified. The first question in FAST—“How often do you have eight or more drinks on one occasion?”—correctly identifies up to 70% of hazardous drinkers who answer either weekly or daily/almost daily. Thus, it can be administered rapidly, and one need not ask additional questions unless someone answers the first question as monthly, less than monthly, or never. CAGE is another common screening tool. CAGE is the mnemonic for the four questions asked: (1) Did you ever feel the need to Cut down on your drinking? (2) Have friends or family Annoyed you by criticizing your drinking? (3) Have you ever felt bad or Guilty about your drinking? (4) Have you ever had a drink in the morning, an Eye opener, in order to get rid of a hangover? This was developed in 1974 and focuses on lifetime rather than current drinking. It is the most widely used in clinical practice and takes only a minute to administer. Two positive responses are considered a positive result. Because CAGE does not focus on patterns and amounts of drinking, it does not identify currently hazardous drinking. Sensitivity ranges from 60% to 90% and specificity from 40% to 95%. In order to avoid the lengthiness of AUDIT and limitations of CAGE, the Five-shot screening tool was developed that incorporated the first two questions of the AUDIT with three questions from the CAGE. This includes two questions regarding frequency and the amount of alcohol with three basic questions from the CAGE and their various responses as noted in Table 5. At a cut off score of 2.5, the Five-shot tool was found to

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54 Table 5 The Five-shot Questionnaire

How many drinks containing alcohol do you have on a typical day when you are drinking?

Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over?

Other scores use a different scoring range for women when the number of drinks typically consumed is considered. Total score = SUM (points for all 5 questions). Interpretation: minimum score: 0 maximum score: 7 A score of 4 or more is seen in male alcoholics. Performance: A score of 3.0 was 77% sensitive and 83% specific for moderate or heavy drinking. The overall accuracy was 83%. A score of 4.0 was 56% sensitive and 94% specific. The overall accuracy was 90%. A score of 5.0 was 29% sensitive but 98% specific. The overall accuracy was 90%.

0 0.5 1.0 1.5 2.0 0 0.5 1.0 1.5 2.0 0 1 0 1 0 1

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Never Monthly or less often 2 to 4 times per month 2 to 3 times per week 4 or more times per week 1 or 2 3 or 4 5 or 6 7 to 9 10 or more No Yes No Yes No Yes

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have a sensitivity of 96% to 100% and a specificity of 76%, which provides an overall accuracy of 78%.

Diagnosis

MAST, the Michigan Alcohol Screening Test, was developed in 1971 to detect alcohol dependency. The original tool was 25 questions in length, but this too has been modified to provide for more rapid screening. Its major drawback is its emphasis on lifetime drinking rather than current patterns of alcohol use; thus, it is a poor tool for early detection. Its sensitivity is 86% to 98%, and its specificity 81% to 95%. Primary care physicians have found it difficult to incorporate screening tools into their practices. This occurs for a variety of reasons: Time constraints often preclude their ability to screen every possible problem that may be hidden from them adequately, fears of offending their patients often cause discomfort in broaching the subject, and finally, a sense of helplessness in being able to refer the patient to the appropriate care if the problem is identified. One way around this discomfort is to reframe the questions in as positive and nonthreatening manner as possible. For example, instead of asking a leading question from the CAGE (“you’ve never tried to cut down on your drinking, have you?”), you ask the more positive question (“you’ve tried to cut down on your drinking before, right?”), as if to imply we have all tried to cut down on our drinking. Because a large proportion of traumas are alcoholrelated patients, they are first asked to answer a series of questions regarding any history of trauma on their general health questionnaire:

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1. Have you had any fractures or dislocations to your bones or joints? 2. Have you been injured in a traffic accident? 3. Have you ever injured your head? 4. Have you ever been injured in a fight or assault? If the patient answered yes to one or more of these questions, an additional question was asked: 5. Did any of these injuries occur during or after alcohol use? If the patient answered positively to two or more questions, the physician would then ask about frequency and quantity of alcohol use. If consumption was high, the physician then asked the CAGE questions. This method reduced the number of patients asked about alcohol to one in seven and identified one in four of trauma patients as having an alcohol problem. This screening system correctly identified 70% of alcoholics and was felt to be reasonably unobtrusive. Interestingly, in the primary care setting, the sensitivity and specificity of the various screening tools differ than in the research setting. For example, the CAGE has been found to be only 62% sensitive for males and 54% sensitive for females in the primary care setting. The AUDIT was found to be more sensitive than the CAGE, though still less so than in the research setting. The other downside of the AUDIT is its lengthiness. As a result of these retests, at least in England, the Five-shot was ultimately found to be the quickest and most effective screening tool to administer, with a sensitivity and specificity of 63% and 95%, respectively. What is the utility of screening tools independent of

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Susan’s comment: Like many of you who read this book, my struggle with my son’s addiction to alcohol didn’t start when he began to drink. I still say that I wasn’t in denial. I really had no idea that he was different—different from all his friends who did all of the same things, or so I thought. Somehow I turned the other way when some signs were revealed. Because his father, my exhusband, was and still is an active alcoholic, it was easy to believe that all of those empty vodka bottles hidden around the house belonged to him. It has taken me a long time to realize that I wanted to believe the excuses Ben gave me. Actually, he was in denial for a very long time even after I faced the horrible truth. It was a very slow process getting him to “get his arms around” being an alcoholic. For me, not one day goes by that I don’t look at other males his age and wonder why my son is totally disabled by something that all of his friends did with no consequence, something that is part of all my extended family’s “war” stories, something that society thinks I should be ashamed of, and something that may cause this mother to bury her only son.

Screening tools are found to influence patient behavior alone, with reductions in alcohol consumption occurring simply by bringing it to the patient’s awareness and attention.

Everyone who loves an alcoholic has his or her own way of coping. Mine has been to do three things: (1) to see to it that my only son gets every chance to live by any means necessary, (2) to be very forthcoming regarding his condition so that he doesn’t ever feel that I am a part of the overwhelming shame I know he feels, and (3) to study alcoholism extensively in an effort to understand “the enemy.” Those things have often resulted in tears, heartbreak, and despair. Most of the time, however, I have felt

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intervention? Screening tools are found to influence patient behavior alone, with reductions in alcohol consumption occurring simply by bringing it to the patient’s awareness and attention.

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relief that my son and I were not alone in his suffering. My husband, not Ben’s father, wishes that I would be much less open about his “problem,” but I function as I must—one day at a time. Incidentally, of the words abuse, addiction, and dependency, I find that the use of “dependency” is the least of the “evils.”

18. What is the difference between type I and type II alcoholics? The pursuit of categorizing subtypes of alcoholics has been an ongoing one for at least the past 200 years. Jellinek was the first physician to subdivide alcoholism into four distinct phases: the prepathogenic period consisting of occasional symptoms of alcohol abuse, a pathogenic period consisting of a prodromal phase, a crucial phase, and a chronic phase. The prodromal phase was notable for the onset of blackouts, the crucial phase by the onset of loss of control, and the chronic phase by prolonged intoxication. The rate at which individuals pass through these phases appeared to follow two distinct patterns and was associated with distinguishable personality characteristics that are now referred to as type I or type A alcoholics and type II or type B alcoholics. Studies suggested the following distinguishing features between type I and type II alcoholics: Type I characteristics include an onset later in adulthood; drinking to relieve anxiety; the development of psychological but not physical dependence; and finally, although it may be inherited, usually an environmental trigger. Type II characteristics include an association with criminal behavior (sociopathy); an onset in teen or early adult years; drinking specifically to get high; and finally, more likely inherited. Sons of type II alcoholic

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persons are seven times more likely to develop type II alcoholism compared with the general population. A recent Korean study published in 2005 demonstrated that a link exists between the gene coding for the enzyme known as alcohol dehydrogenase that breaks down alcohol into acetaldehyde and type II alcoholics. The theories from these studies remain controversial; however, recent evidence of varying responses to particular psychotropic medications based on one’s particular subtype adds further support. These medications are discussed in detail in Question 52. Data on daughters of persons with alcohol problems are less clear. Daughters might be at an increased risk if the biological mother is alcoholic, but these studies do not delineate between subtypes. A recent twin study in women found higher concordance in identical twins than in fraternal twins. Susan’s comment: Like any other theory, the distinction between type I and type II alcoholism is not as simple as it may seem, and Ben is an example. Although his history indicates type II alcoholism, he has never demonstrated violence or sociopathic behavior; however, the notion of different “types” does provide some guidelines that more people should be aware of. Too many type I alcoholics mistake type II alcoholics as the only type. In that way, they can stay in denial regarding their own consumption because they can function most of the time.

19. Are there any biological tests that aid in the diagnosis of alcoholism? No biological test is available that alerts a patient or physician about whether an individual is at risk of becoming an alcoholic if he or she drinks regularly.

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The science of alcoholism is still far away from discovering specific genetic markers to identify those at risk; however, some biological tests help to identify those patients who have developed medical consequences of repeated heavy drinking. These tests are not specific for alcoholism per se. The fact that one has biological findings suggestive of alcoholism, therefore, is not a definitive test of one being an alcoholic. Nor is it the case that the absence of such biological findings rules out any possibility that one is an alcoholic. Many alcoholics never develop any laboratory abnormalities as a result of their drinking. To reiterate why there is this phenomenon, recall that the diagnostic criteria for alcohol dependence and alcohol abuse discussed earlier in Questions 13 and 14 do not require such evidence to establish the diagnosis.

Biological tests for alcoholism measure both the direct and indirect effects of chronic alcohol use on one’s body. GGT (Gamma Glutamyl Transpeptidase) a liver enzyme that when elevated is associated with alcoholic liver disease (among other diseases).

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However, the biological effects of chronic heavy alcohol use result in laboratory findings that demonstrate a consistent and reliable pattern. For this reason, anyone presenting to a physician’s office with this pattern will be asked in detail about his or her pattern of drinking and, in all likelihood, will be told to stop all drinking no matter how much or little alcohol is consumed. This is because—even if the laboratory abnormalities are not a result of alcohol—alcohol may be contributing to the problem irrespective of whether someone is an alcoholic. People with hepatitis should not drink for any reason. Biological tests for alcoholism measure both the direct and indirect effects of chronic alcohol use on one’s body. Alcohol’s most direct impact is on the liver, leading to hepatitis, with a characteristic increase in various chemistries, most notably GGT (gamma-glutamyl transpeptidase), but also AST

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Chronic alcoholism also affects the hematological system. Alcohol has both direct and indirect effects on this system. First, most alcoholics use alcohol as their primary source of calories. This inevitably leads to severe vitamin deficiencies, notably the B vitamins, thiamine, and folate. These, in turn, lead to anemia that is known as macrocytic, meaning that the red blood cells are enlarged. This causes a low hemoglobin and hematocrit associated with an elevated mean corpuscular volume. Direct effects of alcohol, however, can affect the entire hematological system, including the white blood cells, which are a part of the body’s immune system, the red blood cells, which carry oxygen throughout the body, and finally the platelets, which are involved in the clotting process. Alcohol suppresses all of these, leading to anemia, immunosuppression, and thrombocytopenia, or a lowering of

AST (Aspartate Aminotransferase) an indicator of acute liver disease. See ALT. ALT (Alanine Aminotransferase) an indicator of acute liver disease. See AST. Carbohydratedeficient transferrin a protein found in blood involved in transferring iron to cell tissues. Clotting factors a group of proteins specifically designed to interact together to cause blood to clot and stop bleeding. Thiamine vitamin B1. Macrocytic from “macro” for large and “cytic” for cell. Primarily in reference to large red blood cells from thiamine deficiency (pernicious anemia) that is common in chronic alcoholics whose nutrition is poor. Hematocrit measures of the proportion of blood volume that is occupied by red blood cells.

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(aspartate aminotransferase) and ALT (alanine aminotransferase). GGT is the most sensitive in detecting alcohol consumption and therefore monitoring relapse, but false negatives and false positives do exist. Carbohydrate-deficient transferrin is another biomarker; though less sensitive, it is more specific for alcoholism. AST and ALT are elevated in all forms of hepatitis and are not particularly sensitive but are more specific in detecting the affects of alcohol consumption. They are also late-stage indicators that may normalize after maintaining about 6 weeks of sobriety. Because the liver is involved in the production of clotting factors, these can be affected by alcohol’s effect on the liver, leading to increased bleeding times.

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Mean corpuscular volume a measure of the size of the red blood cells. Anemia a deficiency of red blood cells. Immunosuppression involves an act that reduces the activation or effectiveness of the immune system. Thrombocytopenia the presence of relatively few platelets in blood. Platelets also known as thrombocytes. A type of blood cell involved in the cellular mechanisms of the formation of blood clots.

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the platelets, which leads to prolonged bleeding and easy bruising. Additionally, potassium, phosphate, calcium, and magnesium levels can be affected in chronic alcoholism. Other effects of alcoholism on the body will be further detailed in questions 61 and 62.

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PART III

Risk, Prevention, and Epidemiology What is the prevalence of alcohol use and alcoholism?

What is the risk of inheriting alcoholism?

What other risk factors are associated with alcoholism?

More . . .

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20. What is the prevalence of alcohol use and alcoholism? Prevalence refers to the current number of people suffering from an illness in a given year. This number includes all of those who have been diagnosed in prior years as well as in the current year. Per capita alcohol consumption has declined from its peak in 1980 of 2.8 gallons per year to its current level of about 2.2 gallons. Rates vary regionally and are higher in New England and lower in the Midwest and Southeast, with Florida as the exception. Amounts peak in the 18- to 29-yearold group and then gradually decline. Currently, nearly 14 million Americans, or 1 in every 13 adults, abuse or are dependent on alcohol.

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Currently, nearly 14 million Americans, or 1 in every 13 adults, abuse or are dependent on alcohol. About 4.6 million of these individuals are women. When considering percentages, the following apply to the U.S. adult population: • • • • • • •

Current drinkers: 44% Former drinkers: 22% Lifetime abstainers: 34% Abuse and dependency in the past year: 7.5% to 9.5% Lifetime prevalence: 13.5% to 23.5% Adult hospital inpatients: 20% Emergency room visits that are associated with alcohol: 10% to 46% • Patients in community-based primary care practices who engage in at-risk drinking: 1 in 6 • Traffic fatalities in 1998 that were related to the presence of alcohol in one or more of the accident participants: 38% • The U.S. adult population who were currently abusing or dependent on alcohol and that had received any treatment in the 12 months before interview: 10%

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• Individuals with a past diagnosis of alcohol dependence who reported ever having any kind of alcohol treatment: 28% • People who recovered from a previous alcohol disorder and who did so without having received any treatment (often termed “natural recovery”): 75% • Costs for alcoholism each year in the United States: $185 billion In contrast to the U.S. statistics, the WHO examined mental disorders and found that alcohol dependence or harmful use was present in 6% of patients evaluated in primary care offices worldwide. In Britain, one in three patients in community-based primary care practices had at-risk drinking. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.

21. What is the risk of inheriting alcoholism? Increasingly, all kinds of conditions or diseases are attributed to genes. What exactly does this mean? Genes are a series of molecules that are passed on from parents to children. They provide a code for proteins. Proteins are the workhorses that make people into who they are physically, cognitively, and behaviorally. The question of what genes do in coding for people’s personalities and behavioral propensities has never been completely understood. The cascade of interacting effects that begins with a series of genes transcribed into a protein that ultimately leads to a propensity toward alcoholism is too vast to be fully elucidated. Consider a simple trait that is fully determined, such as eye color. Even in the instance where

Gene a specific sequence of nucleotides in the DNA and RNA, which is a unit of inheritance that controls the transmission and expression of specific traits in people and other living organisms. Scientists and clinicians believe that alcohol dependence and abuse is influenced by genetic factors.

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Mendelian the central tenets of genetics developed by Gregor Mendel. They relate to the transmission of hereditary characteristics from parent organisms to their children; they underlie much of genetics. Muscular dystrophy a group of heritable diseases characterized by the progressive wasting of muscles. Cystic fibrosis an inherited disease found in Caucasians that appears early in childhood. Phenylketonuria an inherited metabolic disease that causes mental retardation because of the inability to oxidize the metabolic product of phenylalanine. Down’s syndrome a person with Down’s syndrome is mentally delayed and has characteristic facial features.

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the likelihood of two blue-eyed parents having a blueeyed child is almost certain, it remains possible for them to have a brown-eyed child possibly due to local environmental, albeit biological, effects. Environment actually entails not only what people commonly think of including their culture, nationality, occupational choices, friends, family, how many bars and liquor stores are available, but also local cellular environments that include other genes, proteins, and various chemicals interacting on a specific gene—then one begins to appreciate the complexity of the question. It is difficult enough to work out the influence that genes have on physical structures. No scientist has yet to predict with 100% accuracy how genes determine the developmental biology of even simple organisms. Genes are not a blueprint in the way that blueprints are conceived. If biological development is so fraught with unpredictability, imagine the degree of difficulty in being able to predict behavioral problems as a result of genetic influences.

Genetic and Environmental Factors The range in which genes and the environment interact is vast, from clear but not 100% predictable genetic determinism to unclear genetic influence. The diseases that are clearly genetic are generally single gene errors that follow Mendelian patterns of inheritance. The scientist Gregor Mendel, who was the first man to demonstrate how patterns of inheritance can be mathematically described, explained the Mendelian or Gene Theory. Such diseases include muscular dystrophy, cystic fibrosis, and phenylketonuria. There are also genetic diseases that are not inherited per se, but rather are due to direct damage to the genes. The most common example is Down’s syndrome. Finally, there

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are polygenic diseases, meaning that multiple genes are involved in influencing the development of a particular disease. These diseases include cancer, heart disease, diabetes, and most mental illnesses.

Inheritance The question of inheritance often implies genetic inheritance, entailing a sense of predestination or determinacy. The underlying theme behind the idea of inheritance is that it is beyond one’s control, and therefore, the individual is not held responsible for his or her actions. This concept is fraught with ethical and political overtones that have been discussed at some length previously. To say that genes determine a particular outcome is to lead to misconceptions. There are a myriad of influences that genes are subject to both before and after they code for a particular protein that are not immediately determined. Alternatively to say that the environment escapes deterministic notions is equally absurd. People not only inherit their parents’ genes, but also their parents’ home and culture. They have no more choice about the environment they were born into than they have about their parents’ genes.

Nature Versus Nurture The misconception is that if a set of behaviors is due to a person’s genes, then it must be an illness that requires medical treatment, but if the behaviors are due to a poor environment, then the illness must be due to a social, political, or moral problem (see Question 10 again to review the issues surrounding voluntary behavior). The real questions are as follows: What are the various genetic and environmental influences? How much does each contribute to the development of an individual’s physical, cognitive, and behavioral

The underlying theme behind the idea of inheritance is that it is beyond one’s control, and therefore, the individual is not held responsible for his or her actions. This concept is fraught with ethical and political overtones that have been discussed at some length previously.

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For example, by studying the offspring of alcoholics, we know that of 100 people with alcoholism, 18 will have children who will also become alcoholics, whereas of 100 people who are not alcoholics, only 5 will have children who will become alcoholics. Concordance rates the rate at which genetically related individuals share with one another a particular trait.

makeup, or what are their contributions to a disease? All that can really be done is to examine a population of related individuals and note the variations in both a particular behavior and a group of symptoms and their genetic relatedness. For example, by studying the offspring of alcoholics, we know that of 100 people with alcoholism, 18 will have children who will also become alcoholics, whereas of 100 people who are not alcoholics, only 5 will have children who will become alcoholics. These statistics still do not allow us to specifically predict the 18 who will develop the condition and the 82 who will not. The two biggest studies on alcohol and genes are twin studies and adoption studies. A third study was designed in the laboratory.

Twin and Adoption Studies Twin studies focus on the relationship of identical twins to fraternal twins and their varying rates of alcoholism. If alcoholism is inherited, identical twins ought to become alcoholics at greater rates than fraternal twins because they share 100% of their genes—in contrast, fraternal twins share only 50% of their genes. A number of studies have consistently shown higher concordance rates for drinking behavior and possibly alcoholism in identical twins compared with fraternal twins. The heritability estimates for genetic influence account for between 50% and 60% of the variation in the risk for alcoholism in males. Studies of female twins, in contrast, however, demonstrate smaller rates of concordance, although studies using populationbased twin registries have found that genetic influences on alcoholism to be of similar magnitude in both males and females. What evidence is found from adoption studies? Adoption studies examined biological children of alcoholic

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parents adopted into nonalcoholic homes and biological children of nonalcoholic parents adopted into alcoholic homes. If environment plays a greater role, then the home a child is raised in will have the greatest influence in the development of alcoholism. If, on the other hand, genes play a greater role, then the child’s biological parents will have the greatest influence in the development of alcoholism. In all studies of male adoptees, those whose biological parents were alcoholic were at a significantly higher risk for alcoholism than were children whose biological parents were not alcoholic (i.e., 1.6 to 3.6 times greater). These data portray a genetic contribution to the risk for developing alcoholism. The studies of female adoptees demonstrated mixed results, perhaps providing some evidence of possible sex differences in heritability, but the numbers of alcoholic female adoptees in the studies were too small to draw any definitive conclusions. In the laboratory, one is able to measure subjective and objective responses to the consumption of alcohol and compare those responses between sons of alcoholics and nonalcoholics. The sons of alcoholics report decreased subjective ratings for feeling intoxicated, and they objectively had evidence of intoxication given the same amount of alcohol as sons of nonalcoholics. The study population consisted of white male college students who drank alcohol but were not alcohol dependent. Ten-year follow-up data were recently published for these young men. Of the sons of alcoholics, 26% were alcohol dependent by 30 years old, as opposed to 9% of the control group whose fathers were not alcoholic. Furthermore, 56% of the sons of alcoholics who reported fewer objective and subjective reactions to alcohol became alcohol dependent, as opposed to 14% of the sons of alcoholics who did not report decreased

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Amygdala attached to the tail of the caudate structure of the brain that is considered a part of the limbic system.

reactions. Few sons of nonalcoholic fathers became alcoholic. There are some biological propensities toward alcoholism that are independent of but may be influenced by genes. Finally, a study examining the brains of alcoholic versus nonalcoholic subjects found that the amygdala is smaller in subjects with family histories of alcoholism, suggesting that inherited differences in brain structure may also affect risk. The amygdala is an area of the brain that is thought to play a role in the emotional aspects of craving, which can lead to addiction.

22. What other risk factors are associated with alcoholism? The concept of risk is a modern one. The word derives from the Italian riscare, meaning “to dare.” Before such a concept, the future could only be predicted by consulting the gods, prophets, or astrologers, and when bad things happened, they were attributed to fate. The concept of risk was born out of a simple yet practical question regarding games of chance when money was at stake. Given certain known events that just occurred in the game, what are the odds for winning the game? From there, everything about predicting the future grew, and forecasting with degrees of certainty for future events of all kinds developed. Humans, however, are poor at assessing risk, and as a result, they are lousy predictors of the future. Studies have regularly demonstrated that humans overly focus on sensational events that are highly unpredictable to the exclusion of much more mundane events that pose greater risks and are more predictable. The most common example of this is fear of flying because of plane crashes and more recently terrorism, yet the person doesn’t give any thought that driving

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one’s car to work daily poses a far greater risk. The lesser fear associated with driving one’s own car comes from both the illusion of control and its daily occurrence. A less common but more recently described sensational example is the risk associated with swimming pools verses guns. What is more dangerous: a swimming pool or a gun? This answer, based on simple statistics, is swimming pools. In 1997, 550 children who were 10 years old and younger drowned in swimming pools. There are 6 million swimming pools in the United States, which translates statistically into one drowning annually for every 11,000 pools. In 1998, 175 children 10 years old and younger died as a result of guns. Approximately 200 million guns are in the United States, translating into one death for every million guns. Thus, if you own both a gun and a swimming pool, your child is 100 times more likely to die from the swimming pool than the gun. Knowledge of risk provides some power over predicting future events so as to make the odds more favorable to attaining one’s goals. For example, although wearing seat belts does not change the odds of getting into an accident, it does change the odds of surviving one. In medicine, knowledge of risk helps the clinician understand the odds of developing certain diseases. Remember, however, that odds, no matter how favorable or unfavorable, are still just odds, with the outcome for any particular event still unknown. Just because the odds of developing lung cancer are greater for one who smokes a pack of cigarettes a day than one who does not does not mean that the outcomes are certain. Some risk factors you can change, and other risk factors you cannot. Individuals cannot change the genes inherited from their parents, but they can use the

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Individuals cannot change the genes inherited from their parents, but they can use the knowledge of their family history to help make choices in life to reduce other risk factors contributing to the probability of developing a particular disease.

knowledge of their family history to help make choices in life to reduce other risk factors contributing to the probability of developing a particular disease. Modifiable risk factors are those factors that can be changed, such as stopping smoking, changing one’s diet and exercise regimen, or abstaining from alcohol. Other opportunities for “beating the odds” include following the recommendations for various diagnostic tests for breast cancer, colon cancer, and heart disease, depending on whether someone has a family history for a particular condition. Now that you have been introduced to the concept of “risk,” here are some of the risk factors associated with alcoholism. Being poor and uneducated increases the risk for alcoholism. George Valliant, the doyen of alcohol research, found that innercity, non–college-educated men began drinking approximately 10 years earlier than collegeeducated men. They were also more likely not to drink, but if they drank, they were more likely to die as a result of their drinking. This fact demonstrates that it is not the frequency of alcohol consumption as much as it is the pattern of alcohol consumption that places a person at risk. Mortality from both groups, however, was more commonly related to tobacco use. Being Caucasian or Hispanic as opposed to African American increases the risk for alcoholism. Additionally, Native Americans tend to have the highest rates of alcoholism, whereas Asian Americans have the lowest. This may be partly due to the genetic variation in alcohol-metabolizing enzymes alcohol dehydrogenase, which depends on one’s race (see Table 6).

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Table 6 Genetic Variation in Alcohol-Metabolizing Enzymes • Alcohol Dehydrogenase Polymorphism occurs at ADH2 and ADH3 gene

White American African American Asian

ADH2*1

ADH2*2

ADH2*3

ADH3*1

ADH3*2

95% 85% 15%

< 5% < 5% 85%

< 5% 15% < 5%

50% 85% 95%

50% 15% 5%

15% of African Americans have the ADH2*3 allele, causing an increased alcohol metabolic rate and an increased elimination of acetaldehyde. • Aldehyde Dehydrogenase (ALDH) 85% of Asians have the ALDH2*2 allele, causing a decreased elimination of acetaldehyde (and alcohol) and flushing response

Males are at greater risk for alcoholism than females. Lifetime prevalence was 20% in men and only 8% in women. When examining rates in the past year, they are 10% and 4%, respectively. This is partly attributed to the fact that women do not metabolize alcohol as efficiently as men and thus are more prone to the immediate negative effects of it. When women do develop problems with alcohol, they tend to develop them later in life, tend to combine alcohol with prescription drugs, and are less likely to be recognized as having a problem or receive treatment for their problem. This may be because women are less likely to work outside of the home, and thus, they are less exposed to the financial, occupational, and legal troubles that may accompany heavy drinking. Finally, as you age, the prevalence of alcoholism decreases. The prevalence of alcoholism in people over 65 years old is around 3%; however, these numbers may not be as reliable and are harder to recognize, and

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less alcohol is required to cause a significant problem for the individual.

23. Are certain religious groups at greater risk for alcoholism? Religious and cultural differences also influence the risk for developing alcoholism. By far, the groups associated with lowest risk have been Jews and Muslims, but it appears to be for very different reasons. In Judaism, wine is used primarily ritualistically from a very early age, and thus, patterns of use are established early and maintained throughout one’s religious life. Judaism as a faith offers no real moral opinion on the use of alcohol, but through practice, it offers examples of a balanced, moderate approach to its use. Although occasional drunkenness is tolerated, repeated examples can lead to isolation from the community. Islam, on the other hand, strictly prohibits the use of alcohol. This is interesting because the Koran is no more disapproving of wine than the Bible and because the prophet Muhammad looked on wine as the embodiment of well-being, wealth, and fertility and recommended moderation. The early history of Islam has many examples of regular alcohol use among its practitioners; however, because of the rise of conservatives throughout the Muslim world during the last few centuries, alcohol consumption has been strictly prohibited. This may partly have been due to an attempt to demonstrate outwardly Islam’s uniqueness from the other religions. The Bible generally describes moderate use of wine without condemnation; it does contrast that with

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The Bible generally describes moderate use of wine without condemnation; it does contrast that with drunkenness, which it clearly condemns.

24. How do African Americans, Hispanics, Native Americans, and Asian Americans compare with respect to risk of developing alcoholism? African Americans Depending on the study, young African American men either drink less or have similar drinking patterns as young white men. Clearly fewer binge drinking episodes exist in black universities as compared with white universities. Black women drink less then their white counterparts; however, blacks suffer more from health problems related to alcoholism, such as cirrhosis of the liver, alcohol-withdrawal delirium, esophageal cancer, and so forth. Most legal problems stem from drug use. The prison population is made up more of cocaine users than alcoholics.

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drunkenness, which it clearly condemns. Catholicism and Protestantism, on the other hand, generally view alcohol as a potential evil and alcoholism as a sin, but the emphasis in books, catechisms, sermons, and pastoral addresses is typically focused on issues of sex, such as masturbation, premarital and extramarital sex, abortion, and artificial insemination to the exclusion of drunkenness. With an emphasis on the sinfulness of virtually all pleasurable activities, along with the general silence regarding drunkenness, as opposed to other overindulgences, the inability to develop an institutionalized reliable response leads parishioners to vacillate between abstinence and overindulgence without any real opportunity to develop models for moderate ritualized use.

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Hispanics Hispanics are the second largest ethnic group in the United States and constitute an extremely diverse group because of their varying ethnic backgrounds and openness to intermarriage. Thus, keep that in mind when examining the evidence. Among the largest group of Hispanics are Mexican Americans, followed by Puerto Ricans and Cubans. These three groups have different cultural heritages and different economic and geographical distributions. Mexican Americans have higher rates of alcoholism than other Hispanic groups. Puerto Ricans have higher rates of cocaine dependence. Inhalant use is more common among Cubans in South Florida. When Mexican Americans acculturate to the United States, their use of alcohol increases further.

Native Americans There are 400 recognized tribes in the United States, with each having different customs and rituals, values, and beliefs. These differences reflect not only cultural variations but genetic variations as well; however, there does seem to be a genetic vulnerability to alcohol that is common to all, including the Native Alaskans, whose modern history was less traumatic than their lower continental counterparts. The predisposition has not yet been fully elucidated and probably has to do with the population’s lack of exposure to alcohol until late in its evolutionary history. Other factors also play a role that cannot be denied, such as their displacement, a lack of economic opportunities, and resulting poverty. A large percentage of Native Americans are sent to boarding schools, which only increases their risk of developing alcohol and other drug-dependent prob-

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lems on their return home. Selling alcohol to Native Americans was illegal until 1953 when they were granted full citizenship. The incidence of alcoholism among Native Americans is twice the national average. Tribal rates of adolescent suicide, auto accidents, child abuse and neglect, and spousal abuse differ and can be directly linked to the rates of alcoholism.

Asian Americans Asian Americans constitute the fastest growing minority in the United States. They also are an extremely diverse group, as Asia is the largest continent in the world but also geographically encompasses groups from its far western regions such as Turks and Arabs that are more European to its far eastern outposts in the Pacific such as Samoa that are not part of the Asian continent. The largest groups consist of Chinese, followed by Filipinos, Indians, and Vietnamese. The vast majority is either on the west coast in Chicago or New York City, but the southeastern states are growing. National surveys have difficulty capturing such a large and diverse population, and thus, conclusive generalizations cannot be made. Asian Americans tend to have the lowest rates of alcoholism among all U.S. citizens. Asians are far more likely to use alcohol rather than other drugs. Teen alcohol use is growing probably with the acculturation to the United States. Still, within-group differences do occur, with Koreans having higher rates then Chinese. Vietnamese teens have the highest rates of drug and alcohol abuse among Asian Americans. Genetic differences appear to play an important role in rates of alcoholism among Asian Americans, as demonstrated in Question 22 (Table 6).

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25. What is the morbidity and mortality associated with alcoholism? A curious fact about health care in the past 50 to 70 years has not been the great technological developments that have sprung up but the general eradication of many of the infectious diseases that once took a devastating toll on the younger and older populations. Although the most dramatic improvements in morbidity and mortality in human history are attributed to improved hygienic measures (potable water, plentiful noninfected food, vaccine programs, proper waste management), the last half century has improved on those foundations to the point where the most dangerous diseases are now associated with a largesse of resources.

The total burden of disease related to chronic alcohol use accounts for 7% in North America.

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The leading cause of death, cardiovascular disease, is clearly associated with our changing lifestyle, which is now largely sedentary and given to overconsumption. Cancer, the second leading cause of death, is also due to lifestyle issues, which includes not only tobacco, but also diet and exposure to environmental carcinogens as well. Thus, alcohol-related morbidity and mortality may be considered to be in good company, as there are 85,000 deaths annually attributed to its overuse, at least half from accidents directly related to it, whereas the other half from diseases associated with it. This number may seem large, but it pales in comparison to cardiovascular disease and cancer. It is another curious fact that cancer and cardiovascular diseases associated with lifestyle choices are not viewed with the same “jaundiced eye” as those associated with alcoholism. The total burden of disease related to chronic alcohol use accounts for 7% in North America. Worldwide, the burden can be broken down into the following problems:

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• Cirrhosis: 32% • Motor vehicle accidents: 20% • Traumatic brain injury patients that have been drinking: More than 50% • TBI patients are three times more likely to sustain a second head injury. After their second TBI, they are eight times more likely to sustain a third head injury. • Mouth and oropharyngeal cancers: 19% • Esophageal cancer: 29% • Liver cancer: 25% • Breast cancer: 7% • Homicides: 24% • Suicides: 11% • Hemorrhagic stroke: 10% • Leading cause of death among persons under 44 A standard drink is defined as one 12-ounce beer, one 5-ounce glass of wine, or one mixed drink containing 1.5 ounces of spirits (80 proof ); the relative risk for the noted maladies with consumption of four or more drinks daily is as follows: • Cirrhosis: for men, 7.5; for women, 4.8 • Injuries: for men, 1.3 • Ear, nose, and throat cancer; esophagus cancer; liver cancer: for men, 2.8; for women, 3 Drinking more than one standard drink daily appears to increase the risk of breast cancer in women. Recent data suggest an increase in coronary calcification with moderate alcohol consumption in young adults. Binge drinking exacerbated this effect. Binge drinking is defined as four drinks in a row in women and five drinks in a row in men. In men 18 to 25 years old, 60% report that they binge drink. This activity significantly increases the risk of injury, the risk of acquiring a

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Half of all violent crimes are alcohol or drug related, and 60% to 70% of domestic violence incidents involve alcohol.

Epidemiological the basic science of public health, having to do with epidemiology. Antisocial personality disorder (ASPD) an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture is pervasive, inflexible, and most often has an onset in late adolescence.

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sexually transmitted disease, the risk of assault, the risk of unwanted pregnancy, and the risk of harming an unborn child (see Questions 75 and 76). Half of all violent crimes are alcohol or drug related, and 60% to 70% of domestic violence incidents involve alcohol. A strong association exists between alcohol and tobacco use. People who start smoking early are more likely to develop problems with alcohol, and those who develop alcohol-related problems will have a harder time quitting smoking.

26. What is the link between alcoholism and violence? The association between drinking and crime was first made in London during the 18th century during an era known as “the gin craze,” although overcrowding and unemployment may have played a larger role than cheap gin. Whether or not it was drinking or poverty and overcrowding, the era engendered the notion that alcoholism was the cause of the poor becoming violent. In the past century, research has consistently linked alcohol intoxication and violence. This has come from both epidemiological as well as experimental studies. For example, a positive correlation exists between the quantity of alcohol consumed and the frequency of a wide variety of violent acts, including sexual assault, child abuse, and homicide. This is particularly true for people with antisocial personality disorder (ASPD), or what is better known as sociopathy. As a group, antisocial individuals have higher rates of alcohol dependence and more alcohol-related problems than the general population, but alcoholism makes constitutionally aggressive individuals more aggressive

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whether or not they are antisocial. Violent offenders in state prisons frequently report having used alcohol before their offense. Approximately 50% of sexual assaults involve alcohol consumption by the perpetrator, the victim, or both. Alcohol is a factor in 60% to 70% of homicides, 40% of suicides, and 38% of fatal motor vehicle accidents. Likewise, in laboratory studies, people with ASPD show greater increases in aggressive behavior after consuming alcohol than people without ASPD. The association between ASPD and alcohol-related aggression may result from biological factors, such as ASPDrelated impairments in the functions of certain brain chemicals (e.g., serotonin) or in the activities of higher reasoning, or the executive brain regions. Alternatively, the association between ASPD and alcohol-related aggression may stem from some undetermined factor(s) that increases the risk for aggression in general.

Executive functions brain functions involving planning and decision making.

Not all people exhibit increased aggression under the influence of alcohol. There is an enormous variation in the way people behave when they drink. In some Scandinavian and Anglo-American societies, alcohol is associated with violent and antisocial behavior, whereas in Mediterranean and some Asian societies, drinking behavior is largely nonviolent. This variation is clearly related to different individuals, as well as cultural beliefs about the expectations of how alcohol intoxication affects behavior. In other words, alcohol consumption promotes aggressive behavior in individuals or societies where it is expected to and the society accepts it as a consequence. This has been borne out by research that studied the effects of people who believed they

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had drunk alcohol and then began to act more aggressively, regardless of whether they actually consumed the alcohol. Societal expectations that alcohol promotes male aggression against both other males and toward females, combined with the widespread perception that intoxicated women are sexually receptive, probably account for the association between drinking and sexual assault.

27. Is there a gateway drug that can lead to alcoholism? The concept of a gateway drug has always been controversial. For many years, it was identified as marijuana. To a large extent, this has been debunked; however, children are continuing to experiment with drugs of all types, and the drug that is most available and easily accessible becomes the drug that is first used. For those children who are at risk for developing alcoholism, their first drug does not seem to matter so much as the fact that they use it. Children 12 to 17 years old who use marijuana are 85 times more likely to use cocaine; children who drink are 50 times more likely to use cocaine, and those who smoke are 19 times more likely to abuse other drugs. Additionally, these numbers increase the younger the child is at first use. Because alcohol is often found in peoples’ homes, it often becomes the first drug that children use. Because of its accessibility, the number one problem for children remains alcohol abuse. Lately children have been using inhalants and over-the-counter medications to get high because those are easier to obtain. Finally, never underestimate the use of tobacco. This is truly a gateway drug that leads to other drug and alco-

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28. I read somewhere that drinking alcohol was good for you. Is that true?

Neurochemical a broader name for neurotransmitter. Any chemical that has effects on nerve cells.

Maybe. Experts for many years have discussed the idea that a moderate intake of alcohol may actually be beneficial to one’s health, although it has only recently received any major press coverage. There has been concern about the potential for misinterpretation of the message if it were spoken too openly. The concept that moderate alcohol may be beneficial, after all, flies in the face of those who preach complete abstinence. So what exactly are the benefits? Statistical analysis has shown that total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption. This is thought to be due to reductions in the risk of developing diabetes and cardiovascular disease. The amount of alcohol associated with the lowest mortality appears to be two standard drinks per day in men and one standard drink or fewer per day in women. More recent studies refute that, however, stating that the previous studies were flawed and that moderate alcohol use confers little to no benefit,

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hol use. For one reason, it is generally not associated with intoxication or behavioral impairment, and thus, parents are sometimes more accepting of its use. For another reason, children are much more willing to report tobacco use then they are other drug use because it is more socially acceptable. Tobacco is perhaps the most addictive substance known. It has unique properties through dose titration of being both a stimulant and an antianxiety agent. It is therefore a drug for all occasions, but tobacco’s neurochemical effects are similar to other drugs in boosting dopamine in the brain, which stimulates the reward system.

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whereas greater use clearly confers greater risk of many diseases. The window between health “giving” and health “taking” is very narrow.

29. What is a safe level of alcohol consumption? If a person is alcohol dependent, then no level is safe. If an individual is concerned that he or she may be a problem drinker, it is important to understand the information in Table 7. Even individuals who never exceed the daily or weekly limit are not entirely immune from the possibility of alcohol abuse or dependence, however low the risk. For individuals who exceed the daily and weekly limits regularly, however, only one in five will develop abuse, and one in four will develop dependence. Although these numbers are draTable 7 Amount of Alcohol Associated with Risk of Dependence or Abuse Drinking pattern no more than 4 per day and 14 per week for men and 3 per day and 7 per week for women Never exceeds weekly or daily limit Exceeds only the weekly limit Exceeds only the daily limit one time per week Exceeds only the daily limit more than one time per week Exceeds both the weekly and daily limits

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Prevalence in U.S. adults 18 years and up (%)

Abuse without dependence

Dependence with or without abuse

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Less than 1 in 100

Less than 1 in 100

1

1 in 17 (6%)

1 in 100 (1%)

16

1 in 8 (12%)

1 in 20 (5%)

3

1 in 5 (19%)

1 in 8 (12%)

9

1 in 5 (19%)

More than 1 in 4 (28%)

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matically higher, the fact that a person drinks that much is still no guarantee that he or she will become ill. As stated in Question 16, the reason is that although increasing amounts of consumption may increase the odds of developing the disease, it is not dependent on the frequency or the amount of use, but rather the consequences of one’s use. These facts are probably the strongest evidence that supports the concept of alcoholism as a disease because although the disease of alcoholism is clearly linked to alcohol use, there is no guarantee that one will develop the disease—just as smoking cigarettes does not absolutely determine that the individual who smokes will develop lung cancer or emphysema even though both are clearly the consequences of chronic smoking. The risks increase dramatically when the daily limits are exceeded, as demonstrated in Table 7.

30. What is a dry drunk? The concept of a “dry drunk” is controversial. No systematic personality studies have demonstrated the validity of this concept, yet its application persists in the recovery field. The concept of a dry drunk is generally linked with Alcoholics Anonymous (AA) and is used to describe the individual who has stopped drinking but continues to display the thinking and behavior of an active alcoholic. Its origins are derived from two sources. The first source is from the early founders of AA, and the second source can be found in the work of Dr. Elizabeth Kubler-Ross, the first physician to elucidate the stages of grief and loss. A dry drunk exhibits specific personality traits, and these individuals are thought to be “one-steppers”—that is, they have only completed the first step toward abstinence, without achieving true sobriety. AA has developed 12 steps

The concept of a dry drunk is generally linked with Alcoholics Anonymous (AA) and is used to describe the individual who has stopped drinking but continues to display the thinking and behavior of an active alcoholic.

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that an individual must complete in order to reach sobriety and a full recovery. The traits of a dry drunk or one-stepper consist of the following: • • • • • • • • •

Grandiose behavior A rigid, judgmental outlook Impatience Childish behavior Irresponsible behavior Distorted rationalization Projection Overreaction Exaggerated self-importance and pomposity

Another source that can be used to understand the phenomenon of the dry drunk may be from the work regarding the stages of grief and loss that Elizabeth Kubler-Ross developed. Dr. Kubler-Ross purported that any loss that significantly impacts a person’s daily life is accompanied by a number of stages of grieving, which include denial, anger, bargaining, depression, and finally acceptance. To an alcoholic, abstinence usually constitutes a big loss. Unfortunately, according to the theory of the dry drunk, alcoholics often get stuck in the stage of anger. Thus, they are constantly irritable and find it difficult to engage interpersonally. Although the validity of this remains hazy at best, it does make intuitive sense. Alcoholics and all addicts, in order to maintain abstinence, lose a huge part of what constituted their daily activities, in terms of thinking about, pursuing, and engaging in alcohol consumption. Many alcoholics and addicts also lose friends who were their “drinking buddies.” The only possible way to get over a consuming activity is to replace it with other activities. Until that happens the ever-present feeling of loss will remain extremely palpable. The chances of being irritable and

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edgy as a result of the frustration at not acting on those desires will continually plague the recovering addict or alcoholic. Irritability often leads to poor interpersonal interactions with family, friends, and other acquaintances. Thus, the consequences of alcoholism both medically and socially can continue even though sobriety has been achieved.

31. My mother has been drinking wine daily since my father died. Could she be an alcoholic, or does she need treatment for depression? The possible risk of an untreated depression is the development of co-morbid substance abuse, including alcohol abuse. Alcohol and drugs make people feel better temporarily; unfortunately, however, this effect is only temporary. As the high wears off, despair can set in. After the death of a spouse or other close family member, if excessive drinking develops, depression may be present. Alcohol abuse can often be missed in older women, particularly if it involves only wine or beer consumption. Alcohol abuse can cause depression itself—in such circumstances, recovery from the substance abuse usually leads to resolution of the depression. Depression often precipitates the abuse of alcohol and/or drugs as an attempt to relieve the emotional pain and thus acts as a treatment for the depression; however, traditional medical treatment for depression will be necessary in order to promote the recovery from the substance abuse (see Question 68 for further discussion on mood disorders and alcoholism). Alcoholism is an arguable risk factor associated with depression or other mood disorders because it remains

Alcohol abuse can cause depression itself—in such circumstances, recovery from the substance abuse usually leads to resolution of the depression.

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Regardless of whether alcoholism causes depression or depression causes alcoholism, alcohol to a depressed person is clearly like throwing an incendiary device on a dry, brittle forest.

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scientifically unclear how the two are associated. Generally, in patients with true depression, the symptoms exist independently of the amount of alcohol consumed, and the symptoms will not improve simply by maintaining abstinence. Second, in individuals in whom alcohol is clearly playing havoc with their moods, generally a lot of environmental stressors exist as a consequence of the alcoholism that impacts on mood independently of alcohol’s direct biological effects. Losing a job, a broken marriage, poor financial supports, or a lack of housing as a result of the singleminded pursuit of alcohol all impact a person’s mood. In this situation, merely taking an antidepressant medication with the thought that the problem is depression is akin to ignoring a broken leg by treating it with only pain medication. Generally, if in one’s past a person has had significant periods of sobriety in which mood symptoms have abated, then the depression is more likely caused by the alcohol than an underlying mood disorder. This is not definitive, just more likely. Regardless of whether alcoholism causes depression or depression causes alcoholism, alcohol to a depressed person is clearly like throwing an incendiary device on a dry, brittle forest. The chances of a depressed person attempting suicide are doubled when that person drinks. Therefore, for any improvement in mood to occur, the person must stop drinking immediately; for many people with depression, however, this simple task seems not only absurd (it often becomes their only pleasure), but also close to impossible. As a result, the alcohol problem must be treated along with the depression. For most people, just telling them to stop drinking will not suffice. Support and persistence are required. Support may or may

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not come from programs such as AA, but it must come from family and friends. The more support systems that an alcoholic has, the better his or her chances are for a successful recovery.

32. Am I at risk for other kinds of addictions if I have been addicted to alcohol? Alcohol shares many properties in common with other drugs of abuse. Chemically it acts on dopamine, the final common pathway of all drugs of abuse and the instrumental chemical in the brain’s reward system. Alcohol also acts on opiate receptors, which are the target of opium and its variants, namely heroin. There is a theory based on the discovery of a chemical found in the brains of alcoholics known as tetrahydroisoquinolone (THIQ). The theory is that THIQ, which is a breakdown product of heroin and is also highly addictive, is uniquely produced in alcoholics. THIQ leads to both intoxication and withdrawal, similar to other sedative hypnotics and opiates. Physiologically, alcohol addiction and heroin addiction share a similar chemical in common leading to euphoria, tolerance, dependency, and craving. Environmentally, alcohol and heroin share many of the ritualized behaviors that become linked to the pleasure of using other substances. Although many people have a drug of choice, the likelihood of developing an addiction to another substance when one is addicted to alcohol is certainly higher than when a person is not addicted at all. If an individual is in recovery, all of the doctors must know so that they can choose medications with the least addictive potential

Tetrahydroisoquinolone (THIQ) a chemical compound that can be formed by combining acetaldehyde (the toxic breakdown product of alcohol) and dopamine (the neurotransmitter). It is thought to be specific for alcoholics and has opioid-like activities causing euphoria, thereby explaining their increased propensity toward addiction when compared to the normal population.

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and so that they can monitor the effects of the medications and therefore reduce the potential for addiction.

33. What are some of the triggers to relapse?

Euphoric a happy and elated mood.

The triggers to relapse are numerous but can be boiled down to extremes in emotion. Feeling sad or angry or let down or disappointed may lead to frustration and a careless attitude toward one’s current success. “Who cares?” is a sentiment that can echo in the bottle. Euphoric feelings from achievement or success can lead to complacency and a desire to “celebrate.” An alcoholic’s excuses to drink are endless. As one alcoholic said to another, “Don’t give me any of that BS about why you drink! You drink because you’re thirsty!” Although triggers are the final common pathway toward drinking again, specific triggers differ for each individual. Identifying the triggers is critical because you can then put into place a crisis plan to deal with them. The plan should include steps to be taken and who to turn to for support in order to avoid slipping, as well as a plan for an evaluation and the possibility of re-entry into treatment if a slip leads to the old patterns of drinking. Both your family and primary care physician should know the plan. If you are attending outpatient treatment, the staff should know the crisis plan. Relapse can rapidly progress to the point of even greater problems than before sobriety was attained. The chances for adverse effects are too great to take the chance of drinking again. The adverse effects include social, psychological, and physical problems, which often occur the second time to an even greater degree of severity.

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Risk, Prevention, and Epidemiology

Susan’s comment: I have had many conversations with Ben about what makes him relapse. His answer is twofold: He “picks up,” as they say in AA circles, as a result of what is referred to as frustration and carelessness. He expresses his sentiment as, “What the —?” He then explains the sad reality that after he starts, he must continue, so that he won’t get sick. Only a severe case of addiction can cause someone to drink so that they stay well.

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PART IV

Treatment Who is qualified to diagnose and treat alcoholism?

What is AA, and how does it work?

What is ASAM, and what are the criteria for placement in a particular program?

More . . .

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34. Who is qualified to diagnose and treat alcoholism?

The choice of the type of practitioner will depend on the need for therapy, medication, or both.

American Board of Psychiatry and Neurology the governing body that oversees clinical standards for both psychiatrists and neurologists and the various subspecialty fellowships such as child and adolescent psychiatry and addiction psychiatry.

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Many clinicians of various educational backgrounds are qualified to diagnose and treat alcoholism. The choice of the type of practitioner will depend on the need for therapy, medication, or both. Your internist or family practice doctor can diagnose and treat alcoholism to a limited degree, as can a nurse practitioner. This usually entails managing the medical consequences of heavy drinking, but may also include prescribing medication specifically indicated for alcoholism (see Questions 47–52). They will also refer you to a mental health specialist for a more in-depth evaluation. Some internists have specialty certification through the ASAM. Psychiatrists can also receive ASAM certification but often receive advanced fellowship training in addiction psychiatry through the American Board of Psychiatry and Neurology. Internists and psychiatrists typically oversee programs and evaluate and treat symptoms of withdrawal and any underlying medical and psychiatric problems that occur along with the alcohol problem. Psychologists, licensed clinical social workers who have specialized in addiction treatment, or other therapists who have received certification through one of a variety of programs depending on the discipline and the particular state in which they work provide most types of psychotherapies—individual, family, and group. Certification as an addiction counselor usually requires a minimum number of hours of supervised work (typically in the thousands). Addiction counselors may have only a high school diploma before they complete their supervised clinical work, but more typically, they have

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either an associate’s degree or a bachelor’s degree. Occasionally, they can also have a masters’ degree, but these degrees are more often associated with licensed clinical social workers. Addiction counselors are not authorized to specifically diagnose, but they do participate in evaluations and treatment. Mental health specialists who can evaluate for and treat alcoholism include the following: • Social workers • Psychologists • Psychiatric clinical nurse specialists or nurse practitioners • Psychiatrists

Social Workers Social workers provide a full range of mental health services, including assessment, diagnosis, and treatment. They have completed undergraduate work in social work or other fields, followed by postgraduate education to obtain a Master’s of Social Work or a doctorate degree. A Master’s of Social Work is required in order to practice as a clinical social worker or to provide therapy. Most states require practicing social workers to be licensed, certified, or registered. Postgraduate education includes 2 years with courses in social welfare, psychology, family systems, child development, diagnosis, and child and older person abuse/neglect. During the 2 years of coursework, social work students participate in internships that are concordant with their interest. After completion of the master’s program, direct clinical supervision is usually required for a period of time to apply for a license, which may vary from state to state.

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Psychologists Psychologists have completed undergraduate work followed by several years of postgraduate studies in order to receive a doctorate degree (Ph.D. or Psy.D.) in psychology. Graduate psychology education includes study of a variety of subjects, notably statistics, social psychology, developmental psychology, personality theory, psychological testing (paper and pencil tests to help assess personality characteristics, intelligence, learning difficulties, and evidence of psychopathology), psychotherapeutic techniques, history and philosophy of psychology, and psychopharmacology and physiological psychology. After the coursework, a year is spent in a mental health setting providing psychotherapeutic care and psychological testing under the supervision of a senior psychologist. Psychologists must demonstrate a minimum number of hours (usually around 1,500) before eligibility to sit for state psychology licensure exams.

The Psychiatric Clinical Nurse Specialists or the Nurse Practitioners Professional nurses, prepared with a minimum of a baccalaureate degree in nursing and advanced practice nurses, prepared at the master’s level, work with alcoholic and drug abuse patients. The baccalaureate degree in nursing most often works with patents in an inpatient setting and may or may not be certified in alcohol addiction, depending on the requirement of the agency. The professional nurse provides the direct care for the patient 24 hours per day. Both the nurse practitioner and the clinical nurse specialist work in both inpatient and outpatient settings; however, they are more frequently involved in community-based care. All three

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are schooled in general nursing, including psychiatric nursing, and have studied alcoholism. The focus of the nurse practitioner’s practice is on the physical health of the alcoholic or drug abuser. The nurse practitioner conducts physical assessments and prescribes medications, as well as monitors the patient’s response to the medications. The clinical nurse specialist’s focus is on the mental health of the patient and the family. The clinical nurse specialist conducts mental health assessments and mental status exams, facilitates groups, and works with both the patient and family to meet their mental health needs. All advanced practice nurses, both the clinical nurse specialist and the nurse practitioner, are certified by the American Nurses Association Credentialing Center, after receiving their master’s degree from an accredited college or university. All advanced practice nurses receive ongoing clinical supervision during their course of study. In many states, both the state board of medicine and the state board of nursing license the nurse practitioner, whereas the clinical nurse specialist is not under the jurisdiction of the board of medicine. The state board of nursing licenses all nurses.

American Nurses Association the American Nurses Association is a professional organization of nurses to advance the profession of nursing.

Psychiatrists Psychiatrists are medical doctors with specialized training in psychiatry. They have completed undergraduate work followed by 4 years of medical school. Medical education is grounded in basic sciences of anatomy, physiology, pharmacology, microbiology, histology, immunology, and pathology, followed by 2 years of clinical rotations through specialties that include medicine, surgery, pediatrics, obstetrics and gynecology, family practice, and psychiatry (as well as other elective clerkships). During this time, medical

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students must pass two examinations toward licensure. After graduation from medical school, physicians have a year of internship that includes at least 4 months in a primary care specialty such as medicine or pediatrics and 2 months of neurology. After internship, physicians must take and pass a third exam toward licensure in order to be eligible for licensure (and subsequently practice) in any state. Psychiatrists in training have 3 more years of specialty training in residency, the successful completion of which makes them eligible for board certification. After residency, many psychiatrists pursue further training in a fellowship that can last an additional 2 years. Such fellowships include child and adolescent psychiatry, geriatric psychiatry, consultation– liaison psychiatry, addiction psychiatry, forensic psychiatry, and research. To become board certified, psychiatrists take both a written and an oral examination. Certain psychiatry specialties also have a board certification process. Board certification is not a requirement to practice and may not be obtained immediately on completion of residency, although many hospitals and insurance companies do require physicians to be board certified within a specified number of years in order to treat patients.

35. What is AA, and how does it work? AA, or Alcoholics Anonymous, grew out of the Christian temperance movements in the 19th century. These movements were connected to local churches, and selfprofessed alcoholics who pledged abstinence formed them. A drinking buddy introduced the eventual founder of AA, Bill W., to one of these church groups. The buddy falsely claimed that he had been treated by Dr. Jung, who told him that he was a lost cause unless

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The 12-step approach works on developing strong social support networks and the use of role models. Thus, obtaining a sponsor is an important component toward successful sobriety. The sponsor should be older, sober, and the same gender in order to provide a mentoring role. The concept of a higher power deters people because they attribute a higher power to “God” and assume it is “faith based”; however, the required faith is in the 12-step process. The concept of faith is generic. For example, faith in a variety of authority figures is required in order to depend on their guidance, including doctors, other professionals, even mechanics, spouses, parents, and so forth. The type of faith that AA seeks to instill in its members has to do with the AA community and should not be mistaken for any specific religious faith. The important concept is that one cannot recover on one’s own. Thus, the “higher power” is the power that comes from faith in the community and the recovery process. It is important for the recovering alcoholic to understand his or her own personal limits in order to enlist the support of a community of members and have faith in the recovery process to achieve and maintain sobriety. The higher power is different for each person because everyone has unique challenges to achieve and maintain sobriety. The first several AA meetings may be uncomfortable and may seem foreign. The usual response is this: “I am not like these people.” They are too old, too young,

Treatment

he experienced a religious epiphany. AA grew slowly out of the roots of the Christian temperance movement, and in 1938, the Big Book was written and published. The AA name was first used along with the 12 steps that Bill W. developed.

The 12-step approach works on developing strong social support networks and the use of role models.

It is important for the recovering alcoholic to understand his or her own personal limits in order to enlist the support of a community of members and have faith in the recovery process to achieve and maintain sobriety.

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too ethnic, too white, too rich, or too poor. To address the initial reaction, there are a variety of meetings that comprise individuals of similar demographic backgrounds so that one can feel “more at home.” Although this may temper the initial discomfort, it is often the people that initially seem the most different that inevitably have the greatest impact in helping to maintain sobriety. The important lesson is to stick with it through the initial discomfort. Studies have shown that patients who attend regularly, as little as once a week, have better success rates than those who drop out (Tables 8 and 9).

Table 8 The 12 Steps 1. We admit we are powerless over alcohol—that our lives have become unmanageable. 2. We believe that a Power greater than ourselves can restore us to sanity. 3. We have made a decision to turn our will and our lives over to the care of God as we understand Him. 4. We have made a searching and fearless moral inventory of ourselves. 5. We have admitted to our God, to ourselves, and to another human being the exact nature of our wrongs. 6. We are entirely ready to have God remove all of these defects of character. 7. We humbly ask Him to remove our shortcomings. 8. We have made a list of all persons we have harmed and become willing to make amends to them all. 9. We have made direct amends to such people wherever possible, except when to do so would injure them or others. 10. We have continued to take a personal inventory and when we are wrong promptly admit it. 11. We have sought through prayer and meditation to improve our conscious contact with God, as we understand Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as a result of these steps, we have tried to carry this message to alcoholics and to practice these principles in all our affairs.

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Table 9 The 12 Traditions

36. What is ASAM, and what are the criteria for placement in a particular program? ASAM is the American Society of Addiction Medicine, the major certifying body for physicians trained in addiction medicine. ASAM sets the criteria for how patients are placed in particular treatment settings. The ASAM Patient Placement Criteria, 2nd Revision, or PPC-2R, provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of

Treatment

1. Our common welfare should come first; personal recovery depends on AA unity. 2. For our group purpose there is but one ultimate authority—a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern. 3. The only requirement for AA membership is a desire to stop drinking. 4. Each group should be autonomous except in matters affecting other groups or AA as a whole. 5. Each group has but one primary purpose—to carry its message to the alcoholic who still suffers. 6. An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose. 7. Every AA group ought to be fully self-supporting, declining outside contributions. 8. AA should remain forever nonprofessional, but our service centers may employ special workers. 9. AA, as such, ought never be organized, but we may create service boards or committees directly responsible to those they serve. 10. AA has no opinion on outside issues; hence, the AA name ought never be drawn into public controversy. 11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films. 12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

American Society of Addiction Medicine (ASAM) its mission is to train medicine student faculty and residents to provide treatment and rehabilitation and to develop strategies for prevention of alcoholism.

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care for each group. Generally, two distinct types of care exist: detoxification and rehabilitation. Here are the brief descriptions of settings and levels of services: • Level I: outpatient treatment. An organized outpatient treatment clinic or an office practice with designated addiction professionals providing alcohol or drug treatment. This treatment occurs in regularly scheduled sessions usually totaling fewer than 9 contact hours per week. An example includes weekly or twice-weekly individual therapy, weekly group therapy, or a combination of the two in association with regular participation in self-help groups. • Level II: intensive outpatient treatment. This is also known as an outpatient rehabilitation program. It is an organized program in which addiction professionals provide several treatment modalities. Treatment consists of regularly scheduled sessions within a structured program, with a minimum of 9 treatment hours per week and up to 6 hours daily. Examples include day or evening programs in which patients attend highly structured group and individual services. • Level III. This ranges from a halfway house to medically monitored intensive inpatient treatment. This is what is commonly thought of as rehabilitation and is an inpatient or residential program. It is an organized service conducted by addiction professionals who provide a planned regimen of aroundthe-clock professionally directed evaluation, care, and treatment on an inpatient setting. A multidisciplinary staff functions under medical supervision.

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• Level IV: medically managed intensive inpatient treatment. This is commonly thought of as acute inpatient care, but can also include either an emergency room or an inpatient psychiatric unit. It is an organized service in which addiction professionals —medical and psychiatric clinicians—provide a planned regimen of 24-hour medically directed evaluation, care, and treatment in an acute care inpatient setting. Patients generally have severe withdrawal and/or medical, emotional, or behavioral problems that require primary medical, psychiatric, and nursing services. Detox levels of care: • Level I-D: Ambulatory or outpatient detoxification • Level II-D: Ambulatory detoxification with onsite monitoring • Level III.2-D: Clinically managed residential detoxification • Level III.7-D: Medically monitored inpatient detoxification • Level IV-D: Medically managed intensive inpatient detoxification Clinicians have expressed a concern that placement standards may restrict some individuals from receiving the required level of care. Other concerns include the potential stifling of innovative treatment approaches. In response to those concerns, a study was conducted to examine the utility of the patient placement protocols, using a standardized computer algorithm as well as the input from a group of clinicians in placing patients in particular levels of care. The hypotheses

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Rehabilitation is a therapeutic intervention that attempts to provide the patient with the tools that he or she requires in order to maintain sobriety after returning to the community. Intensive outpatient treatment program (IOP) a program usually run by inpatient personnel, as part of the discharge plan for continuing follow-up treatment for their inpatients, upon discharge.

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tested were that patients matched to the recommended level of care would have better outcomes than those patients who were mismatched and received either undertreatment or overtreatment. The mismatched group of patients had no better outcomes than those matched to the appropriate levels of care. The mean number of days of any alcohol use during the last 30 days decreased for all groups, although those with matched care and overtreatment had better results. Surprisingly, the computer-driven algorithm assigned patients to overtreatment more frequently than clinician-recommended levels of care. In both cases, however, the study concluded that in general the ASAM patient placement criteria were effective in reducing both undertreatment and overtreatment.

37. What is rehabilitation, and how is it different from AA? Rehabilitation is a therapeutic intervention that attempts to provide the patient with the tools that he or she requires in order to maintain sobriety after returning to the community. Rehabilitation programs offer several levels of intensity of care as the patient placement protocols suggest. Rehabilitation generally offers very structured programs that include individual and group therapy as well as educational programming and occupational/vocational support. Additionally, either a psychiatrist or an internist who specializes in addiction medicine is available for consultation. These programs range in the degree of intensity from as little as 9 hours per week as defined by an intensive outpatient treatment program (IOP) to inpatient 24 hours a day 7 days a week for up to several months. AA is relatively unstructured, does not

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follow a specific didactic program, and relies completely on the fellowship of its members to provide the support necessary to maintain abstinence. Most addiction medicine specialists feel that AA alone is generally inadequate but is a critical adjunct to a well-structured rehabilitation program. AA is also required for follow-up after completing a rehabilitation program. These two treatment modalities are seen as complementary and not mutually exclusive. Rehabilitation is more comprehensive and follows a medical model. This has meant, at least in the past, that the concept of addiction as a disease was held to more strongly by rehabilitation programs and the use of medication more readily administered and accepted as an adjunct to care for the alcoholic. Only recently has AA become more accepting of that model, although members remain generally divided on which medications they are willing to consider as reasonable. Some AA members continue to condemn the use of various medications for either a psychiatric condition or their alcoholism.

38. What are the different kinds of outpatient and inpatient rehabilitations? IOPs and partial hospital programs (PHPs) generally differ in the amount of time that a person spends in them during the day. Insurance companies define those differences and thus determine whether they are willing to pay for one or the other. An IOP provides 3 hours of treatment daily for up to 9 total hours weekly (Monday, Wednesday, and Friday). A PHP offers a 4hour program daily for a total of 20 hours weekly (Monday through Friday). PHPs are generally used as a stepdown from an inpatient psychiatric stay, and then

Partial hospital program (PHP) a program usually run by inpatient personnel as part of the discharge plan for their inpatients.

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the amount of time the individual spends in the program rapidly decreases over the following weeks (such as decreasing by a day each week over 4 weeks). Most programs do not offer ambulatory or outpatient detoxification but require detoxification to occur before the individual is accepted into the program. Generally IOPs and PHPs require patients to attend daily AA meetings in addition to the treatment that they offer. Most insurance plans will pay for inpatient programs based on the patient placement protocol, which usually requires a patient to have failed an outpatient program first. Such inpatient programs range in the length of stay from 2 weeks to several months. Insurance benefits usually also determine this. Most private insurance companies will pay for up to 2 weeks of inpatient rehabilitation annually. Inpatient rehabilitation is less restrictive than an inpatient psychiatric facility, and for that reason, it should really be regarded as a residential program rather than an inpatient program. First, rehabilitation programs are entirely voluntary. Many patients hospitalized psychiatrically with drug or alcohol problems are hospitalized involuntarily because a physician has considered them to be at high risk for harming themselves or others as a result of a mental illness and not merely because of their drug or alcohol use. Second, rehabilitation programs generally do not provide daily physician contact as occurs in the acute psychiatric or medical setting; patients in rehabilitation programs are considered to be medically and psychiatrically stable. The only long-term (i.e., more than 1 month and up to 6 months) residential programs available to patients are those that accept either private pay, payment from state general assistance, or a combination

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of those two along with an opportunity to work for your keep. Finally, even within inpatient rehabilitation programs, varying levels of support exist. Halfway houses are a less intense form of residential care and offer approximately 5 hours of professional services weekly. The expectation is that while the patient is in the halfway house, he or she will find work, attend AA meetings regularly, and attend the program. In contrast, sober houses offer no programs to their residents. Both halfway houses and sober houses require residents to support their stay financially through either working for the program or obtaining employment on the outside.

39. What is the difference between a faith-based program and others? The idea of faith-based treatment for alcoholism comes out of the AA movement but is more religiously based and historically Christian in its orientation. Unfortunately, “faith-based” has become a politically charged term, suggesting on the one hand a zealous, narrow-minded approach to care, and on the other an excuse to cut government funding for addiction treatment. This is the work of politicians and not the work of the treatment centers. “Faith-based” programs support an underlying religious belief and commitment to specific doctrinal principals. Faith-based programs do not view addiction problems as simply a crisis of faith that can be remedied just by the word of God alone. Typically, the concept of dual diagnosis is understood, including both the medical and psychiatric co-morbidities, and the need to appropriately treat them. Although the primary goal is addiction treatment, faith-based programs have the ultimate goal of demonstrating the power of

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Although the primary goal is addiction treatment, faith-based programs have the ultimate goal of demonstrating the power of the word of God and the power that faith plays in one’s life, not just in terms of addiction but also in other aspects of life.

Therapeutic communities the environment on an inpatient unit that is developed to be a healthy milieu for staff and patients and that facilitates the development and implementation of treatment.

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the word of God and the power that faith plays in one’s life, not just in terms of addiction but also in other aspects of life. “Faith-based” programs are an important option for anyone considering treatment.

40. Does it matter how long I stay in an inpatient program? How successful are they? Although the evidence demonstrating “treatment” efficacy in alcoholism is overwhelming, the type of treatment or the environment of care remains debated. Any intervention is better than no intervention, but exactly what that intervention should constitute beyond some key elements is unclear. Studies have shown little difference in success rates between outpatient and inpatient rehabilitation programs. The patient placement protocols described in Question 36 help clinicians to determine which care setting will have the greatest chance of success for a particular patient. They outline a general structure and setting with parameters on frequency and intensity of treatment without clearly specifying duration. Regardless of setting, the duration of care clearly improves abstinence rates. It is not clear whether the environment of care (i.e., inpatient versus outpatient) plays a role in that. The two long-term inpatient programs can be divided into residential programs that follow a 12-step model and are generally shorter stay programs and therapeutic communities, which are greater than a year in duration and often expect patients to seek employment as part of their recovery program. Intuitively, it would make sense that the longer one is out of the environment that supported one’s addiction the better the chance of success when one eventually returns to that environment.

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Unfortunately, no real “geographical cures” are available for those struggling with addiction. Thus, it appears that the critical factor is length of successful treatment rather than length of stay.

41. How successful are the various treatment options? Regardless of the type, it is well known that treatment works. In fact, in a large California study, it was found that for every $1 invested in treatment, $7 in lost revenue was saved from various illnesses, accidents, hospitalizations, and loss of productivity. In a study on three types of treatments, including cognitive behavior therapy, motivational enhancement therapy, and 12step facilitation, the number of drinking days over a 12-month follow-up was reduced from a baseline of 78 to approximately 20. The number of hospitalizations for physical health problems, overdoses, and mental health problems was also reduced by as much as 60%, and the number of doctor visits, emergency room visits, and hospital days was reduced by as much as 40%. A large study of 65,000 patients conducted in 1994 demonstrated that 60% of those who completed treatment maintained sobriety a year later. With respect to AA attendance, of those who attended at least weekly, 73% remained abstinent; of those who attended occasionally, 53% remained abstinent, and of those who dropped out, 44% remained abstinent. Duration clearly had an effect as well; 85% who remain in treatment maintained abstinence. For those who dropped out between 6 and 12 months, 70% maintained abstinence. For those who dropped out in 5 months or less, 55% maintained abstinence. In a random survey of AA

Cognitive behavior therapy a therapeutic intervention that reinforces “positive thinking” and extinguishes “negative thinking” (i.e., changing undesirable cognitive functioning). Motivational enhancement therapy cognitive interventions are used to enhance the substance abuser’s desire to stop using.

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members, 35% were sober for more than 5 years, 34% between 1 and 5 years, and 31% for less than a year.

42. How is treatment different for someone with a dual diagnosis? Over half of all individuals struggling with alcoholism are also struggling with some other underlying psychiatric disorder.

Over half of all individuals struggling with alcoholism are also struggling with some other underlying psychiatric disorder. This has been partly addressed in Question 31 and is addressed further in Question 68. The question of whether one condition causes the other is controversial and fraught with misunderstanding. Although it is likely that depression can lower one’s ability to maintain abstinence, it is unlikely that treating the depression will cause the alcoholic to remain abstinent. Alternatively, if one has struggled with long-standing depression even when sober for several months, the likelihood that sobriety will “cure” the depression is extremely low. It is best not to ask “the chicken or the egg” question of what came first because after a while it is a moot point. For successful treatment, both alcoholism and mental illness need to be treated simultaneously. Patients and their family members too often wish to attribute one’s behavior problems all to one diagnosis or the other, thinking and hoping that somehow less stigma is attached to a diagnosis of depression or alcoholism. Therefore, treatment is different only in so far as the underlying mental illness must be managed in conjunction with an appropriate rehabilitation program, not before or after the completion of treatment in the rehabilitation program. Some rehabilitation programs do not treat anyone who is on a psychotropic medication and demand that the medication be tapered and

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discontinued during one’s stay. If discontinuation of the medication is done before a detailed psychiatric assessment is completed to evaluate the appropriateness of the medication, then this type of program is not appropriate for the individual suffering from both alcoholism and a psychiatric disorder. Alternatively, if a psychiatric assessment is performed and tapering medication appears to be indicated, then that is a reasonable rehabilitation program; however, the patient must ask the psychiatrist for the rationale behind the decision to discontinue the medication. If the patient doesn’t get a reasonable explanation, then the patient cannot provide informed consent to taper and discontinue the medication. Shop around for a different treatment program, one that will address both the problem of addiction and the underlying mental health problem.

43. All of the programs I attend are group based. I really feel I need some individual treatment. What should I do? Many, if not most, patients express an initial reluctance to attend group therapy, thus preferring individual therapy. They think they will feel more at ease and get better care. Although individual therapy provides more individual attention, it generally cannot provide the daily treatment that group therapy can. Published studies generally show no differences in success rates between these two forms of therapy. Group therapy is more cost-effective. The likelihood of getting individual therapy is low unless one is willing to pay at one’s own expense. The focus should be on outcomes. Real success depends more on staying in treatment than on the type of treatment. Group therapy can offer something individual therapy cannot: an opportunity to find

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a support group. At least one person in the group will be the person that one can really connect with in a way that supports sobriety unlike any other connection. The feeling that a professional therapist just doesn’t understand often leads to mistrust and an easy excuse to stop treatment. With group therapy, everyone understands, and often one individual really understands in a way that is both supportive and profoundly helpful. Alcoholism can be combated only with strong support systems. The more people the individual reaches out to, the greater the likelihood of finding those key supports. After a brief period of time, everyone overcomes the initial reticence to speaking up in a group. The cohesiveness that develops among the group members is unparalleled in its power for the individual feeling understood and supported.

44. I understand that some programs teach alcoholics to drink moderately. How successful are those programs? Treatment in the United States as AA and the temperance movements were developed emphasized complete and permanent abstinence from alcohol and all intoxicating substances. The concept of a return to moderate or controlled drinking is rejected. Alternatively, European and Commonwealth countries have offered controlled drinking therapy as an option for quite some time. When attempting to study success rates, however, little to no distinctions are made between individuals suffering from alcohol dependence, alcohol abuse, and problem drinking. Another confusing factor is the definition of relapse. Many studies place little emphasis on the amount that is drunk and the consequences of an episode of drinking when defining relapse or a return to use. Does drinking one glass of wine at a

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George Valliant defined abstinence as drinking less than once a month and including a binge lasting less than a week each year. Ninety percent of alcoholics will either slip or relapse in the first 4 years of treatment. Because of these staggering numbers, some clinicians feel that the demand for complete abstinence is at best unrealistic and, at worst, possibly detrimental, as it may even cause the alcoholic to reject treatment, altogether. Defining patient types (i.e., problem drinker, alcohol abuser, alcohol dependent) and patterns of drinking is difficult to credibly sort out whether or not a return to controlled drinking is possible for the alcoholic. Clinicians, who emphasize harm reduction, are happy when a patient’s alcohol use is on the wane, even if it continues; however, others feel drinking in moderation is a setup for disaster. Motivational interviewing, a type of therapy for addictions, attempts to begin where the patient is in terms of his or her own beliefs about alcohol use, and through slow but persistent psychotherapeutic work, the patient is moved through various stages of recovery from (a) precontemplation to (b) contemplation and ultimately (c) acceptance. During these stages, an individual’s commitment to abstinence will differ while treatment continues. (See the glossary for principles of motivational interviewing.) Research demonstrates that patients who slip are at greater risk for repeated relapse compared with patients who are completely abstinent. Ironically, studies also show that a return to controlled drinking is

Treatment

Christmas dinner constitute relapse? If not, where does one draw the line? Most clinicians define that one glass constitutes a slip, whereas a return to one’s previous pattern of out-of-control drinking is a relapse.

Motivational interviewing a brief treatment approach designed to produce rapid internally motivated change in addictive behavior and other problem behaviors.

Research demonstrates that patients who slip are at greater risk for repeated relapse compared with patients who are completely abstinent.

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Another psychiatric disorder associated with higher rates of alcoholism and other addictions among adolescents is attention deficit hyperactivity disorder (ADHD). Attention deficit hyperactivity disorder (ADHD) a persistent pattern of inattention and/or hyperactivity and impulsivity that is seen more frequently in children with ADHD than in children at comparable developmental levels.

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more common among alcoholics who reject treatment altogether. The single biggest determinant for the ability to maintain controlled drinking appears to be the severity of the alcohol problem, rather than whether the individual has sought treatment. Individuals who have severe alcohol problems require abstinence or they will lose everything, including their own lives. In contrast, individuals who are alcohol abusers or problem drinkers and the severity of their drinking has not been extreme enough to threaten their livelihood if not their lives may be able to drink in moderation. These individuals are less likely to end up in treatment and are more likely to be able to control their drinking. Moderation management may be good for some and a complete disaster for others.

45. Is the treatment approach for adolescents different than adults? Many differences exist between adolescent and adult alcoholics. Adolescents typically tend to be problem drinkers or alcohol abusers and have not yet developed a pattern of regular daily heavy drinking. Consequently, they are rarely alcohol dependent and are therefore less apt to develop physiological withdrawal symptoms compared with adult alcoholics. Adolescents generally have not settled on one or two drugs of choice. They tend to abuse many drugs in addition to alcohol. Additionally, adolescent alcoholics have higher rates of secondary psychiatric disorders, particularly anxiety disorders and most notably PTSD, as many of them have a history of physical and/or sexual abuse. Another psychiatric disorder associated with higher rates of alcoholism and other addictions among adolescents is attention deficit hyperactivity disorder

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Psychostimulant “Psycho” pertains to the brain and its cognitive functions. A stimulant is an agent or drug that increases the functional activity or efficiency of an organ.

Treatment

(ADHD). A great deal of controversy has been aroused around the use of psychostimulant medications such as Ritalin or Dexedrine in treating ADHD, with some people believing that these medications may lead to problems with addiction. These medications are frequently abused, and these medications may cause addiction problems. Many studies have repeatedly demonstrated that having the diagnosis of ADHD is an independent risk factor for the development of substance abuse and alcoholism whether or not the ADHD is treated with psychostimulants. In fact, more recent studies have demonstrated that the risk of drug and alcohol use increases without treatment for ADHD.

Ritalin the trade name for methylphenidate. It is used to treat ADHD. Dexedrine a psychostimulant that is prescribed to treat ADHD.

Alcohol Treatment for Adolescents Because of the differences between adolescents and adults, treatment tends to be more aggressive in its approach to the underlying psychiatric conditions, whereas it is more conservative in treating the substance abuse or alcohol problem. Peer-oriented groups focus on the adolescent’s developmental challenges. Medications such as naltrexone (ReVia), acamprosate calcium (Campral), or disulfiram (Antabuse) for drug or alcohol problems, as described in Questions 47–52, have not been examined thoroughly in this age group and should be used only in the most extreme treatment-resistant cases. Psychotherapeutic approaches are paramount and include all forms from 12-step down to individual therapy. Although improved function despite continued use may satisfy some clinicians, controlled use in this population should never be the goal of treatment. Most adolescents will interpret this as permission to continue to use as long as they function better. ASAM patient

ReVia trade name for naltrexone. Campral a drug used to maintain alcohol abstinence. Disulfiram generic name for Antabuse, which is the most widely used medication for alcoholism in this country.

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placement criteria also exist for adolescents and generally follow similar guidelines as those used for adults.

46. What exactly is an “intervention”? Interventions have become the subject of sitcoms and soap operas as depicted in Seinfeld and the Sopranos. Regardless of the humor or bathos associated with them, they can be an effective approach at getting a loved one into treatment. Interventions should be orchestrated in advance, preferably by a professional who is a skilled interventionist so that nothing is left to chance and all anticipated countermeasures have been considered and are ready to be implemented. The key term is leverage. Unfortunately, most alcoholics are in denial about their problem and stridently object to the idea that they have a problem with alcohol until they are in jeopardy of losing something more valuable than their alcohol. The major touchstones include the following: 1. The intervention should be linked in time to a recent alcohol-related incident so that the connection between the drinking and the negative consequences are blatantly obvious. 2. The intervention needs to occur when the individual is sober. 3. A specific narrative should be prepared as to how this, as well as past incidents of drinking, has negatively impacted you. The reason for the intervention is to get the alcoholic into treatment. 4. Explain the future consequences of continued drinking in terms of your relationship with him or

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her. Tell the person that until he or she seeks specific treatment to maintain sobriety you are prepared to carry out your plans. Do not threaten! Threatening will be viewed as merely inflammatory. Make only promises that you are absolutely prepared to act on and explain that you are doing this to protect yourself. This may range from refusing to go to any alcohol-related social activities to moving out of the house. Involving other loved ones who have also been directly affected by the person’s alcohol use may strengthen the leverage. They should be prepared to discuss their own negative experiences with the alcoholic. Having some loved ones who are also in recovery can be particularly persuasive. 5. Be prepared to have treatment options. Plan to have a bed ready in advance for inpatient detoxification and/or rehabilitation. If outpatient treatment is appropriate, names and appointments should be made in advance. Offering to accompany the alcoholic to the initial appointment or first AA meeting is very helpful, as it demonstrates your support.

47. What different kinds of medications are available for alcoholism? Medications for alcoholism can be divided into several categories: (1) Medications can treat alcohol withdrawal syndromes. These syndromes are medical emergencies and medication is a medical necessity. (2) Medications can treat the underlying psychiatric disorders that may be contributing to though not causing one’s alcoholism. (3) Medications or treatments can offer a behavior modification approach. The individual

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needs to know that if he or she drinks while taking some of the medications he or she will become violently ill. (4) Finally, medications can directly act on the brain to reduce craving or maintain abstinence. The Federal Drug Administration (FDA) has approved only three of these medications specifically for the treatment of alcoholism, whereas all other medications used for the treatment of alcoholism are off-label (i.e., currently not a medication that the FDA approved for that particular use). The three approved are discussed in greater detail in the next three questions. Medications that treat alcohol withdrawal are covered in Question 56 under detox.

Bipolar disorder a mental illness defined by cyclic episodes of mania or hypomania, classically alternating with episodes of depression; however, the condition can take various forms, such as repeated episodes of mania only or only one episode of mania and repeated episodes of depression or rapid cycling between mania and severe depression.

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The degree to which individuals and clinicians believe in the importance of taking medications varies with each category. Everyone in the profession understands and agrees that detoxification is a medical problem requiring medication. Most agree that treating underlying psychiatric illnesses such as schizophrenia, bipolar disorder, or depression is necessary, even though the use of these medications can entail some degree of controversy. This is true particularly among those alcoholism specialists who zealously believe that all medication used to modify behavior cause a form of dependency. The use of medications that are prescribed specifically for alcohol dependence or abuse varies dramatically with the philosophy of various clinicians and treatment programs. In some hospitals, no patients are offered medications, whereas in others, no patient leaves without a prescription for a medication. Historically, 12-step programs have frowned on individuals receiving any psychotropic medication. In this more enlightened era,

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there is an increased understanding of psychiatric comorbidities and this attitude has mostly disappeared.

Antabuse is the first medication that the FDA approved for the treatment of alcoholism. It is in the class of medications that are used for behavior modification. As mentioned in Question 22 (Table 6), a correlation exists between those groups of individuals who are able to metabolize alcohol and the rate at which they are prone to alcoholism. The enzyme that metabolizes alcohol is aldehyde dehydrogenase. The groups of people who are more prone toward alcoholism have more aldehyde dehydrogenase available in their bodies to break down the alcohol, whereas people who are less prone toward alcoholism have less aldehyde dehydrogenase available. Thus, a decrease in aldehyde dehydrogenase leads to a reduction in the tendency toward alcoholism. Disulfiram (Antabuse) was developed to mimic this genetic variation by reducing the relative amount of aldehyde dehydrogenase. This medication inhibits or blocks aldehyde dehydrogenase, which reduces the amount of this enzyme in the body that is available to break down alcohol, thereby resulting in an accumulation of acetaldehyde when one drinks alcohol. Acetaldehyde causes nausea, low blood pressure, flushing, headache, and weakness. This can last anywhere from 30 to 60 minutes. The reaction varies with the amount of alcohol that is consumed. More severe reactions can include cardiovascular problems and convulsions. Other potential risks include peripheral nerve damage and hepatitis. One needs to

Antabuse a drug given to alcoholics that produces nausea, vomiting, dizziness, flushing, and tachycardia (a fast heart rate) if alcohol is consumed; thus it is a deterrent to drinking and acts as a negative reinforcer.

Treatment

48. What is Antabuse, and how does it work?

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wait at least 72 hours before his or her last drink before starting the medication because of the risk of having a bad reaction. Any food or medicine containing alcohol, including after-shave lotion, can potentially cause a reaction. Because of these risks, Antabuse is rarely, if ever, offered to people who are beginning treatment. A full medical history must be taken along with a battery of blood tests to rule out other medical conditions that preclude its use, such as liver or kidney disease, hypothyroidism, or diabetes. Patients rarely drink while taking this medication. Alcoholics who are motivated to maintain abstinence stay on the medication, and those who are not stop the medication and resume drinking. In other words, rarely does an Antabuse reaction ever occur to produce the negative consequences necessary to prevent continued drinking (see Table 10 for details).

Table 10 Disulfiram Details Drug Name

Adult Dose Pediatric Dose Contraindications

Metronidazole Generic name for Flagyl, an antibiotic medication that rarely can have an Antabuse-like effect for patients taking it and drinking alcohol.

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Interactions

Pregnancy Precautions

Disulfiram (Antabuse)—Decreases number of drinking days but does not increase abstinence. Directly observed therapy might be more beneficial but has not been studied in a good randomized trial. 250 mg PO qd Not established Documented hypersensitivity, severe myocardial disease, coronary occlusion Do not administer with metronidazole; use with caution in patients on phenytoin (levels of phenytoin might increase) C—Safety for use during pregnancy has not been established. Adverse effects are uncommon, but hepatitis, optic neuritis, neuropathy, and skin rash reported

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49. I understand that ReVia is an opiate. I have never been addicted to opiates. Why would that be prescribed, and will I become addicted? Medications do two things: (1) They attach to a specific receptor, and (2) they alter the receptor in a specific way. Opiates are a class of medications that specifically target opiate receptors in the body. Normally one thinks of opiate receptors as pain receptors and opiates as pain medications. Hence, the term derives from Opium, the poppy and its analgesic properties. In fact, however, there is more than one opiate receptor, and each opiate receptor can be altered in more than one way. It is commonly known that some opiate receptors alter pain. It is not well known which other opiate receptors alter other physiological and psychological properties. By thinking about the various physiological effects of opium, we can understand that better. Besides reducing pain, opiates can also cause sedation (neurological effects), can lead to respiratory depression (respiratory effects), can make us nauseous and constipated (gastrointestinal effects), and can produce euphoria (psychological effects). Each of these varying properties appears to be affected by its own set of opiate receptors. In addition to these specific receptors, various changes can occur in each receptor with a particular drug. For example, a drug can cause the receptor to respond positively or more strongly through agonism, a term used in pharmacology for stimulation, or a drug can cause the reverse effect or have the receptor respond in the opposite direction, known in pharmacology as reverse agonism. A drug can also block a

Reverse agonism a chemical (drug) that has reverse activity on the receptor rather than just merely blocking the receptor.

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Antagonism the mechanism that causes the blocking of the biological responses at a given receptor site, due to a drug or other chemical. Agonist a drug capable of combining with a receptor on a cell and initiating a reaction or activity. Endogenously functional causes occur from internal factors in the mind or the body. Partial agonist a chemical (e.g., drug) that can both block and stimulate a receptor depending on the relative amount of neurotransmitter present in the synaptic cleft. Naloxone generic for Narcan. It is an opioid antagonist and competes with opioids at the opiate receptor sites. Narcan an opioid antagonist and antidote to opiate overdoses.

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receptor, rendering it completely inactive. This is known in pharmacology as antagonism. Finally, a drug can be created that acts as either an agonist or antagonist, depending on the local environment (i.e., the amount of endogenously available neurotransmitter). When the amount of neurotransmitter is low, the drug acts as an agonist. When the amount is great, the drug acts as an antagonist. Such a drug is known as a partial agonist. Thus, an entire array of effects can be produced on each particular receptor with varying chemicals, almost like fine-tuning a radio station to provide the best reception. As an example, when patients come to the emergency room because of a heroin overdose, they will receive a medication known as naloxone (Narcan), which is an antagonist that blocks the effect of heroin on all the opiate receptors. Thus, respiratory depression, the cause of death from heroin overdose, as well as all of the other effects, is reversed. The downside of this is that if the patient is heroin dependent, he or she will go into immediate withdrawal because, again, all of the effects of heroin are reversed. ReVia is the trade name for a medication generically known as naltrexone (see Table 11). It is the second medication that the FDA approved and has been in use since 1994. Naltrexone is an opiate antagonist that blocks opiate receptors and thereby decreases the craving for alcohol, resulting in not only less interest in alcohol but also in less alcohol consumption. (See question 32 on p. 89 for additional information about the link between alcohol and opiates.) Consequently, there may be slips but fewer relapses. Studies in nonhuman animals clearly demonstrate that alcohol consumption causes an increase in endogenous opiates, and thus, it is

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Table 11 Naltrexone: An Opiate Antagonist Drug Name

Pediatric Dose Contraindications Interactions

Pregnancy Precautions

postulated that naltrexone blocks the effects of this increase on the brain; thus, the “rush” associated with drinking alcohol is not felt. A recent brain-imaging study showed that alcoholic persons have increased opiate receptors in a part of the brain associated with reward and pleasure and that the number of receptors correlates with the degree of craving. Additionally, naltrexone indirectly increases the amount of dopamine, the major neurotransmitter associated with reward (see Question 6). Unfortunately, the effect in reducing relapses is a modest 12% to 20%, depending on the study. Combining medications with other forms of therapy improves the outcomes by a third.

Studies in nonhuman animals clearly demonstrate that alcohol consumption causes an increase in endogenous opiates, and thus, it is postulated that naltrexone blocks the effects of this increase on the brain; thus, the “rush” associated with drinking alcohol is not felt.

Treatment

Adult Dose

Naltrexone (ReVia)—Patients must be abstinent for 5–7 days before beginning therapy. Monitor liver function during treatment. Expensive, approximately $4.50 per pill. Pure antagonist and is not addicting. 50 mg PO qd Some physicians give 25 mg for the first 2 days of therapy; some believe 100 mg works better than 50 mg, but no trials demonstrate this. Not established Documented hypersensitivity, acute hepatitis, liver failure Inhibits effects of opiates; patients currently taking opiates or who have been on long-term opiate therapy in previous 7 days can experience severe opiate withdrawal C—Safety for use during pregnancy has not been established. Nausea/vomiting, abdominal pain, daytime sleepiness, and nasal congestion were more common versus placebo in largest randomized trial to date; discontinuation due to adverse effects was uncommon in most clinical trials.

Naltrexone generic for ReVia. It is an opioid antagonist that competes with narcotics at opiate receptor sites, blocking the opioid analgesics.

Naltrexone use is controversial, which stems from the fact that it appears to moderate the amount of alcohol

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The main side effects of naltrexone are nausea and/or vomiting, abdominal pain, sleepiness, and nasal congestion.

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consumed rather then actually preventing one from consuming alcohol altogether. Thus, it paradoxically appears to be more effective for people who continue to drink alcohol and want to control their consumption rather than those who are attempting to achieve complete abstinence. The idea of a medication to moderate one’s alcohol consumption rather than to eliminate it altogether, however, is abhorrent to many and has led others to fear that it will not assist in attaining the ultimate goal of complete abstinence, which defeats the entire goal associated with alcoholism treatment. Remember that although there seems to be a continuum from problem drinker to alcohol abuser to alcohol dependence, when one looks at all alcoholics, it remains to be determined whether the continuum exists within individual alcoholics. Whether any individual with alcohol abuse will ultimately become alcohol dependent if left unchecked remains hotly debated. The abstinence-only model argues for this continuum, whereas the controlled-drinking models argue that at least some alcoholics can control their drinking and will never become alcohol dependent. Naltrexone may be most effective for the alcoholic who wants to continue to drink, through a process known as pharmacological extinction, where it acts on the opiate receptors to block the pleasurable effects that come from regular drinking thereby reducing the pleasure associated with the activity. The main side effects of naltrexone are nausea and/or vomiting, abdominal pain, sleepiness, and nasal congestion. Pregnant women, individuals with severe liver or kidney damage, or those who cannot achieve abstinence for at least 5 days before starting should not use

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it. Also, people who are dependent on opiates such as heroin or morphine must stop their drug use at least 7 days before starting naltrexone or they risk precipitating withdrawal. Aside from side effects, which are usually short lived and mild, alcoholics report that they are largely unaware of being on this medication. Naltrexone usually has no psychological effects and patients don’t feel either “high” or “down” while they are on naltrexone. It is not addictive. Naltrexone does not cause physical dependence, and it can be stopped at any time without withdrawal symptoms. In addition, available findings regarding cessation do not show a “rebound” effect to resume alcohol use when naltrexone is discontinued. If naltrexone is tolerated and the patient is successful in reducing or stopping drinking, the recommended initial course of treatment is 3 months. At that time, the individual and his or her physician should evaluate the need for further treatment on the basis of the degree of improvement, the degree of continued concerns about relapse, and the level of improvement in areas of functioning other than alcohol use.

50. I heard of a new injectable form of medication for alcoholism. What is it, and what are its advantages? The FDA has recently approved an injectable form of naltrexone (known by its trade name as Vivitrol) that is a long-acting form of the drug and therefore requires only monthly injections. The purpose of the monthly injection is to enhance medication adherence, which is the biggest stumbling block for many patients struggling with mental illnesses. The approval, based

Vivitrol an injectable, long acting form of naltrexone.

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on a study published in the Journal of the American Medical Association in April 2005, demonstrated that Vivitrol resulted in a 25% decrease in the event rate of heavy drinking days. A heavy drinking day is defined as equal to or greater than five standard drinks a day for men and four standard drinks a day for women. The event rate of heavy drinking is defined as the number of heavy drinking days divided by the number of days at risk for heavy drinking. The injections were well tolerated, with few adverse events and no evidence of liver disease, which had previously been a concern regarding this medication. Not surprisingly, the average decrease in heavy drinking days was greatest in those individuals who drank the most during the study. (The more one drinks, the greater opportunity there is to cut down.) The placebo group also received therapy in addition to sham injections. This group also demonstrated improvement in event rate of heavy drinking days but not to the same degree as those on the injectable naltrexone. The general conclusion was that injectable naltrexone offers a very important alternative to oral naltrexone by increasing adherence and therefore improving outcomes. Table 11 provides a summary of naltrexone.

51. How is acamprosate different from other medications? Acamprosate (Campral) is the third and final medication approved for the treatment of alcoholism. Its mechanism of action is unknown, although it is referred to as a glutamate receptor blocker. As you may recall from Question 6, glutamate is the major excitatory neurotransmitter in the brain. It is believed that chronic alcohol ingestion adds to the effects of the

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major inhibitory neurotransmitter, GABA. In order to compensate for this, the brain decreases GABA effectiveness and improves the effectiveness of glutamate in order to achieve a balance. When alcohol is suddenly removed from the rebalanced system, GABA is now left in a deficient state while glutamate is overactive. This is believed to cause many of the craving and withdrawal symptoms that people experience with alcohol dependency. It is thought that acamprosate enhances GABA transmission and inhibits glutamate transmission in order to restore the brain to its previous uncompensated state. Unlike naltrexone, which focuses on reducing problem drinking, acamprosate targets abstinence. Acamprosate has been studied thoroughly in Europe, and very good results were demonstrated with 1-year abstinence rates of 18% compared with placebo-controlled abstinence rates of only 7%. At 2 years, the acamprosate group’s abstinence rates fell to 12%, whereas the placebo group’s abstinence rates fell to 5%. Some preliminary studies have suggested that using acamprosate in conjunction with naltrexone is better than using either alone. Acamprosate is well tolerated and can be prescribed for even patients with liver disease. Diarrhea, which eventually improves with time, is the most common side effect. An intriguing use of acamprosate has been proposed based on a study conducted in 2001. Animals that were experiencing alcohol withdrawal symptoms were given the medication. It was shown to reduce glutamate’s excitatory effects, thus possibly providing a neuroprotective effect and reducing the impact of withdrawal on the brain. Thus, the potential of using

Neuroprotective a protection of the nervous system against toxic substances.

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Off-label prescribing of a medication for indications other than those outlined by the Food and Drug Administration.

this medication as an adjunct to detoxification remains an open question; however, it would be an off-label treatment (see Questions 52 and 53 for other medications that are prescribed off-label). For further information regarding the reasons for detoxification and the medications necessary to manage detox effectively, please see Questions 55 and 56 and Table 12.

Table 12 Acamprosate (Campral): A Drug to Maintain Alcohol Abstinence Drug Name

Adult Dose

Pediatric Dose Contraindications Interactions

Pregnancy Precautions

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Acamprosate (Campral)—Synthetic compound with a chemical structure similar to that of the endogenous amino acid homotaurine (structural analogue of GABA). Mechanism of action to maintain alcohol abstinence not completely understood. Hypothesized to interact with glutamate and GABA neurotransmitters centrally to restore neuronal excitation and inhibition balance. Not associated with tolerance or dependence development. Use does not eliminate or diminish alcohol withdrawal symptoms. Indicated to maintain alcohol abstinence as part of a comprehensive management program that includes psychosocial support. Available as a 333-mg tablet. 666 mg PO tid; initiate as soon as possible after alcohol withdrawal when abstinence has been achieved; if < 60 kg, may need to decrease dose by 333–666 mg/day. CrCl 30–50 mL/min: 333 mg PO tid Not established Documented hypersensitivity; severe renal impairment (i.e., CrCl < 30 mL/min) Coadministration with naltrexone increases acamprosate Cmax and AUC, but no dose adjustment necessary C—Safety during pregnancy has not been established. Diarrhea is most common adverse effect (20%), but dropouts are few; additional common adverse effects are dizziness, itching, nausea, flatulence, headache, and increased sexual desire; depression and anxiety incidence slightly higher than that of placebo in one study.

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52. What other medications are prescribed for alcoholism?

Prozac see fluoxetine.

Two other medications have promise based on scientific evidence. These include Zofran, the trade name for ondansetron, and Topamax, the trade name for topiramate. Interestingly, just as SSRIs appear to improve abstinence rates in type I, or late-onset alcoholics, ondansetron appears to decrease preferentially the number of drinks consumed per day and improve abstinence rates in type II or early onset alcoholics.

Trade name the name given to drugs by the company that has the patent rights to the drug, either through purchasing the patent rights from another company, or having discovered or designed them. The trade name is the company name.

Ondansetron Ondansetron blocks a specific serotonin receptor that is involved in nausea and vomiting and is commonly used in patients receiving cancer chemotherapy, where this is a common side effect. This particular

Treatment

Other medications are used off-label specifically for the treatment of alcoholism. One of the earliest thought to improve abstinence was lithium, although this has since proven to be false. Other studies investigating psychotropic medications have looked at the selective serotonin reuptake inhibitors (SSRIs), of which fluoxetine (Prozac) is the best known. The effects have been generally disappointing; however, when attempting to sort out alcoholics who are type I from those who are type II, there appears to be a noticeable though modest effect in type I alcoholics (see Question 18). This is thought to be because type I alcoholics more often suffer from anxiety and depression in addition to their alcoholism, and SSRIs are very effective antianxiety medications in addition to their antidepressant properties.

Zofran trade name for ondansetron. It is an antiemetic that prevents nausea and vomiting by blocking serotonin peripherally, centrally, and in the small intestine.

Topamax the trade name for topiramate. An anticonvulsant. The mechanism of action is unknown. It is used to control seizures.

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Topiramate an anticonvulsant used to decrease the occurrence of seizures. Off label, it may be used as an adjunctive mood stabilizer, especially in bipolar disorders.

serotonin receptor appears to play a role in reinforcement for alcohol consumption in animals. Blocking this receptor reduced alcohol consumption in animals. This was also demonstrated in early-onset or type II alcoholics, but was found to be no better than placebo when administered to late-onset or type I alcoholics. The preferential response to different medications based on one’s subtype of alcoholism further supports a biological difference between these two types.

Topiramate Topiramate is the other medication that appears to reduce craving and consumption in alcohol-dependent patients who are not yet abstinent. Topiramate is an anticonvulsant that is approved for use in the treatment of epilepsy. It was initially thought to also help with bipolar disorder, but studies have been disappointing. Topiramate can lead to decreased appetite and weight loss. The mechanism by which it reduces appetite is as yet unknown. Topiramate facilitates GABA function and antagonizes glutamate. In this manner, it appears to be similar to acamprosate. Its effects on GABA and glutamate, in turn, have an effect on dopamine and thus reduce craving and withdrawal feelings. Daily doses generally need to be 200 mg or greater. Initial studies have suggested that it has a greater effect on drinking than the currently FDAapproved medications, although it is also associated with more severe side effects. These side effects include slowing of thought, short-term memory problems, and word-finding difficulties. People were not required to be abstinent before initiation of topiramate for it to be effective.

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Off-label is used when the FDA has not approved a medication. Does this mean the medication is experimental? No, absolutely not. This means simply that no studies have been submitted to the FDA for approval of the medication for a particular use. It does not mean that no studies have been done. There are many studies that may not have been submitted to the FDA or that have been submitted and approved by European governments. It does not mean that the medication is not widely prescribed for a use other than what the FDA approved. It does not mean that doses under or over the recommended range approved by the FDA are neither effective nor safe. It does not mean that the medication is not safe in age groups younger or older than what the FDA approved. It merely means that when the company submitted the medication for approval to the FDA, it submitted studies that specified a diagnosis, a dose range, and an age group that their study subjects reflected. Drug research and development have a fascinating history. Psychiatric drugs are often discovered serendipitously. Most drugs have multiple effects on the body, and focusing on one particular action to the exclusion of another is often as much a matter of marketing as it is drug action. For example, a trauma surgeon who was specifically interested in finding a medication that could prevent surgical shock, a condition with a high mortality rate at the time, developed and tested the first antipsychotic medication. It was only through

Off-label is used when the FDA has not approved a medication. Does this mean the medication is experimental?

Treatment

53. I have been prescribed a medication off-label. Does that mean that it is experimental?

Most drugs have multiple effects on the body, and focusing on one particular action to the exclusion of another is often as much a matter of marketing as it is drug action.

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Monoamine oxidase inhibitors an antidepressant that is not used as frequently as other antidepressants, namely because of the side effects, which include anticholinergic effects, such as a dry mouth and the danger of high blood pressure (a hypertensive crisis) if a low tyramine diet is not followed. Physician’s Desk Reference a compendium of all of the drugs available to legal prescribers (MDs, DOs, and NPs) in the United States and Canada, along with guidelines about their actions, how each drug is generally used, the drug interactions, side effects, and contraindications.

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clinical observation that it was discovered to have antipsychotic effects as well as a variety of other effects on the body. The company that originally introduced it to the United States did not believe that there would be a market for it as an antipsychotic and thus released it to the public as an antiemetic. Only through multiple physician-driven lectures were psychiatrists in the United States comfortable enough to try it on patients suffering from schizophrenia. Perhaps even odder is the fact that the first antidepressant effects were observed in medications developed to treat tuberculosis. Only later was it discovered that these medications inhibited, or blocked, monoamine oxidase, an enzyme that breaks down norepinephrine, serotonin, and dopamine at the synaptic cleft. To call any particular medication an antihypertensive, an antipsychotic, an antidepressant, or an anticonvulsant is actually a misnomer and really reflects the target clinical problem a particular medication is geared toward when released to the public and not the broad range of effects for which the medication is capable. It also reflects the expense the companies go through in order to obtain FDA approval. The FDA requires that each medication target a specific diagnosis in order to receive approval. This is a hugely expensive enterprise for one diagnosis, much less for multiple diagnoses. Therefore, it is unlikely drug companies will submit studies for approval for more than one or two diagnoses, unless they can see some return on their investment. As a result, clinical practice is often very different from what the Physician’s Desk Reference publishes. Clinical practice moves at a much faster pace than clinical trials and published studies can keep up with. Although clinical trials are considered to be the definitive evidence of

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There are two broad reasons why off-label use makes sense in psychiatry. First, psychiatric diagnoses do not fit into the neat little categories that the DSM-IV-TR attempts to define. They generally have many overlapping symptoms. For example, anhedonia, or loss of interest, can be seen in a number of conditions that include depression, schizophrenia, and frontal lobe damage. Many psychiatrists believe that medications should be prescribed to target the particular neurochemicals underlying such specific symptoms regardless of the DSM-IV-TR diagnosis. Off-label use is practiced with a clear rational for another reason as well. Human nature defies categories. Although broad similarities may exist between two individuals suffering from depression, it is doubtful that any one individual is suffering in exactly the same way as another from both a biochemical and psychological standpoint. Thus, a person may respond to a particular therapy or antidepressant and not the other. The reasons are due to the therapies’ and antidepressants’ biochemical differences, not their similarities. For these reasons, offlabel use in psychiatry is more often the rule than the exception. Consider this example: A man sought out a cardiologist because he noticed he was getting palpitations from one particular brand of cola and not another. The cardiologist dismissed him outright. The man sought out another cardiologist who agreed to perform a stress test after he ingested the different brands, and sure enough, the man experienced premature ventricular beats with one particular brand of cola

Treatment

any particular medication’s efficacy, astute clinical observations have brought the biggest drug discoveries to the world and should not be discounted simply because no study has yet to be published.

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and not another. Never underestimate the power of one.

Open-label a term used to describe the type of study where both the researcher and the volunteer/subjects know the drug or treatment that the subjects are receiving. Double-blind study a drug study that consists of an experimental group of patients/volunteers who receive the experimental drug, medical device, or treatment and a control group who receives a placebo or the current and standard drug, medical device, or treatment. Placebo a drug, medical device, or treatment that looks similar to the experimental drug, medical device, or treatment, but it is in fact an inactive drug, liquid, device, or treatment and will not affect the volunteer’s health or illness.

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54. What is the Prometa® treatment protocol for alcoholism? Experimental clinical trials are an ongoing option for individuals struggling with drug and alcohol dependency. For example, a Los Angeles-based health care services company known as Hythiam developed the Prometa Treatment Protocol, which is currently undergoing clinical trials through the National Institutes of Health. Early open-label studies of the protocol with methamphetamine-dependent individuals have yielded positive results, and double-blind, placebo-controlled studies are currently under way. Current use in alcoholics, although favorable, has been anecdotal at the time of this writing. The protocol relies on two well-established medications that have an impact on GABA: gabapentin (Neurontin) and flumazenil (Romazicon). The FDA has currently approved neither for use in alcoholism. Gabapentin is an anticonvulsant medication that the FDA approved for treating seizure disorders as well as treating neuropathic pain and may be beneficial in helping with anxiety and certain sleep disorders, as both are affected by GABA. Flumenazil is a GABA receptor antagonist and as such blocks the effects of anxiolytics such as Valium or Ativan. This is commonly used for individuals who present to the emergency room with benzodiazepine overdoses, as it reverses the effects. Gabapentin made national news over its controversial use in treating bipolar disorder before adequate trials had been conducted. It proved

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Clinical trials such as the Prometa® treatment protocol are valuable resources for people who have limited means and/or who have failed previous standard treatments. Medical institutions such as universities, research foundations, pharmaceutical companies, and federal agencies often sponsor such trials. An institutional review board, which is made up of at least five members who include physicians, other health care professionals, and lay people, supervises and monitors clinical trials. Institutional review boards are established to protect the volunteer patients’ health and safety as well as to protect them from unethical practices. One of the main benefits of participating in a clinical trial is the opportunity to help others while helping one’s self. Additionally, having access to new experimental treatments while one’s health is being meticulously monitored is invaluable. The major risk, of course, is that an adverse effect may occur putting one’s own health at risk. The other major drawback is time. The enrollment process is often long and complicated, and few get accepted. After acceptance, the time and behavioral requirements can be equally arduous, but the potential payoff is great. It is important to always enter into a trial with a clear understanding of both the risks and benefits before engaging in one.

Flumazenil (Romazicon) a benzodiazepine antagonist that is used to reverse the sedative effects of benzodiazepines in the management of an overdose.

Treatment

to be of limited value in treating this condition. That did not mean, however, that some individuals with bipolar disorder did not benefit from the drug, only that large studies failed to separate it from placebo. Although its use in treating bipolar disorder is now limited, it continues to play a role as an off-label adjunctive treatment for patients with various psychiatric illnesses, and its use in treating addiction is but one example of that.

Clinical trials are valuable resources for people who have limited means and/or who have failed previous standard treatments.

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55. What is detoxification, and how do I know whether I need it?

Alcohol withdrawal delirium also known as DTs or delirium tremors, a syndrome that occurs after the amount of alcohol that is usually consumed has decreased, after prolonged and heavy use of alcohol, which leads to the following: changes in the individual’s vital signs and adverse gastrointestinal and central nervous system symptoms in conjunction with disorintation and hallucinations.

The good news is that most individuals with alcoholism do not require medication for their withdrawal symptoms.

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The concept of detoxification or “detox” has multiple iterations. In this day and age of concern regarding a variety of potential toxins that we routinely ingest either wittingly or unwittingly, “detoxification centers” now exist as a cottage industry that often combines laxatives and purgatives. This treatment is not what is meant by alcohol detox. Alcohol detox requires medical management if the person is at risk for serious medical problems during the detoxification phase. Medical management includes monitoring signs and symptoms of alcohol withdrawal and the administration of medication to reduce or eliminate those signs and symptoms should they become too severe. The most serious medical problems include seizures and alcohol withdrawal delirium or DTs (see Questions 62 and 63 for a fuller explanation of DTs and alcohol withdrawal seizures). Seizures occur in less than 5% of individuals and DTs in about 5%. The good news is that most individuals with alcoholism do not require medication for their withdrawal symptoms. In fact, only about 8% of patients require it. That is not to say that one will not suffer from some kind of withdrawal symptoms. The bad news is that if DTs are not treated, the mortality rate is 15%. Withdrawal symptoms from regular heavy alcohol use occur around 8 hours after the last drink. These symptoms include tachycardia or rapid heart rate, tremor, nausea, and insomnia. Over the next couple of days, anxiety, agitation, sensitivity to light and sound, sweating, headache, and high blood pressure will develop in conjunction with the other symptoms. Between days 2 and 4, symptoms may continue to get worse, including high blood pressure, a rapid pulse and fever, disorien-

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tation, hallucinations, and delusions. These last cognitive symptoms define the DTs. Seizures may occur anywhere from days 2 to 6.

Treatment

There are specific risk factors that increase the probability that one may have serious withdrawal symptoms requiring detox medications. Risk factors that are associated with the development of seizures or DTs include the following: If you had either a previous history of DTs or seizures from any cause, this increases your risk. The higher the amount of daily alcohol use the greater your risk. The older you are the greater your risk. Being male increases your risk. Elevated liver enzymes associated with hepatitis increase your risk. Other medical problems such as pancreatitis, other gastrointestinal problems, and pulmonary or cardiovascular problems increase your risk.

56. What medications are used for detoxification? Alcohol Withdrawal Syndrome As discussed above, detox is medically necessary because of the possibility of developing alcohol withdrawal syndrome (discussed in greater detail in Question 61). The symptoms can be lessened or even prevented with appropriate medication, or the symptoms may progress (though not always) to the point where one suffers from DTs or has a withdrawal seizure. A rating scale known as the CIWA-A (Clinical Institute Withdrawal Assessment for Alcohol) is used to assess the symptoms and their severity in order to guide treatment (see Table 13). Treatment generally lasts approximately 5 days, although more complicated and severe symptoms may warrant more prolonged treatment.

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Table 13 Clinical Institute Withdrawal Assessment Tool Addiction Research Foundation Clinical Institute Withdrawal Assessment-Alcohol (CIWA-Ar) This scale is not copyrighted and may be used freely. Patient: ___________________ Date: /___/___/___ Time: ___ : ______ (24 hour clock, midnight = 00:00) NAUSEA AND VOMITING—Ask “Do you feel sick to your stomach? Have you vomited?” Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves, and vomiting

TACTILE DISTURBANCES—Ask “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” Observation. 0 none 1 mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

TREMOR—Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient’s arms extended 5 6 7 severe, even with arms not extended

AUDITORY DISTURBANCES—Ask “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?” Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

PAROXYSMAL SWEATS—Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats

VISUAL DISTURBANCES—Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?” Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

ANXIETY—Ask “Do you feel nervous?” Observation. 0 no anxiety, at ease 1 mildly anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe 3 delirium or acute schizophrenic reactions.

HEADACHE, FULLNESS IN HEAD—Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe

AGITATION—Observation. 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or 3 constantly thrashes about

ORIENTATION AND CLOUDING OF SENSORIUM—Ask “What day is this? Where are you? Who am I?” 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place and/or person

6 very severe 7 extremely severe

Total CIWA-A Score ____

The medication most commonly used to treat alcohol withdrawal is lorazepam (Ativan), although chlordiazepoxide (Librium) was historically used routinely.

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Treatment

Both of these medications are benzodiazepines, a class known as antianxiety medications. They act on the GABA receptor, modifying it to be more sensitive to the effects of GABA, the brain’s major inhibitory neurotransmitter (discussed in greater detail in Question 6). This is identical to what alcohol does to the GABA receptor. Previously, alcohol itself was used to detox patients, but the development of benzodiazepines has led to safer management with greater control over dosing than alcohol allowed. Three differences distinguish benzodiazepines from one another.

Differences Distinguishing the Benzodiazepines From One Another The first difference is the half-life, or the amount of time the drugs circulate in the body before they are eliminated. The longer the half-life, the longer the medication stays in the body. Librium has a very long half-life relative to Ativan, and for that reason, it is generally preferred, as there is less chance of having symptoms return due to a missed dose. The second difference is how the drug is metabolized for elimination from the body. Some drugs are metabolized by that part of the liver affected by hepatitis and cirrhosis. Under those circumstances, the liver cannot effectively metabolize the drug fast enough, and it can build up to toxic levels in the body. For that reason, Ativan has generally supplanted Librium for patients hospitalized for DTs because the majority of these patients have liver impairment. The third difference is the route of administration. The more routes of administration that are available, the more flexible the medication is in its administration, thus allowing for continued use even when the patient is unable to take oral medication for a variety of reasons. Ativan, for

Half-life the time it takes for half of the blood concentration of a medication to be eliminated from the body. The half-life determines the time to achieve equilibrium of a drug in the blood and determines the frequency of dosing to maintain that equilibrium.

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example, can be given orally, intravenously, or intramuscularly; Librium can only be given orally. Ativan is preferred in the hospital setting as a result of its flexibility in addition to its safety. Although most of the evidence favors the use of benzodiazepines in the treatment of alcohol withdrawal syndromes, detractors do exist. Some physicians prefer the use of anticonvulsants, many of which also target GABA, although in a less direct manner than the benzodiazepines. Their opposition to benzodiazepine use for detoxification is based on a variety of concerns, not the least of which is the idea that benzodiazepines may actually “prime” alcoholics to start drinking again. At least one study compared patients receiving Ativan with those receiving the anticonvulsant carbamazepine (Tegretol). In this study, both drugs were equally effective in managing the withdrawal symptoms, although Ativan was superior in managing anxiety and insomnia. However, the Ativan treatment group had a greater risk of rebound of alcohol withdrawal symptoms after cessation of treatment. Additionally, their risk of having a first drink was three times greater. Finally, with respect to outpatient detox, there is a risk that the patient will drink on top of the benzodiazepine, which places them at even greater risk for alcohol poisoning. Despite this one study and its concerns, benzodiazepines remain the standard of care in the United States. Other medications have also been used to manage alcohol withdrawal symptoms, but these are used primarily as adjuncts and not alternatives to a benzodiazepine. Propanolol (or Inderal), a beta-blocker, is an antihypertensive medication that can lower blood pressure and slow the heart rate in these patients.

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57. If I am suffering from continued anxiety after achieving sobriety, can I continue to take Ativan or similar antianxiety medication? Anxiety, Insomnia, and Depression The level of anxiety and insomnia that one continues to experience after successful detox can remain high for several months afterward. This is sometimes referred to by it’s acronym, PAWS, for Post Acute Withdrawal Syndrome. Depression usually lifts sooner. These symptoms may be one of many reasons that the risk of relapse remains high. The use of sedative/ hypnotic agents during this period of time only prolongs the symptoms; however, the patient must be monitored and evaluated for an underlying mood or anxiety disorder that may be independent of residual withdrawal symptoms. If the symptoms persist, the likelihood of having an underlying anxiety or mood disorder increases with each passing month of sobriety. Most clinicians agree that a period of 12 months of sobriety in which one may or may not experience mood or anxiety symptoms is the best determinant of

Treatment

Haloperidol (Haldol), an antipsychotic medication, is occasionally used for severe agitation and psychotic symptoms such as delusions and hallucinations in some patients, although there is a small risk of causing a seizure. Phenytoin (Dilantin), an anticonvulsant, is the most commonly recommended medication for alcohol withdrawal seizures. Alcohol seizures are discussed further in Question 65. Finally, multivitamins, thiamine, and folate are routinely administered because of the high incidence of vitamin deficiencies that accompany alcoholism.

The level of anxiety and insomnia that one continues to experience after successful detox can remain high for several months afterward. This is sometimes referred to by it’s acronym, PAWS, for Post Acute Withdrawal Syndrome. Depression usually lifts sooner.

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an underlying disorder independent of alcoholism; however, this does not necessarily mean that treatment of the mood disorder should be withheld for those 12 months. It will depend partly on the severity of the symptoms and the level of disability that can result from them. Depression is generally easier to treat under these circumstances, particularly because none of the medications used is addictive. If there is an underlying anxiety disorder, the next question is this: What is the most appropriate treatment?

Treatment Although psychotherapy may be the optimal treatment approach, either through groups such as AA or individual treatment, sometimes it is just not enough to manage the symptoms. The natural inclination would be to turn to an antianxiety agent that works immediately and effectively such as the benzodiazepines, which are a class of antianxiety medications known best by one of their original medications, Valium, or diazepam, and Librium, or chlordiazepoxide. These agents are used for detoxification and were discussed in Question 56. The issue of whether one can continue to take benzodiazepines for anxiety in the face of a history of alcoholism remains highly controversial. The general rule is no. The reason for this is based on their physiological effects. Benzodiazepines enhance GABA activity by making the GABA receptor more sensitive to GABA’s effects. This is exactly what alcohol does to the GABA receptor. Thus, benzodiazepines, in a sense, are a substitute for alcohol. This is why they are so effective for detoxification from alcohol. For this reason, alcoholics tend to abuse these medications at greater rates than the general population. Physiological tolerance does develop from chronic use, and the risks of developing either a withdrawal delirium or withdrawal seizure are just as high. Additionally, long-term

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use of benzodiazepines can impair memory and cognition, as well as contribute to depression.

There are instances in which patients with a history of alcoholism are maintained on benzodiazepines long term. Although there are very specific reasons for this, the use of benzodiazepines long term is a rarity. First, patients who are on benzodiazepines have a clearly documented anxiety disorder independent of their alcoholism. Second, their alcoholism is typically limited to either problem drinking or alcohol abuse but not alcohol dependence. Finally, all other medications that treat the anxiety disorder have been tried and failed for a variety of reasons. Only in this very limited instance are benzodiazepines prescribed to a former alcoholic on a long-term basis, and not without some degree of trepidation and close monitoring.

Treatment

Long-Term Treatment with Benzodiazepines

It is important to bear in mind that the evidence suggesting that benzodiazepines are highly addictive drugs is simply not there. Although it is true that drug and alcohol abusers are more likely to abuse these medications than the general population, it is not true that the general population is as susceptible to becoming addicted to benzodiazepines as they are to alcohol or other drugs of abuse. Everyone will develop tolerance and withdrawal symptoms to one degree or another with long-term use of benzodiasepines, although few will end up dependent as the DSM-IV-TR defines it. In fact, even among alcoholics, it is less common to find them using benzodiazepines at ever-increasing amounts in the same manner that they escalate their alcohol use. This is one of the primary reasons these medications remain so controversial. Those addicted to alcohol often destroy

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their bodies and lives in its pursuit; rarely do they destroy their bodies and lives in pursuit of a benzodiazepine. In fact, most moderate their benzodiazepine use in a manner one could only wish for in their alcohol use. For those who happen to be both alcohol and benzodiazepine dependent, benzodiazepines are rarely ever a complete substitute for the pursuit of alcohol. If not benzodiazepines, what medication is appropriate to manage anxiety?

Alternatives to Benzodiazepines in the Management of Anxiety

Unfortunately, the anxiety that often accompanies alcoholism is quite tenacious and difficult to treat, leading to rather heroic efforts on the part of physicians to try medications off-label.

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This list is long, and most are off-label, although the most prominent medications that treat anxiety disorders are the SSRIs, which are FDA approved and generally effective in managing underlying anxiety disorders. As most type I or late-onset alcoholics suffer from a primary anxiety disorder that often drives their alcohol use, the SSRIs can help them secondarily to moderate their drinking or even help them to achieve abstinence, as discussed in Question 18. Unfortunately, the anxiety that often accompanies alcoholism is quite tenacious and difficult to treat, leading to rather heroic efforts on the part of physicians to try medications offlabel. The most common of these most recently has been a class of medications known as atypical antipsychotics. These include most prominently quetiapine (Seroquel), which is discussed further in managing insomnia; however, other atypical antipsychotics have also been tried with varying degrees of success. These other agents include olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), and aripiprazole (Abilify). All of these medications are FDA approved

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Treatment

for schizophrenia and bipolar disorder so they are clearly used off-label when prescribed for anxiety. And their use comes with a price. First, weight gain can be an issue. Second, metabolic changes can also occur, including increased blood sugar, cholesterol, and triglycerides. Finally, in older people, there is a small increase in the risk of having cerbrovascular accidents. Despite these drawbacks, they can be safe and effective agents in their own right, and their use should be considered when the anxiety is severely debilitating and not responding to more traditional regimens. Anticonvulsant medications are used off-label to treat anxiety. These include valproic acid (Depakote), gabapentin (Neurontin), carbamazepine (Tegretol), and the newer anticonvulsants lamotrigine (Lamictal), tiagabine (Gabatril), and pregabalin (Lyrica). Table 14, which also includes medications from Question 56, contains a general list of some of the medications used in the treatment of anxiety and insomnia.

Distinguishing Discontinuation Syndromes Many of these medications, including the SSRIs, the atypical antipsychotics, and some of the anticonvulsants, cannot be discontinued abruptly or else various side effects can occur. The side effects are known collectively as discontinuation syndromes. It is important to distinguish between four types of discontinuation syndromes that can occur when you stop a medication that you have been taking daily for an extended period of time. These four syndromes include withdrawal (which we have previously discussed), rebound, recurrence, and medication specific. Withdrawal is accompanied by clear physiologically measurable changes, including vital signs changes, skin color and temperature changes, and psychological distress. For some

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146 Table 14 Medications for Anxiety/Insomnia Major Drawback

Zolpidem, et al.

Non-BZDP hypnotic

Chronic insomnia

Lorazepam, et al.

BZDP

Fluoxetine, et al.

SSRI

Short term treatment for insomnia Short term treatment for anxiety, seizures Depression, anxiety

Trazadone

Atypical Antidepressant

Depression

OCD, premature ejaculation Anxiety, insomnia

Rebound and chronic insomnia Dependency, tolerance, and withdrawal Sexual dysfunction

Ramelteon

Insomnia

None

Mirtazepine Doxepine

Melatonin Receptor Agonist Atypical Antidepressant Tricyclic Antidepressant

Depression Depression

Quetiapine

Atypical Antipsychotic

Schizophrenia, bipolar disorder

Olanzapine

Atypical Antipsychotic

Schizophrenia, bipolar disorder

Risperidone

Atypical Antipsychotic

Schizophrenia, bipolar disorder

Anxiety, insomnia Insomnia, anxiety, panic, neuropathic pain Impulsivity, anger management, anxiety, insomnia Impulsivity, anger management, anxiety, insomnia Impulsivity, anger management, anxiety, insomnia

Chronic anxiety

Low blood pressure, hangover Nonsedating Dry mouth, constipation Dry mouth, constipation, weight gain Weight gain, metabolic effects Weight gain, metabolic effects Weight gain, metabolic effects, increased prolactin, extra pyramidical side effects*

*Include muscle spasms, tremors, restlessness, and other abnormal movements.

(continued)

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Medication

Major Drawback

Ziprasidone

Atypical Antipsychotic

Schizophrenia, bipolar disorder

Impulsivity, anger management, anxiety

Aripiprazole

Atypical Antipsychotic

Schizophrenia, bipolar disorder

Impulsivity, anger management

Carbamazepine

Anticonvulsant

Tiagabine Valproate

Anticonvulsant Anticonvulsant

Bipolar disorder, depression Anxiety, mania Anxiety, panic

Gabapentin

Anticonvulsant

Lamotrigine

Anticonvulsant

Pregabalin

Anticonvulsant

Diphenhydramine

Over-the-counter allergy medication

Seizures, neuropathic pain Seizures Seizures, bipolar disorder, neuropathic pain Seizures, neuropathic pain Seizures, bipolar depression Seizures, neuropathic pain Allergies, sleep

Weight gain and metabolic effects less, less sedating Weight gain and metabolic effects less, less sedating Toxic in overdose, blood levels required Delirium Weight gain, birth defects Generally of limited effectiveness Dangerous rash if increased too rapidly Delirium

None

Weight gain, hangover, dry mouth

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Anxiety, insomnia, restless legs Unipolar depression, anxiety Insomnia, anxiety

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Table 14 Medications for Anxiety/Insomnia (continued)

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drugs, such as benzodiazepines, this can be a lifethreatening emergency. For this reason, one needs to always consult a physician when deciding to discontinue a medication to see whether such a withdrawal syndrome could occur. Rebound occurs when the symptoms for which one was receiving the medication become transiently worse than the symptoms one had before treatment commenced. This is a potential risk for any sleep medication from which rebound insomnia can be very severe; however, this is a transient effect that abates within days. Unfortunately, most people don’t realize that rebound is expected and transient and immediately they go back on their sleeping medications. Physiological changes generally do not accompany rebound. Recurrence is simply the return of symptoms for which one originally received the medication. Recurrence is more delayed in the time line after stopping a medication than either withdrawal or rebound. Finally, medication-specific discontinuation syndromes occur with respect to the SSRIs. Symptoms can start abruptly and last for days to weeks depending on the medication one stopped. The symptoms include headaches, dizziness, electrical sensations running down the arms and legs, and feeling like you are coming down with the flu. Often the symptoms are misinterpreted as a recurrence of depression. Typically, if one begins to experience symptoms as early as a few days after stopping antidepressant medications, these actually represent rebound or a discontinuation syndrome (no measurable physiological changes). Rarely is it due to recurrence. Thus, it is a good idea to taper the medications. When the medications are appropriately tapered, any symptoms that return can properly be attributed to recurrence, and thus, increasing the medication back to

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a therapeutic dose may be a wise choice. In summary, although these medications can cause various discontinuation syndromes, they are not addictive.

Lack of sleep is probably the single most unsettling symptom that former alcoholics have to struggle with, sometimes on a chronic basis. Even after months or years of sobriety, many alcoholics continue to complain of a lack of restful sleep and excessive daytime sleepiness. Lack of sleep can have serious implications, including breathing difficulties and heart and mood problems. Additionally, excess daytime sleepiness can affect the ability to focus and concentrate and to remember and perform normal daytime functions, the most serious being automobile driving.

Sleep Architecture Sleep has a characteristic pattern in adults, known as sleep architecture, as measured by an electroencephalogram. The two most prominent components include slow-wave sleep and rapid eye movement (REM) sleep. Alcohol has an initial stimulant effect among nonalcoholics, followed by a decrease in sleep onset. This prompts many to use alcohol as a sleep inducer. The sedative effects of alcohol wear off after about 6 hours, usually leading to a rebound effect causing people to wake up. Chronic consumption of alcohol over time only magnifies this problem, prompting ever further increasing amounts of alcohol to “chase” this problem. In alcoholics, the general sleep pattern becomes a decreased sleep onset, frequent awakenings,

Lack of sleep is probably the single most unsettling symptom that former alcoholics have to struggle with, sometimes on a chronic basis.

Treatment

58. Ever since I quit drinking I can’t sleep at night. What should I do?

Sleep architecture a predictable pattern during a night’s sleep that includes the timing, amount, and distribution of rapid eye movement (REM) sleep and non REM. Slow-wave sleep a state of deep sleep that occurs regularly during a normal period of sleep with intervening periods of rapid eye movement (REM) sleep. Rapid eye movement (REM) rapid eye movements that occur during a stage of sleep that appears on EEG as if the subject is awake. Dream sleep.

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and excessive daytime sleepiness. In this instance, if alcohol is stopped, withdrawal symptoms lead to a worsening of the pattern. Often there is no restful sleep. Even after withdrawal has ended, slow wave, or restful sleep, can only return after a bout of heavy drinking, further reinforcing dependency.

Chronic Insomnia Alcoholics who suffer from chronic insomnia are twice as likely to turn back to alcohol in order to sleep as those who don’t report insomnia. They therefore suffer from more severe alcohol dependence and depression. One study demonstrated that alcoholics who had higher levels of REM or dream sleep after cessation of alcohol predicted relapse within 3 months after hospital discharge in 80% of patients. Sleep problems, whether verbalized by patients or documented in a sleep lab, clearly predict higher rates of relapse.

Treatment for Insomnia The need to treat insomnia therefore is paramount in preventing relapse. Three options are available: (1) behavioral treatments, (2) over-the-counter medications, or (3) prescription medications. No particular behavioral treatment has been found to be superior over another, although all are useful. These include progressive muscle relaxation, guided imagery, and word and imagination games (e.g., counting sheep). Behavioral treatment tends to improve sleep onset more than medication, although overall improvement in sleep is no different between the three options. The most common over-the-counter medication is any of the variety that contains diphenhydramine (Benadryl).

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The final option for insomnia is prescription medication. The ideal medication would be one that has a quick onset of action, a short half-life (body eliminates it rapidly), does not interact with other medications, is not metabolized by the liver, and finally, does not lead to another problem with addiction. As mentioned in Question 57, benzodiazepines are a poor but ever present choice in the battle against insomnia. Recent focus has been on the use of a new class of sleeping agents that allegedly meet these criteria. These agents are specific to the benzodiazepine receptor, which affects only sedation and not memory or anxiety, and therefore are allegedly not addictive. One cannot miss the ads for zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). Unfortunately, there are growing case reports of multiple problems with these medications, including addiction as well as sleep walking, making these potentially problematic for insomnia related to alcoholism. Other possibilities exist for treating insomnia, including trazadone (Desyrel), mirtazepine (Remeron), doxepine (Sinequan), gabapentin (Neurontin), and quetiapine (Seroquel). Each medication can induce and sustain sleep. Each has the potential for significant adverse effects (Table 14 shows a list of medications for insomnia). At least one study has been conducted using gabapentin for alcoholism-induced insomnia. It probably has the fewest adverse effects associated with it, and 300 to 1,800 mg have been found to be superior to either placebo or trazadone.

Treatment

This is not a good medication for sleep because of its tendency to disrupt all stages of sleep, and it can cause a hangover effect along with other side effects, including dry mouth, constipation, and increased appetite.

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) these are all sleepenhancing or sleepinducing medications that are not benzodiazepines but do act on one of the GABA receptors in a manner similar to benzodiazepines.

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Finally, the FDA has recently approved a novel sleep medication called ramelteon (Rozerem). This medication uniquely acts on the receptor involved with melatonin, a long-standing natural sleep remedy used for the treatment of insomnia. Melatonin is thought to assist in regulating the body’s sleep/wake cycle. Ramelteon is a different molecule than melatonin. Because of that, its attachment to the melatonin receptors involved in regulating sleep and circadian rhythms is three to five times greater than for melatonin. Additionally, ramelteon is up to 17 times more potent at those receptors than melatonin. It is not addictive; however, neither does it cause drowsiness. It must be taken regularly for it to be effective. This often leads to frustration among people suffering from insomnia who have tried other sleep medications because they are looking for the feeling of sedation that usually comes with a sleeping pill and they do not get this with ramelteon. As a result, they often discontinue the drug prematurely. This is unfortunate, as studies demonstrate that ramelteon is safe and effective in treating chronic insomnia. Whether ramelteon has a place in treating insomnia associated with alcoholism remains to be seen, but it is certainly an option to be considered. There is no natural remedy to detoxification from alcohol other than alcohol itself, which is not recommended.

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59. Are there any alternative treatments or herbal remedies for alcoholism? There is no natural remedy to detoxification from alcohol other than alcohol itself, which is not recommended. Alcohol withdrawal is a medical emergency with significant morbidity and mortality and requires close medical monitoring and the judicious use of benzodiazepines. Some promising studies suggest at least

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two herbal remedies that may help reduce the amount of alcohol consumed. Finally, there may be some natural remedies for insomnia related to alcoholism.

Treatment

General nutritional deficiencies often occur from alcoholism, including thiamine and vitamin B deficiencies. Patients with alcohol dependence often obtain the majority of their calories from alcohol and thus forego basic nutritional requirements. Additionally, alcoholics are prone to develop pancreatic and liver disease as a result of alcohol’s toxic effects, which can also lead to poor nutrition. These vitamin deficiencies must be replaced; otherwise, there is a risk of developing anemia and/or dementia as a result of severe deficiencies (see Question 61 for further details). Milk thistle (Silybum marianum) extract has been thought to counteract the harmful effects of alcohol on the liver. In one study, milk thistle extracts reduced death rates due to alcohol-induced cirrhosis of the liver, although another double-blind study did not confirm this finding. Milk thistle extract may protect the cells of the liver by both blocking the entrance of harmful toxins and by helping remove these toxins from the liver cells. Milk thistle has also been reported to regenerate injured liver cells. Two herbs may directly aid in alcoholism itself. Presently, the most promising natural remedy appears to be kudzu (Pueraria lobata), an herb that grows in the southeast United States, China, and Japan. Chinese traditional medicine men have been using it for centuries to treat alcohol intoxication and hangovers. A recent study published in the Journal of Alcoholism: Clinical and Experimental Research demonstrated that kudzu led to reduced consumption of alcohol among

Kudzu (Pueraria lobata) a plant used in alternative medicine to reduce alcohol cravings.

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St. John’s Wort (Hypericum perforatum) a plant used in alternative medicine as an alternative to antidepressant medications.

Valerian (Valeriana officinalis) an alternative medicine that is used in place of sedative drugs.

binge drinkers by as much as 50%. The mechanism was thought to occur by making alcohol more readily available to the brain by increasing blood flow to the brain, thereby leading to a more potent effect with a reduced amount. No real adverse effects were noted, but further research was advised before a recommendation for its use could be made. Currently, however, the formulation that the researchers used is not available in health food stores. Another herb with promising effects in reducing alcohol consumption appears to be St. John’s Wort (Hypericum perforatum), commonly thought to have mild antidepressant properties. The effectiveness of St. John’s Wort is not without side effects and can interact with other medications such as SSRIs. Insomnia (see Question 58) can be a chronic disabling problem. Aside from the remedies already described, some natural remedies may aid in sleep. Melatonin is a natural food supplement that is available over the counter and is produced by the brain to regulate the sleep/wake cycle. It has been used with modest success, although studies generally fail to show overall efficacy. Valerian (Valeriana officinalis) is an herbal product that improves one’s sense of quality sleep when taken over a 1- to 2-week period for people struggling with mild to moderate insomnia; however, there have been no studies using this herbal product with patients suffering from insomnia related to alcoholism.

60. Are vaccines available for various addictive drugs? The idea that one can become vaccinated against alcoholism or any other addiction is an intoxicating notion. The idea is to have the body produce antibod-

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Antibodies occur in response to an antigen, as larger numbers of proteins that have high molecular weights. Antibodies are a normal immune response to fight infection.

Treatment

ies against the addictive drugs. Antibodies are molecules produced by the body’s immune system that attach to foreign invaders, in this case, the intoxicating drugs, such as alcohol, cocaine, or nicotine, rendering them incapable of either entering the brain altogether or attaching to the receptors that lead to the sensation of intoxication. Many pharmaceutical companies have developed such agents, and they have begun human clinical trials. As exciting as that line of research is, no fruitful vaccine against alcoholism or any other addiction has yet to be either discovered or invented although attempts have been made. To date, however, the vaccines have been disappointing. A Google search on the Internet yields nothing beyond the year 2002. Aside from whether such vaccines may be effective, investing in their development by pharmaceutical companies has some more practical issues to contend with. Who will pay for the treatment? Most people with substance abuse problems lack the resources. The other issue has to do with the simple fact that it is hard to run a clinical trial with this population because of issues of compliance (i.e., staying in the study, taking the medication, following the instructions, and getting to the appointments). A 30% to 50% dropout rate can spell disaster for a clinical trial.

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PART V

Associated Conditions What are the medical consequences of alcoholism?

Can alcoholism cause dementia?

Are there other neurological effects of alcoholism?

More . . .

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61. What are the medical consequences of alcoholism?

The most obvious and direct medical consequences are the injuries resulting from intoxication and its resulting impact on impulse and judgment.

The medical consequences of alcoholism are manifold. Until clearer criteria were developed to diagnose alcoholism, these conditions allowed for the definitive diagnosis of alcoholism. The most obvious and direct medical consequences are the injuries resulting from intoxication and its resulting impact on impulse and judgment. Everyone is acutely aware of the impact of drunken driving, but alcohol has a devastating impact on the human body, leaving few organ systems free of its toxic effects. These organ systems include the respiratory system, the gastrointestinal system, the cardiovascular system, the hematological system, the immune system, the musculoskeletal system, the genitourinary system, the endocrine system, metabolism, and finally, the central nervous system. The most important issues of each system (excluding the central nervous system, discussed in Questions 62 and 63) are covered in this question.

Respiratory System Before going into alcohol’s chronic and pernicious effects on various organ systems, you must understand that acute alcohol intoxication or alcohol poisoning can kill, and it does so with alarming regularity particularly in adolescents and young adults. A year does not go by where an article in a local paper discusses a youth who is found dead in a fraternity room, a dorm room, a friend’s house after a high school party, or their own home after a binge drinking episode. This occurs simply because alcohol in high doses can lead to unconsciousness and can suppress respiratory drive,

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Gastrointestinal System The most commonly known effects on the gastrointestinal system are alcoholic hepatitis and eventual cirrhosis, which ultimately culminates in liver failure and death. Everyone has also heard of the alcoholic developing stomach ulcers. This is due to the fact that alcohol promotes the growth of the bacteria H. pylori in the stomach, well known to be the cause of peptic ulcers. Less well known are its effects on the pancreas, leading initially to pancreatitis and over time pancreatic failure and a panoply of illnesses associated with it, not the least of which is insulin-dependent diabetes, as the pancreas is the source of the body’s insulin production.

Cardiovascular System Chronic heavy drinking can lead to hypertension (high blood pressure). It can also raise cholesterol and triglycerides in the bloodstream, all risk factors for the development of coronary artery disease, or the build up of plaques, which clogs the coronary arteries. This buildup increases the odds of suffering from a heart attack. Additionally, the poor nutrition that is often associated with chronic alcoholism can lead to vitamin deficiencies that can lead to heart muscle damage, particularly thiamine, which causes a rare condition commonly known as alcoholic beriberi or thiaminedependent cardiomyopathy.

Hypertension high blood pressure, which can appear without an apparent cause. Hypertension can damage other organs in the body and is frequently the cause of strokes.

Associated Conditions

leading one to stop breathing. This is one of the biggest risks that alcohol has when consumed rapidly in large quantities, and young people are forever ignorant of this potential danger.

Coronary artery disease the build up of plaque in the coronary arteries constricting blood flow to the heart muscle, leading to chest pain (angina) and the potential for muscle death (myocardial infarction). Beriberi from Sri Lankan for “I cannot, I cannot.” A condition caused by thiamine deficiency, leading to damage to the central nervous system and causing memory and emotional disturbances (Wernicke’s encephalopathy), weakness and pain in the limbs, and periods of irregular heart beats. Swelling of bodily tissues is common. In advanced cases, the disease may cause heart failure and death.

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Congestive heart failure the heart is unable to maintain adequate circulation of blood to the body’s tissues and is unable to pump out venous blood via the venous circulation system.

There is a more direct and pernicious impact that chronic heavy drinking has on the heart, however. This affects up to one in four individuals who have a greater than 10-year history of sustained alcohol dependency. Alcohol is directly toxic to heart muscle, thus bypassing the eventual buildup of coronary artery–clogging plaque that causes heart muscle damage from coronary artery disease. This direct toxicity causes an inflammation to the heart muscle called myocarditis, just like it causes inflammation to the liver called hepatitis. Eventually, the inflammation can lead to heart muscle death just as chronic inflammation to the liver can lead to liver cell death known as cirrhosis. When too much heart muscle dies off, whether from coronary artery disease or from the toxic effects of alcohol, the heart either pumps irregularly or fails to pump. Irregular pumping is known as an arrhythmia or dysrhythmia, which can be fatal. Alternatively, when the heart fails to pump an adequate amount of blood to the body, it leads to a condition known as congestive heart failure. The most distressing event occurs when congestive heart failure causes a buildup of fluid in the lungs, making it difficult to breathe. This is particularly acute at night when one is lying down and gravity doesn’t have the opportunity to pull the fluids away from the lungs.

Hematologic and Immune Systems Alcohol is also toxic to the bone marrow or the hematological and immune systems both directly and indirectly through the various vitamin deficiencies that result from poor nutrition and alcohol’s direct toxic effects to bone marrow itself. The hematological system produces and maintains red blood cells that carry oxygen throughout the body, white blood cells, or cells

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Leukopenia a condition in which the number of leukocytes (white blood cells) circulating in the blood stream is low, commonly due to a decrease in the production of new cells in conjunction with various infectious diseases, drug reactions, other chemical reactions, or radiation therapy.

Associated Conditions

responsible for fighting infections and other foreign intruders, and various clotting factors that allow for blood to clot properly preventing excess blood loss. Anemia is the result of loss of red blood cells. Many types of anemias occur because of chronic alcoholism. Leukopenia (leuko is a root word for white, and penia is a root word for loss) is the medical term for loss of white blood cells, which can lead to an increase in infections and cancers because these cells are instrumental in fighting these ever-present threats. Leukopenia is an immune deficiency syndrome of which there are many causes, the most famous being AIDS. Alcohol can increase the risk of cancer not only by lowering the body’s ability to fight off cancer cells but also causing cancer cells to grow through its direct toxic effects on the mouth, throat, larynx (voice box), and esophagus. Alcohol increases the risk of colon and rectal cancer in a manner not currently well understood. In women, the risk of breast cancer increases from as little as one drink daily.

Musculoskeletal System Just as alcohol has a direct toxic effect on heart muscle, it also has a direct toxic effect on skeletal muscle, causing a condition known as alcoholic myopathy. The toxic effects of alcohol can cause skeletal muscle to breakdown. When muscle tissue breaks down at a rapid rate, the muscle proteins clog the kidneys in their attempt to eliminate them from the body, which in turn can lead to kidney (renal) failure. Slow muscle breakdown can lead to weakness and fatigue over time. Myopathy can also occur from alcohol’s indirect effects on one’s nutritional status and from resulting endocrine abnormalities. Alcohol can also impact bone density and growth, causing osteopenia (remember the root “penia” for

Myopathy a disorder of the muscle tissue, typically causing wasting and weakness.

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Hyponatremia low blood sodium. Hypokalemia low blood potassium. Hypomagnesemia low blood magnesium. Hypocalcemia low blood calcium. Hypophosphatemia low blood phosphorous. Parathyroid hormone a hormone produced by the parathyroid gland that is next to the thyroid. ACTH Adrenocorticotropic Hormone. A hormone released by the pituitary gland, which stimulates the adrenal glands to release adrenalin. Prolactin a hormone found in the anterior lobe of the pituitary that induces and maintains lactation during the postpartum period in a female.

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decreasing) and hastening osteoporosis, leading to an increased risk of fractures or broken bones.

Genitourinary/Endocrine Systems and Metabolism Heavy alcohol consumption is never more devastating than when it plays havoc on the body’s metabolism. Because of alcohol’s chronic and pernicious effects on various organ systems, the body is exceptionally vulnerable to various assaults that can occur metabolically.

Insulin Sensitivity Both alcohol intoxication and withdrawal can affect insulin sensitivity, resulting in dangerously high or low blood sugars. This, in turn, can impact other metabolic functions that lead to electrolyte abnormalities such as low sodium (hyponatremia), low potassium (hypokalemia), low magnesium (hypomagnesemia), low calcium (hypocalcemia), and low phosphorus (hypophosphatemia). Additionally, endocrine abnormalities can occur. Parathyroid hormone, insulin, ACTH, prolactin, cortisol, and growth hormone levels may all be altered. Sex hormones (such as testosterone, estrogen, and progesterone) levels may lead to sexual dysfunction and infertility with chronic heavy alcohol use. Alcoholics frequently come to the emergency room with intractable nausea and vomiting, accompanied by extreme abdominal pain. They usually are unable to eat or drink anything for several days, and as a result, their last alcoholic drink will have been several days previous to their presentation. They are is malnourished and vulnerable to infection, and their liver, pancreas, heart, and immune systems are all compromised. Alcoholics are anemic; however, more critical is that the

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Cortisol also called hydrocortisone. It is derived from cortisone and is also used to treat inflammatory conditions, including arthritis.

62. Can alcoholism cause dementia?

Everyone is aware of the phenomenon known as the “blackout”—a transient period of memory loss or amnesia during intoxication with no real evidence of neurological injury.

Everyone is aware of the phenomenon known as the “blackout”—a transient period of memory loss or amnesia during intoxication with no real evidence of neurological injury. It generally coincides with a rapid, rather than slow, elevation of blood alcohol and may be an early predictor of alcohol dependence. Repeated episodes have long-term consequences with respect to memory impairment. Because of alcohol’s intoxicating effects, there can be long-term consequences to the brain in particular and the nervous system in general. The damaging effects can be far reaching. They are due both to alcohol’s direct toxic effects, but also to its indirect effects

Growth hormone secreted by the pituitary gland and regulates growth.

Associated Conditions

alcoholic now has dangerously low electrolytes, including potassium, sodium, magnesium, calcium, and phosphorus in addition to blood sugar. This person is beginning to withdraw from alcohol, demonstrating a rapid heart rate and high blood pressure. He or she may also be disoriented to time and place and may be hearing and seeing things that are not there. Correcting his or her electrolytes becomes urgent, particularly when it comes to sodium. This leads to a delicate balancing act. Failure to correct the sodium can lead to cerebral edema, a buildup of fluid in the brain; brain damage occurs because of the increased pressure pushing the brain against the skull and other support structures, eventually leading to seizures and death. Correcting the sodium too rapidly can lead to a condition known as central pontine myelinolysis, which is a loss of white matter in the brain known as myelin that is critical for nerves to function correctly. The myelin in the brain literally dissolves, leading to brain damage and possibly death.

Cerebral edema swelling of the brain because of an abnormal accumulation of fluid. Central pontine myelinolysis disintegration of the myelin sheath in the pons that is associated with malnutrition, most often due to alcoholism.

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through the various nutritional and metabolic abnormalities as well as the resulting withdrawal syndrome. The various neurological effects are discussed.

Wernicke/Korsakoff ’s Syndrome

Anterograde amnesia loss of memory where new events are unable to be transferred to longterm memory. Confabulation filling in the memory gaps through fabrication (i.e., making up stories to cover the loss of memory). Malabsorption faulty absorption of nutrients from the alimentary canal. Neurotoxic toxic or lethal to the nerve and/or nervous tissue. Atrophy a decrease in the size of an organ or muscle, or a wasting away of a body part or tissue.

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Probably the most well-known, although not the most common, form of memory disturbance caused by alcohol is Wernicke’s encephalopathy and Korsakoff ’s dementia. Wernicke’s encephalopathy refers to an acute disease process caused by thiamine deficiency, leading to confusion, apathy, drowsiness, an unsteady gait, and visual disturbances, due to nerve palsy’s affecting the motor system of the eyes. When memory loss for events after the onset of the disorder occurs on a chronic basis (known as anterograde amnesia), it is referred to as Korsakoff ’s dementia. Often individuals suffering from this will fill these memory gaps with events that never occurred. This is known as confabulation and is different from lying in that there is no real ulterior motive behind it. Korsakoff ’s is not a true dementia in that it does not affect other areas of cognition in the same manner that Alzheimer’s disease does. The more proper term for this condition therefore is alcohol amnestic disorder. Both Wernicke’s and Korsakoff ’s begin when heavy drinking causes intestinal malabsorption and thiamine (vitamin B1) deficiency. Treatment involves administration of thiamine 100 mg daily over 3 months. Untreated, it carries a mortality rate of 15%. Even with treatment, only a third of those with memory impairment fully recover.

Alcohol-Related Dementia Alcohol has a direct neurotoxic effect on the brain, accelerating to a generalized atrophy or shrinkage of the brain that often occurs with aging. Some studies

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Glial cells that support and nourish the brain’s neurons.

Associated Conditions

suggest that this process may be reversible and that abstinence may aid in halting the progression and even reversing it. Apparently, alcohol attacks the coating of the nerve cells, known as glial cells that make up the myelin, or white matter, rather than the nerve cells themselves. Unlike neurons themselves, glial cells have the capacity to regenerate. Other studies, however, have disputed this. What is known is that the progression of alcohol dementia can be halted with abstinence, unlike the progression of Alzheimer’s disease, which continues to progress. Most studies support the contention that alcohol does not hasten the progress of Alzheimer’s disease, and it is doubtful that alcohol is a risk factor in the development of early Alzheimer’s, although this remains somewhat controversial.

Vascular Dementia Complicating this picture, however, is the fact that many times the dementia is not reversible. Alcoholics can develop Alzheimer’s disease, and any damage that alcohol has caused to the brain of an Alzheimer’s patient will worsen the condition. What is not controversial is the fact that alcoholism can increase the risk of stroke for the very same reason that it increases the risk of heart attack, as the two processes are essentially identical though they involve different organs. One of the most common forms of dementia is vascular dementia. Many times strokes are undetected because the blood clots or thrombi are so small that they affect only the tiniest of blood vessels. This leads to a condition that can be seen on brain imaging scans known as microvascular changes that can also lead to brain atrophy and dementia without the obvious signs of stroke. Finally, alcoholics are prone to accidents that frequently involve the head. One head

Vascular dementia a cognitive disease with mental and emotional impairments, plus neurological signs and symptoms. Thrombi plural for thrombus or blood clot. If the clot detaches and moves, it is known as an embolus. Microvascular the part of the circulatory system made up of minute vessels or capillaries measuring less than 0.3 millimeters in diameter.

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MarchiafavaBignami Syndrome named after the two Italian pathologists who first discovered the condition. A syndrome first identified in alcoholics of Italian origin who died after suffering from seizures resulting in a coma. Dysphasia the loss of the ability to use or understand language as a result of an injury to the brain or a disease. Cerebellar system the part of the nervous system that has to do with coordination of muscles and the maintenance of equilibrium. Pseudobulbar palsy condition caused by damage to the cranial nerve pathways that can lead to unprovoked outbursts of laughing or crying along with other neurological deficits.

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injury dramatically increases the risk for another head injury. Multiple head injuries increase the risk of developing traumatic brain injury, which invariably leads to multiple cognitive and personality changes that can be viewed as dementia. Up to 30% of nursing home patients have alcohol-related dementia due to any of the previously mentioned problems.

63. Are there other neurological effects of alcoholism? Numerous obscure neurological conditions, such as Marchiafava-Bignami Syndrome, which attacks wine drinkers of Italian heritage, appear to affect individuals from certain ethnic backgrounds. Very specific areas of the brain are affected, causing confusion, difficulty speaking (dysphasia), seizures, and dementia. Alcohol can more commonly impact on numerous other neurological systems. Alcohol has a predilection for the cerebellar system of the brain, which is critical in coordinating voluntary movements. This occurs with acute intoxication, thus leading to the staggering gait. It can also lead over time to chronic degeneration of the cerebellar system, causing the gait disturbance even when the individual is sober. This occurs in about 1% of chronic alcoholics. Central pontine myelinolysis, which was discussed in Question 61, results from rapid correction of low sodium, or hyponatremia, and can cause pseudobulbar palsy, which consists of an overemotional state known as pathological laughing and crying, speech difficulties, facial paralysis, quadriplegia, confusion, and coma, if one survives.

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Peripheral neuropathy refers to degenerating of the nerves outside of the central nervous system, including the cranial nerves but not the optic or spinal nerves or the autonomic nervous system.

Associated Conditions

Finally, however, the most common neurological condition is peripheral neuropathy. This occurs in anywhere from 5% to 15% of alcoholics. Chronic alcohol intake can destroy peripheral nerves, particularly the smaller nerves in the hands, feet, and lower legs. The experience is similar to those who suffer from diabetic neuropathy. There is a “stocking-glove” distribution of weakness, numbness, and burning of the hands and feet. One can feel burning pain in the soles of the feet, particularly when walking. Later stages can lead to a foot or wrist drop with muscle wasting. This condition has the potential of traveling up the limb, although rarely does it cause complete paralysis of the affected limb.

64. What are DTs? Probably the most well-known, although rarest (affecting only about 5% of alcoholics), but a treatable event can result from daily heavy alcohol use followed by abrupt cessation. Delirium Tremens is an acute confusional state that affects a variety of cognitive processes. These include a waxing and waning of consciousness, disorientation to place and time, attention and concentration impairment, supersensitivity to extraneous stimuli, visual and auditory hallucinations, and paranoid delusions. Tremens is another word for tremors or shakes. The individual suffering from this condition also demonstrates severe tremors as well as high blood pressure and a rapid pulse. This is a medical emergency with upward of a 15% risk of mortality if untreated. Symptoms may begin a few hours after the last drink and peak around 48 to 72 hours later.

Delirium Tremens (DTs) an acute withdrawl syndrome from alcohol.

As mentioned in Question 6, two primary brain chemicals are involved in the development of this condition:

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As mentioned in Question 6, two primary brain chemicals are involved in the development of this condition: GABA and glutamate. Downregulation the process by which a cell decreases the number of receptors to a given hormone or neurotransmitter to decrease its sensitivity to this molecule.

Upregulation the process by which a cell increases the number of receptors to a given hormone or neurotransmitter to improve its sensitivity to this molecule.

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GABA and glutamate. With chronic use of alcohol, the GABA system attempts to compensate for its increased use by making itself less accessible to alcohol in what is know as downregulation. Over time, in order for the GABA to function correctly, it will need alcohol regularly or risk shutting down altogether. Without GABA, an excited state emerges. This is compounded by the glutamate system, which is the brain’s major excitatory neurotransmitter. As alcohol chronically pushes GABA downward, glutamate also tries to compensate by increasing its activity in what is known as upregulation. When alcohol is suddenly withdrawn, the combination of GABA being shut down and glutamate running amok leads to the brain being in an extremely hyperexcitable state. In terms of motor systems, tremors result along with tachycardia or a rapid heart rate and hypertension or high blood pressure. In terms of sensory systems, overstimulation occurs without the ability to process and make sense of the overwhelming amount of information from the environment bombarding it. Thus, the individual becomes disoriented and demonstrates hallucinations, insomnia, irritability, and paranoia. Benzodiazepines are the treatment of choice, as described in Question 56. Susan’s comment: Nothing in the entire experience has “brought me to my knees” like psychosis and DTs. Even seizures, although horrific to witness, don’t last very long. All of the other experiences seem to pale in comparison to watching your offspring in wrist and ankle restraints. It is like watching a nightmare unfold, with your “baby” as the main character. The dull look in his eyes and the mumbling about nonsensical things are shattering events for a mother. I have been able to maintain my composure through everything else but

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Associated Conditions

that. I make myself very scarce at those times and limit my visits to peeking in on him and talking to the nurses so that he doesn’t hear my voice. I always drive home in tears.

65. I had withdrawal seizures. Does that mean that I now need to take an anticonvulsant? Alcohol withdrawal seizures may or may not occur with DTs but are certainly more common, affecting up to one third of patients with chronic heavy alcohol use. Of those patients who have alcohol withdrawal seizures, between 30% to 50% will end up developing DTs. The seizures are generalized, meaning that they affect the entire body and occur within the first 24 to 48 hours after the last alcoholic drink. They tend to be brief and occur in a cluster of one to three seizures in fairly rapid succession. Generally, there are no auras or warning symptoms. An electroencephalogram and CT scan are usually normal, and the seizures usually do not recur. Electrolyte deficiencies can play a role in the intensity and duration of the seizures, particularly low sodium and magnesium. The seizures generally cease spontaneously and do not recur, although in about 3% of individuals the seizures will be prolonged. This condition is known as status epilepticus. When this occurs, further investigation is necessary to exclude other underlying medical conditions such as a head injury, an infection, or the development of epilepsy. Seizures are generally well controlled with benzodiazepines.

Aura a subjective sensation of voices or colors prior to a seizure.

Status epilepticus a state in a person whereby seizures occur in rapid succession without recovery of consciousness.

Dilantin is often also initiated in the emergency room but remains a controversial subject. The ASAM provides the following clinical practice guidelines for the use of Dilantin in alcohol withdrawal, as outlined in Table 15. (The grading of each recommendation is

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Table 15 Clinical Practice Guidelines for the Use of Dilantin in Alcohol Withdrawal Prophylaxis preventing the occurrence of something.

Epileptogenic causing epileptic attacks or seizures.

1. For patients with alcohol withdrawal syndrome and no history of seizures, phenytoin is not recommended as routine prophylaxis against alcohol withdrawal seizures. (Grade A recommendation.) 2. For patients with alcohol withdrawal syndrome and a history of seizures that are not alcohol related, phenytoin or other anticonvulsant therapy appropriate for the seizure type, in addition to adequate sedative–hypnotic medication, is recommended. (Grade C recommendation.) 3. For patients with alcohol withdrawal syndrome and a history of alcohol withdrawal seizure, evidence is limited and conflicting, and expert opinion is mixed as to the benefit of adding phenytoin to adequate sedative–hypnotic medication. Therefore, sedative– hypnotics alone or with phenytoin are both options. (Grade C recommendation.) 4. Long-term phenytoin prophylaxis, except when indicated for seizure disorder unrelated to alcohol, is not recommended. (Grade C recommendation.) 5. For patients with alcohol withdrawal syndrome and other possible epileptogenic factors, factors that may increase the risk of alcohol withdrawal seizures, in addition to previous history of withdrawal seizure, include head injury, focal brain lesion, meningitis or encephalitis, and a family history of seizure disorder; however, no available research evidence clarifies the significance of these factors or provides guidance for appropriate management, and there is no clear consensus among experts. Therefore, sedative–hypnotics alone or with phenytoin are both options. (Grade C recommendation.) 6. For patients with acute alcohol withdrawal seizures, intravenous phenytoin is not recommended for patients with isolated, acute alcohol withdrawal seizure. (Grade A recommendation.) 7. For patients with alcohol-related status epilepticus, anticonvulsant therapy, which may include intravenous phenytoin, is appropriate for patients who develop alcohol-related status epilepticus. (Grade C recommendation.)

based on the amount and quality of the available research to support each recommendation. Grade A is obviously the best.) Thus, the general consensus is that short of having recurrent seizures from an underlying seizure disorder, the need for long-term Dilantin administration is not recommended. The maintenance of sobriety is the best anticonvulsant one can recommend.

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In medical school, one is taught that visual hallucinations are generally indicative of an underlying medical problem, whereas auditory hallucinations are more indicative of a psychiatric problem. This is only a general guideline, however. Most patients suffering from delirium see and hear things that are not there. A variety of medical problems, including but not limited to alcohol withdrawal, cause delirium. Some psychiatric patients report visual hallucinations that are clearly the result of their psychiatric illness. The idea that an alcoholic can hear voices, however, “seems” to cross the boundary between what is medical and what is psychiatric.

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66. A family member hears voices even when he is not drinking. Is it caused by the alcohol, or does he have schizophrenia?

We have covered a number of devastating effects that alcohol has on the brain. Is it any wonder that short of dementia, delirium, seizures, metabolic derangements, and the high incidence of head injury someone might not hear voices as well? All of these conditions can be the reason for hearing voices and can certainly increase the risk for hearing them, but hearing voices can occur even without any of these conditions present. In fact, this rare but frightening symptom occurs in roughly 3% of alcoholics during intoxication and/or withdrawal and can linger long after physiological withdrawal symptoms (rapid heart rate, high blood pressure, tremors, and insomnia) abate. The more frequently one “see-saws” through intoxication and withdrawal, the easier it is to develop withdrawal symptoms such as seizures, DTs, and hallucinations with an ever-lessening amount of alcohol. Thus, for some patients, even a day’s worth of drinking

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Kindling an effect on the brain whereby repeated electrical or chemical stimulation of the brain eventually induces seizures. This may explain why cocaine and alcohol previously did not lead to seizures but after repeated use now do. Psychosis a state in which an individual experiences hallucinations, delusions, and disorganized thoughts, speech, and/or behaviors.

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followed by abstinence can set it off. The brain has become sensitized. This process of heightened sensitivity to the neurotoxic effects of alcohol occurs through a process known as kindling. Kindling was first demonstrated in rats when it was shown that ever-lessening doses of either seizure-inducing electricity or drugs caused the rats to have ever more intense and prolonged seizures. Although antipsychotic medication can treat the symptoms and decrease the agitation associated with them, sustained abstinence is the only cure. If the voices fail to clear after sustained abstinence, further investigation of the underlying causes should be pursued. Alcohol-related psychosis may be confused with other psychiatric disorders. Other street drugs, particularly the stimulants and the hallucinogens, can cause hallucinations. Psychiatric causes can include schizophrenia, but the diagnosis of schizophrenia is based predominantly on symptoms other than the presence of hallucinations. Mood disorders, particularly manic depression or bipolar disorder, can present with hallucinations. Patients with psychiatric disorders do tend to abuse drugs and alcohol to a greater degree than the general population. The cause of alcohol-related psychosis is generally determined by the patient’s past history and family genealogy. In general, however, for patients with severe alcohol dependence, the most likely cause of his or her hallucinations is probably medical and directly related to the consequences of chronic heavy drinking.

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A clear link exists between addiction and depression. The rates of depression are three times higher in male addicts and four times higher in female addicts than in the general population, and a third of all depressed patients suffer from an addiction. Men typically develop a substance abuse disorder first, whereas women typically develop a mood disorder first. The link between these conditions has biological, psychological, and social roots. Biologically, many addictive substances are depressants, whereas many other addictive substances, when withdrawn, cause depression. Additionally, both addiction and depression run together in families, placing individuals with family histories of both conditions at risk. Psychologically, certain personalities are prone to addiction and depression. People who have difficulty with impulse control and who are quick to anger and are abrupt seem to be more prone to addiction, perhaps as an attempt to help modulate their feelings. Unfortunately, these self-medication attempts are only transiently beneficial and generally backfire. Alternatively, people who are shy or reserved and who become very anxious in social settings are more prone to depression and addiction as well, again because they often use substances as a way of trying to feel more comfortable “in their own skin.” Socially, people who struggle with depression and addiction find themselves isolated from others and unable to hold down a job. Social isolation, job loss, and loss of access to health care and housing can lead people to further worsening symptoms of depression and addiction.

The rates of depression are three times higher in male addicts and four times higher in female addicts than in the general population, and a third of all depressed patients suffer from an addiction.

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67. How are alcoholism and mood disorders linked?

Self-medication taking medications that are not prescribed by a physician or nurse practitioner, including alcohol or other drugs, to cope with emotional distress (e.g., drinking alcohol or smoking marijuana to calm down when one is feeling anxious).

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Although addiction and depression are linked, treating one problem will generally not resolve the other problem; instead, the likelihood is high that if someone is receiving treatment for one problem the other may also be present and require treatment simultaneously if progress is to be made (see Question 29). Although the concept of self-medication remains controversial, some evidence supports it, as many patients describe their use unwittingly as an attempt to “self-medicate” depression. Unfortunately, no evidence exists showing that treatment with antidepressant medication alone leads to abstinence. Although the “self-medication hypothesis” may seem right for some individuals, after an addiction develops, it takes on a life of its own. It is unlikely that medicating a mood disorder away will simultaneously medicate the addiction away. On the contrary, if one continues to use drugs or alcohol while receiving antidepressant medication, those substances render antidepressant medication essentially useless.

68. My spouse has mood swings along with his/her addiction problem. Could he or she have bipolar disorder? Because of the recent surge in interest in bipolar disorder, this topic warrants separate attention than what was discussed in Question 67. Bipolar disorder, or manic depression, is a mood disorder affecting upward of 1% to 5% of the population, depending on the diagnostic criteria. Traditionally, bipolar disorder was a very serious psychiatric condition with episodes of acute mania that invariably caused psychotic symptoms and led to hospitalization. The major difficulty in diagnosing it was distinguishing it from schizophrenia, as the clinical manifestations of an acute manic episode and an exacerbation

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of schizophrenia were indistinguishable. With the advent of lithium, such a distinction was imperative, as lithium was a specific treatment for bipolar disorder, whereas Haldol or other antipsychotic medications treated both mania and schizophrenia alike. Condemning a patient to life-long antipsychotic medication with its attendant risks was not viewed as good practice when the patient could be effectively managed with lithium alone. Over the years, as the commitment laws changed and psychiatry became increasingly focused on dangerousness, ever larger numbers of patients with serious impulsive behaviors became the focus. These patients rarely if ever demonstrated full-blown mania or other psychotic symptoms. Historically, they were viewed as personality disordered, as impulsive behavior appears to be inherent to the individual and less subject to change with medical intervention. Clearly, however, a great deal of overlap existed between these individuals and patients with mood disorders. Although many of these patients improved with antidepressant medications, a good number of them were made worse and responded better to anticonvulsant medications. The publication of DSM-IV broadened the category to include bipolar II disorder, a condition with predominant depression and few, largely “under-the-radar” episodes of mania. These episodes generally were associated with irritability rather than euphoria and never became severe enough for people around them to remark that they needed professional help or warranted hospitalization. In fact, what was notable was more of a magnification of the worst aspects of their personality: moody, irritable, quick tempered, and impulsive. This just drove family and friends away from them. It did

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not alert them that there might be some other underlying cause to their personality change. Most of these patients presented to the psychiatrist’s office depressed, and it was only through inquiry regarding past behavior that the diagnosis was generally established. This new category has relaxed the criteria and increased the number of patients with this diagnosis. The new concern is no longer distinguishing bipolar disorder from schizophrenia, but rather distinguishing bipolar disorder from either depression or a personality disorder. Complicating the problem is the fact that these patients are more prone to drug and alcohol abuse, which only exacerbates their swings from depression to irritability to euphoria, and the swings do not tend to be sustained, but rather wax and wane along with the substance abuse. These patients come to the emergency room not because of a psychotic break but because of intoxication, withdrawal, or an impulsive suicide gesture, following binge use and some interpersonal difficulty resulting from their binge use. Alcohol, cocaine, heroin, PCP, and marijuana can all cause mood swings that make everyone using these drugs suspect of having a mood disorder in general and bipolar disorder more specifically. When these patients are hospitalized psychiatrically as a result of an impulsive, potentially dangerous behavior in the context of their drug and alcohol abuse, the likelihood of their being discharged on a “cocktail” of psychiatric medications and a diagnosis of bipolar disorder is high. With average lengths of stay in psychiatric hospitals decreasing annually to now less than a week, the accuracy of such a diagnosis is suspect at best. The proof is not even in the pudding because complicating

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69. I have cirrhosis of the liver. Is that reversible? More than 2 million Americans suffer from alcoholrelated liver disease. The most common condition is alcoholic hepatitis, or inflammation of the liver (the root “hepa” refers to liver, and the root “itis” refers to a generalized inflammatory process) as a result of heavy drinking over a long period of time. The symptoms of hepatitis may include fever; abnormal yellowing of the skin, eyeballs, and urine known medically as jaundice; and abdominal pain. These more commonly go unnoticed until a lab test reveals elevated liver enzymes. Alcoholic hepatitis can cause death if drinking continues. If drinking stops, the condition may be reversible. About 10% to 20% of alcoholics develop alcoholic cirrhosis, or scarring of the liver, which is the result of chronic hepatitis. People with cirrhosis should not

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the picture is the fact that the medications one is discharged on are symptom and not diagnostic specific. Therefore, although one may benefit from a mood stabilizer or antipsychotic (increasingly, with the new atypical antipsychotic medications, these two terms are becoming almost synonymous as both decrease irritability), that does not mean one has bipolar disorder. Unfortunately, the danger inherent in the diagnosis is that all too often these patients and their families now focus entirely on this new diagnosis and attribute their continued relapse to their bipolar disorder and an inadequate medication regimen while doing nothing to get treatment for their substance abuse or alcohol disorder. Any mood swings stand a far better chance of improvement from abstinence than from any psychotropic medication offered.

More than 2 million Americans suffer from alcoholrelated liver disease. Hepatitis a liver disease due to a viral infection. Cirrhosis a liver disease where there is widespread disruption of normal liver functions. It is a chronic progressive condition that can eventually lead to death.

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drink alcohol. Although treatment for the complications of cirrhosis is available, a liver transplant may be needed for someone with life-threatening cirrhosis. Alcoholic cirrhosis can cause death if drinking continues. Cirrhosis is not reversible, but if a person with cirrhosis stops drinking, the chances of survival improve over time. People with cirrhosis can feel better, and liver function can improve after they stop drinking. An added complication is the fact that drug and alcohol abusers are prone to developing viral hepatitis as a result of their high-risk behavior (e.g., unprotected sex, intravenous drug use). These viruses include hepatitis B and hepatitis C. About 4 million Americans are infected with the hepatitis C virus, which can cause liver cirrhosis and liver cancer. Some alcoholics also have either the hepatitis B or C virus infection. As a result, their livers may be damaged not only by alcohol but also by the hepatitis virus. People with either hepatitis B or C virus infection are more susceptible to alcohol-related liver damage and should think carefully about the risks when considering whether to drink alcohol.

70. Am I eligible for a liver transplant if my liver failure is from my alcoholism? One of the biggest stories that came in the 1990s was Mickey Mantle’s liver transplant. Mantle, a famous baseball player, was 63 years old in 1995 when his liver failed, and he was placed on the list to receive a transplant. The average waiting time was 3 to 4 months. Mantle, however, received a liver transplant in a day. Unfortunately, the underside of his liver had cancerous cells. The transplant went ahead as planned; however, the cancer then spread to his lungs, and Mantle died 3 months later from the cancer. Critics charged that Mantle was given a liver quickly because of his public

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Mickey Mantle had been an alcoholic since the age of 20 years. He had been abstinent a year and a half, but his liver was by then failing because of his alcoholism and the contraction of hepatitis C. Hepatitis C may have been contracted from a blood transfusion he received during surgery or may have been contracted as a result of his alcoholic high-risk behavior. He also had a tumor in his liver, called a hepatoma, that had not been discovered prior to the time of his transplant.

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prominence. Others charged that he should not have been given a liver because of either his history of alcoholism or his cancer, both of which are reasons not to place someone on the list at some transplant centers.

Should people who are alcoholics receive transplants? Increasingly, transplant centers are not using a history of alcoholism as a reason to deny patients a transplant. When liver transplants first became available in the 1970s and 1980s, centers generally excluded alcoholics because it was thought that they would have worse survival rates because of their inability to maintain abstinence. Since then, multiple studies have been conducted comparing alcoholics with nonalcoholic patients who received transplants. They have found that alcoholics do as well as or better than those whose livers have failed from other causes. Because the outcomes are the same or better, the only reason to deny an alcoholic a transplant would be either the fact that he or she continues to drink or for some other nonmedical reason. Most centers therefore require that alcoholics be abstinent for at least 6 months and to be actively engaged in a recovery program to maintain abstinence. If we were going to reject a person with alcoholism from receiving a liver transplant because it was due to

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their own behavior, then we would have to reject equally the sedentary, type A, overweight cigarette smoker from receiving a heart transplant. If someone needed a liver transplant due to hepatitis C, we would have to explore the way in which that person contracted hepatitis C to see whether some form of “irresponsible” behavior was involved as well. This could go on and on until one could foresee denying all kinds of medical care to individuals simply because of the choices they made in their lives that did not accord with our conception of a “healthy lifestyle.” The first principle of organ allocation is making the best use of the organ in order to save a life that is in immediate danger, but also a life that has the best chance for long-term survival. In this regard, alcoholism is no different from any other disease of lifestyle.

71. Are there any medications that I should avoid if I have hepatitis? The liver is a factory whose job is to process all substances ingested for either utilization by the body or elimination from the body. All medications are therefore processed through the liver; however, some medications are processed in such a manner that they have no effect on the liver, whereas others are processed in a manner that can potentially have a grave impact on the liver (as alcohol can). In fact, medications are the major cause of liver disease, also known as drug-induced hepatotoxicity. This may account for up to 10% of hepatitis cases in adults overall, about 40% of cases in adults over the age of 50 years, and 25% of cases of liver failure. More than 1,000 medications and chemicals can cause this problem.

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One class of pain medications, however, deserves special attention. The most common over-the-counter medication associated with hepatotoxicity is acetaminophen (Tylenol). The simultaneous use of alcohol with acetaminophen can be very dangerous. One tablet of extra strength acetaminophen is 500 milligrams. A therapeutic dose for minor aches and pains ranges from 2 to 6 grams per day (4 to 12 tablets per day). In people without alcoholic liver disease, doses greater than 10 grams (upward of 15 grams) over a 24-hour period may cause drug-induced hepatitis. In people with alcoholic liver disease, doses greater than 2 grams over a 24-hour period may increase the risk for liver damage. Therefore, if one has alcoholic liver disease, one needs to limit acetaminophen use to no more than four tablets in a 24-hour period. Using acetaminophen in this dose

The effects of various medications and chemicals that can potentially impact the liver negatively are cumulative; thus, if one has hepatitis from another cause already (such as alcohol or a virus), it is extremely important to be aware of what medications can exacerbate the condition.

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The effects of various medications and chemicals that can potentially impact the liver negatively are cumulative; thus, if one has hepatitis from another cause already (such as alcohol or a virus), it is extremely important to be aware of those medications that can exacerbate the condition. An already damaged liver that is now subject to a potentially toxic medication can cause the liver to fail, a very dangerous situation. It is critically important to provide your doctor with complete information concerning not only prescription medications, but also over-the-counter medications and herbal and alternative therapies. Even medications that do not have a negative impact on the liver may need to be adjusted, as the liver’s ability to process them may be compromised to the point where the medications build up in the body causing increased side effects or even potentially toxic effects themselves.

The most common overthe-counter medication associated with hepatotoxicity is acetaminophen (Tylenol).

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Nonsteroidal antiinflammatory drugs (NSAIDs) an extremely diverse group of antiinflammatory and analgesic drugs that inhibit the enzyme cyclooxygenase and reduce the synthesis of prostaglandins.

range may be safer than taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), such as Motrin or Advil. These other NSAIDs can cause bleeding, particularly in the gastrointestinal tract, and kidney disorders, in addition to liver injury, making them even more unsafe. The most important aspect is to be aware that other over-the-counter and some prescription medicines can contain acetaminophen, aspirin, or other NSAIDs. Read the label of any medication prior to taking it, and when in doubt, check with your doctor or pharmacist concerning the presence of NSAIDs in a particular medication. Certain risk factors make a person more prone to liver disease, including age, being female, taking higher doses of medication for longer periods of time, the presence of pre-existing kidney disease, making it more difficult to eliminate potentially hepatotoxic chemicals, cigarette smoking, certain autoimmune disorders such as rheumatoid arthritis or systemic lupus erythematosus, obesity, and poor nutritional status. The time it takes to develop drug-induced hepatotoxicity is between 5 and 90 days after initiation of the drug. Liver function tests are usually obtained during this time period, and if the enzymes increase threefold above their normal limit, the medication is usually discontinued. Liver enzymes usually return to normal within 14 to 28 days after discontinuation of the offending agent.

72. What sexual problems does alcohol cause? Several problems of sexuality arise from alcoholism. The first is increased libido because alcohol lowers inhibitions. Although this may not be a problem, it

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can lead to consequences that are clearly problems, notwithstanding unwanted pregnancy or sexually transmitted diseases from unprotected sex. Another potential problem is that alcohol intoxication can cause a phenomenon euphemistically referred to as “the brewers droop,” making it difficult to achieve and/or maintain an erection. These two problems of increased libido and decreased performance can lead to behaviors that may not only be troublesome but also downright dangerous. Intoxication leading to increased libido increases the probability of sexual assault. Intoxication leading to impotency increases the probability of physical assault. Why? Because studies have shown that alcohol is related to sexual jealousy, which can reach pathological proportions when one is intoxicated and then feels rejected by the woman either because of his intoxication or because of his inability to perform. Compounding that fact is the poor judgment resulting from intoxication, leading to misinterpretation of facts and acting irrationally based on the misinterpretation. This is particularly true in troubled marriages in which suspicions often lead to and are, in turn, fueled by intoxication. These are the potential consequences of acute intoxication. What about any long-term consequences of alcoholism, however? Alcoholism can do one of three things to potentially ruin one’s sex life in the long run. First, alcohol lowers testosterone, which is the hormone primarily responsible for libido and sexual performance. Second, alcohol can raise blood pressure and cholesterol, which are major risk factors for the development of vascular disease and, in turn, another cause of impotency. Good circulation is essential for male sexual performance. Poor circulation is also a cause of sexual difficulties

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among women. Finally, alcoholism can cause peripheral neuropathy, damaging the nerve supply to the genitalia, again leading to impotency and anorgasmia.

73. When I stopped drinking, I started smoking a lot more. I’m afraid that if I try to quit smoking I may go back to drinking. What can I do?

The heaviest drinkers are also often the heaviest smokers. This significantly increases the risk of heart disease, stroke, emphysema, and cancers of all forms.

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Research supports the aphorism “smokers drink and drinkers smoke.” The heaviest drinkers are also often the heaviest smokers. This significantly increases the risk of heart disease, stroke, emphysema, and cancers of all forms. For example, the approximate risks for developing mouth and throat cancer are 7 times greater for those who use tobacco, 6 times greater for those who use alcohol, and 38 times greater for those who use both substances. Most drinkers started smoking first and adolescents who smoke are three times more likely to begin using alcohol. Smokers are 10 times more likely to develop alcoholism than nonsmokers! What is the link? Both drugs increase the pleasant effects and ward off the unpleasant effects of each other. Nicotine involves many of the same neurochemical mechanisms of the brain’s reward system that alcohol involves. Nicotine can lead to tolerance, which is the need for ever-increasing amounts to achieve the same desired effects. Some level of cross-tolerance may exist between nicotine and alcohol as well. In other words, the need for ever-increasing amounts of one substance leads to the need for ever-increasing amounts of the other substance and vice versa. Crosstolerance may partly develop from one drug mitigating the negative effects of the other, such as nicotine’s ability to lessen the sedative effects of alcohol and alco-

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Historically, addiction specialists did not address the issue of nicotine addiction, fearing that asking an alcoholic to quit tobacco at the same time would be asking too much and thereby risking relapse. Research has not confirmed this. One study compared two alcohol programs, one that added a smoking cessation program and one that did not. Abstinence differences after 1 year between the two groups were no different, but in the group engaged in smoking cessation, 12% had quit smoking. Another study suggested that smoking cessation actually enhanced motivation to stop drinking. As a result, following along with the prevailing culture, many addiction programs are now smoke free.

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hol’s effects in calming the potential anxiety of smoking too much tobacco. Animal studies have born this out, where nicotine has been shown to mitigate against the cognitive and motor effects of alcohol.

Some caveats are as follows: It appears, because of cross-tolerance, that alcoholics who engage in smoking cessation may require higher doses of nicotine replacement than the normal smoking population. Depression and being female are risk factors working against one’s ability to give up tobacco. Because nicotine induces liver enzymes, antidepressant and mood stabilizer blood levels may be lower than expected, making the medications less effective, which could contribute not only to continued depression, but also to continued nicotine dependency. Thus, keep these factors in mind if you are about to quit. The motivation to stop drinking should be used simultaneously to stop smoking, as the outcomes for both problems and the health benefits are many times greater than either alone! Find a program that is at least smoke free and secondarily offers a smoking cessation program. If no program is

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available, work with the medical director of the rehabilitation center or your primary care physician to provide nicotine or other medications such as Zyban (Wellbutrin) to assist you.

74. I got into a vicious cycle using alcohol to come down from cocaine. The doctors tell me that I’m an alcoholic, but my drug of choice has always been cocaine. Do I need to be concerned?

Cocaethylene a chemical produced by the liver when processing cocaine and alcohol (ethanol) simultaneously that has many pharmacological properties similar to cocaine except that it stays in the body longer and is potentially more toxic to the nervous and cardiac systems.

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Alcohol and nicotine are but one common combination that appears to work together synergistically to increase each other’s pleasurable effects and decrease each other’s unpleasant effects. Another combination that is quite popular is alcohol and cocaine. The feelings generated from the combination is beyond what is felt by either drug alone. Again, the negative effects of alcohol such as learning and motor performance are “improved” with the addition of cocaine, whereas the anxiety and paranoia that cocaine generates are “improved” with the addition of alcohol. People don’t realize the high cost that is associated with this combination. Both are metabolized by the liver, which leads to a metabolite known as cocaethylene, a potent drug in and of itself that has significantly more cardiotoxic effects than using either drug alone. This new “drug” also appears to cause violent thoughts and behaviors that would not necessarily be present if either drug were used alone. This new “drug” is thought to be the most common cause of drug-related deaths because of cardiac effects and violence. Finally, cocaine may cause liver injury independent of alcohol.

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PART VI

Special Populations I was drinking during my first trimester of pregnancy before I knew I was pregnant. What are the risks to my unborn baby? My baby was born with fetal alcohol syndrome. What is that, and what does it mean for my baby? How do I know whether my child is just experimenting with alcohol and drugs or has a real problem with them?

More . . .

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75. I was drinking during my first trimester of pregnancy before I knew I was pregnant. What are the risks to my unborn baby?

Potential mothers need to be aware of the risks associated with unplanned pregnancy and the use of alcohol.

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Because many pregnancies are unplanned, women may unintentionally expose their offspring to alcohol. Potential mothers need to be aware of the risks associated with unplanned pregnancy and the use of alcohol. As noted in Question 85, alcohol is quickly absorbed into a woman’s bloodstream, and if she is pregnant, alcohol quickly passes through the placenta and exposes the baby. Alcohol is broken down more slowly in a baby than in the adult because of the baby’s size and immaturity. As a result, alcohol remains elevated in the baby’s blood stream longer than it remains in the mother’s, potentially causing damage to the baby. Thus, even light to moderate drinking may affect the fetus in several ways, including premature birth, low birthweight, and cognitive and physical deformities. Heart defects have been found in babies whose mothers drank during the first trimester of their pregnancy. Sometimes a baby can appear normal at birth, although subtle effects may present later in the child’s development, even if the mother drank only one drink per week during the pregnancy. One study reported that children 6 and 7 years old exhibited more aggressive behaviors and had other behavior problems, including delinquency, than children whose mothers did not drink at all. Another study demonstrated that moderate alcohol consumption during pregnancy resulted in a higher incidence of offspring having problems with alcohol by the age of 21 years, even after controlling for family history and other environmental factors.

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76. My baby was born with fetal alcohol syndrome. What is that, and what does it mean for my baby? Fetal alcohol syndrome disorder (FASD) is one of the most devastating disorders found in newborn children. It results from exposure to alcohol by mothers

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Although a clear dose-dependent relationship exists between amounts of alcohol one drinks during pregnancy and the extent of damage to one’s unborn child, no definitive answer is available regarding exact amounts of exposure. One or two drinks before you knew you were pregnant will most likely not affect your baby. The baby’s brain and other vital organs begin developing around the third week, so if you stopped drinking by then, the baby is probably safe. The baby is vulnerable, however, by the third week and thereafter; thus, continued exposure to alcohol will place the baby’s brain and other vital organs at risk. To conclude, the risk is low within the first 2 to 3 weeks, increases dramatically after that and throughout the first trimester, and then decreases, although not enough to recommend any alcohol until after the baby is born. The risk is that you may have a baby who in the beginning has serious physical, mental, or behavioral problems or who seems normal and healthy at first but later develops behavioral or cognitive problems. Speak openly with the obstetrician about your drinking and your fears about the baby. The most serious risk to your unborn child is fetal alcohol syndrome (FAS), which is addressed in the following question.

Fetal alcohol syndrome disorder (FASD) a disorder that is found in infants whose mothers ingested alcohol during pregnancy, resulting in the infant being mentally retarded along with having other distinguishing features.

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Teratogen an agent, such as a virus, drugs or alcohol, or radiation, that causes malformations in a fetus or embryo.

Microcephaly an abnormally small head with associated mental retardation.

Some children show signs of cognitive and behavioral problems after exposure to alcohol in the absence of physical features.

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who drink throughout their pregnancy. Experts believe that the degree of severity of the symptoms depends on the amount of alcohol circulating in the mother’s and baby’s bloodstreams, the timing of the toxic exposure, and genetic factors. Currently, no way is available to determine which baby will be affected by exposure to fetal alcohol. Although only a few drinks may be required at a crucial time during pregnancy to cause sufficient damage to the fetus, how much alcohol and at what crucial time have yet to be determined. One in every 750 babies has the full syndrome. It is the leading known cause of mental retardation in newborn children. Alcohol, therefore, is the leading teratogen causing birth defects. Most children exposed to alcohol in utero do not have the full-blown syndrome, which includes not only cognitive and behavioral problems but also distinct physical features. FASD is manifested by specific birth defects characterized by low birthweight, failure to thrive, developmental and psychological delays, autism, and mild to moderate mental retardation (an IQ around 60), along with rather distinct physical abnormalities. Thirty to forty percent of these children have heart defects, which occur in the first trimester of the pregnancy. The distinct physical abnormalities include a cranial malformation known as microcephaly, a narrow forehead, flattening of the mid face, both the cheekbones, and the bridge of the nose, a short nose, and a long, thin upper lip. Other eye, ear, and occasionally hand malformations may also be present. Children who are the less obviously deformed may go undetected until later in life. Some children show signs of cognitive and behavioral problems after exposure to alcohol in the absence of physical features. When this occurs, the symptoms are

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Alcohol-related neurodevelopmental disorder (ARND) a disorder in the development of the nervous system in a fetus. It is related to the exposure of the fetus to alcohol.

The National Organization of Fetal Alcohol Syndrome estimates that at least 12,000 children each year are born with FASD, and as many as 36,000 more children have ARND. A smaller group of children has had some developmental and cognitive effects, but the effects are less severe than the other two syndromes. This population of mentally retarded/developmentally delayed children who were exposed to alcohol while they were in uteri is larger than the number of children born with Down’s syndrome, cerebral palsy, and spina bifida combined. FASD and ARND are the most preventable of all of the mental retardation and physical deformities found in newborn children.

National Organization of Fetal Alcohol Syndrome an organization to educate young women about the dangers of drinking while pregnant, hopefully to prevent the incidence and prevalence of fetal alcohol syndrome.

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referred to as alcohol-related neurodevelopmental disorder (ARND). These children may go unrecognized because they do not have the physical features, although they have the developmental, cognitive, and behavioral deficits. Some may suffer from minimal brain damage, have difficulty concentrating and focusing, may be irritable and/or hyperactive, have difficulty in problem solving, and may be emotionally labile. These children may be diagnosed later on with psychiatric disorders such as attention deficit hyperactivity disorder (ADHD), depression, or bipolar disorder (or manic depression). Such children may not be identified until they are in school. All children who have been exposed to alcohol in utero should have early screenings, close monitoring, and early interventions.

Early diagnosis has been shown to be effective in preventing secondary disabilities, such as school failure, juvenile delinquency, mental health problems, homelessness, and unemployability. Individuals with undiagnosed FASD often end up in institutional settings, including jails, mental health programs, psychiatric

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To conclude, FASD is entirely preventable and is the only form of childhood mental retardation that is preventable. Centers for Disease Control a federally mandated program that was established in 1973 to monitor the nation’s health.

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hospitals, and homeless shelters. Early intervention is critical. The earlier those children can be treated the better their outcomes will be. Families must be included in the therapeutic plan because parents often become overwhelmed by the difficulty in caring for a multiply handicapped child and they need to deal with the guilt of having caused harm to the child. FASD children require environments that are stable, structured, and nurturing. Caregivers must be creative, consistent, and compassionate. During the early life of the child, helping the parents and the child to develop healthy relationships is the first and most important intervention. To conclude, FASD is entirely preventable and is the only form of childhood mental retardation that is preventable. It is a life-long condition that affects every aspect of the lives of the child and the family. Table 16 outlines Centers for Disease Control criteria that are guidelines for the diagnosis of FASD.

77. How do I know whether my child is just experimenting with alcohol and drugs or has a real problem with them? More than 90% of children will have tried alcohol by the time they have graduated high school, which makes experimentation with alcohol a fairly normal experience. Most young people are mature enough to recognize that heavy alcohol use is neither pleasurable nor in tune with their goals for pursuing jobs, families, or higher education. The children who get into trouble with alcohol are those who have begun to pursue it as an end in itself. As a result, school and family life suffer, and these children begin to associate only with themselves or other children with similar problems. If an adolescent is caught using substances, acknowledges

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Table 16 Centers for Disease Control Criteria for FASD

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Criteria 1: –Binge drinking (more than 2 to 3 drinks per occasion) –Daily use (1 to 2 drinks per day) –1st-trimester versus 3rd-trimester use Criteria 2: Growth retardation –Decreased head circumference –Decreased height –Decreased weight Criteria 3: At least two facial features –Indistinct philtrum –Short palpebral fissures –Thin upper lip Criteria 4: Neurodevelopmental disorders –Impaired intelligence –Delayed speech development –Impaired fine motor skills –Attention deficit disorder –Attachment concerns –Learning disabilities –Hearing impairment

it, and is otherwise showing no problems with school, family, or friends, then the likelihood he or she has a substance alcohol abuse disorder is low. Low, however, does not mean nonexistent, and some degree of vigilance must be maintained. Other risk factors raise one’s suspicion, regardless of school or home life. Individual risk factors include other psychiatric disorders, such as ADHD, specific temperamental traits such as an interest in novelty seeking, irritability, impulsivity, and high motor activity. Other risk factors include a family history of alcoholism or substance abuse, a lack of parental attachment, or parents who have a generally permissive management style. Children who bond more quickly to peers at an earlier age and follow their

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lead rather than their parents are also at greater risk. Finally, other environmental risk factors include lower socioeconomic status and neighborhoods that have higher crime rates. Accidents with automobiles, bicycles, and even skateboards should raise one’s degree of suspicion that alcohol or other drug use was involved. Other red flags include unsafe sexual activity or being a victim or perpetrator of a violent act.

78. How old do my children need to be before I start talking to them about alcohol?

Often parents make the mistake of waiting until their children are driving or in high school to talk about drugs, tobacco, and alcohol.

You should talk to them as early as possible but should take into consideration the developmental level of the child. Often parents make the mistake of waiting until their children are driving or in high school to talk about drugs, tobacco, and alcohol. By then it may be too late to prevent a serious accident or perhaps addiction. Parents should keep the communication open and ongoing; otherwise, children will go elsewhere to get their questions answered. The answers from their peers are usually erroneous. The following are guidelines that include (1) some basic principles, (2) facts that parents should know, (3) tips for helping children cope with life’s stressors, and (4) suggestions for parents that are age appropriate for each developmental level.

Guidelines For Parents 1. Basic principles on discussing drug and alcohol use with your children • Listen to your child. Start talking early. Seek your child’s opinions about tobacco, alcohol, and drug

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use. Share your own opinions. Find out what they are learning in school and in the neighborhood and from their teachers, other children, and their own experiences. Ask children about what they think. • Be a good example. Drink responsibly or not at all. Role modeling is a more powerful teaching tool than talking. Children do what their parents do—not what their parents say. • Keep communication open. Start talking to your children about tobacco, alcohol, and drugs when they are young. If you find it difficult to talk to your child about substance use and abuse, you are not alone. Ask your doctor or pediatrician to discuss drug use with your child. Pamphlets are helpful. Give them to your child as a starting point for discussion. Encourage school officials to institute tobacco, drug, and alcohol-prevention programs. • Immunize your children against drug and alcohol abuse. Parents have their children inoculated against measles and mumps at an early age. Parents also need to immunize their children at an early age against tobacco, drugs, and alcohol use by giving them the facts. 2. Facts parents should know • Many children have tried to use alcohol or drugs before high school. Fifty percent of fourth through sixth graders report being pressured by peers to try alcohol. The average age when a child takes his or her first drink is about 12 years, which is the sixth or seventh grade. A 1998 Washington State Survey found that among sixth graders half of those who drank got their alcohol at home and their parents knew about it.

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• The younger a person starts drinking alcohol, the higher the risk for dependence in later years. • Drinking alcohol before the brain is fully developed may cause damage to the areas of the brain responsible for learning and memory. • Alcohol affects judgment and decision making. • The leading cause of teenage injury and death is alcohol related. • Beer and wine are not safer than “hard” liquor. 3. Tips for helping children cope with life’s stressors • Tell the truth. Provide the facts. Do not exaggerate. • Reassure children and allow them to express their feelings. Feelings are okay. You want your children to turn to you, not to a substance, when they are upset in order to feel better. Make sure they know that they are safe and loved. • Make rules for your household clear; if the rules are broken, make the consequences explicit. Consequences should be appropriate to the misdeed. Remember rules for children convey the message that you love them and care about them. • Do not threaten. • Provide opportunities for activities that are alcohol free such as sports, theater, and music. Whenever possible, go to the child’s sports and school events. Get to know their friends and the parents of their friends. • Know where your children are and what activities they are doing. • Create ways for “family togetherness,” doing healthy activities.

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• Confidence helps children handle difficult situations without turning to a substance to cope. 4. Suggestions for parents that are age appropriate for each developmental level a. Preschoolers

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• Freely offer praise. Take advantage of every opportunity to build a child’s social and physical skills, which will enhance his or her self-confidence.

• Very young children are not ready for the facts about alcohol or other drugs, but they are ready to learn how to make decisions and how to solve a problem. For example, allow them to pick out their own clothes. Support their decisions. Let them help you around the house and thank them for their help. • Parents can provide a good example for their children by exercising and eating healthy foods. Provide opportunities to eat with your child and to play with your child. Do healthy activities together, such as playing ball, swimming, or biking. • Watch television with your children, and talk about the advertising messages. Ask your children questions about what they think of the ads. • Monitor what your children watch on television. If a child sees something on a television show about drugs, alcohol, or tobacco and has questions, be available to listen to his or her concerns and answer questions. • If there is an antidrug commercial on television or on a billboard or elsewhere, reinforce the message “just say no.”

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• When giving a child medicine during an illness, the parent can use this opportunity to teach a child about using the appropriate amount for the moment and the dangers of having too much medicine at one time. b. Ages 5–7 • Children this age learn mostly by experience. Conversations should involve experiences or events that children are familiar with, such as what they have seen on television or what they have observed at home or other places. • Teach your child about how the body works and why every person needs good food, clean water, and exercise. Teach them the importance of avoiding eating and drinking foods or substances that are not healthy. • Inform your child in simple terms that alcohol can hurt the body by altering the way it makes you feel, the way you can see, and the way you think because it impacts the brain and makes changes in other parts of the body. Tell them it can make them sick and might make them feel like they had the flu with a headache, nausea, and vomiting. • Children love stories at this age. Telling the facts in story form may be more interesting and provide a more powerful message to grade school children. c. Ages 8–12 • Invite questions. Ask your child what he or she knows about drugs and alcohol. If parents start giving the message to children early that they are available to talk about touchy subjects, children will be more open in the future to come to the parents about their concerns.

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Ask the child about what his or her friends know about alcohol or drugs.

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• Start talking about facts, such as the long- and short-term effects and the consequences of using alcohol. Teach children why alcohol is especially dangerous for them when they are young because of the impact of alcohol on the developing brain. • Teach children to say no to peer pressure. Practice with them on how to say no. Reassure your child that he or she can say no without losing friends. • At this age, children are influenced by their friends. Be sure to meet their friends and families and know what the children are doing when they visit one of their friends. Discuss the rules of the house at their friends’ homes and compare them with your rules. Discuss the differences. • News items, such as steroid use in professional sports, can be the stimulus for conversations about tobacco, drugs, and alcohol use. d. Ages 13–17 • This is the age when children start experimenting with alcohol or drugs. • Continue to make your expectations clear and encourage the teen to come to you for help or to answer questions. • By now, children should know what the rules are and what the parents think about the use and abuse of tobacco, alcohol, and drugs. • Focus on keeping the lines of communication open. Ask your child about their attitudes and their friends’ attitudes. Teens are more apt to

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want privacy. You can help the relationship remain open by showing your respect, love, and concern. Avoid preaching or threatening. Remain nonjudgmental. • Teenagers strive for independence and thus often participate in risky behaviors. Know what your child is doing. Warn him or her of any dangers. • Parents should encourage their children to invite friends to their home; however, do not permit any alcohol or drugs in the home. • By 16 years old, most children are driving. It’s a good idea to develop a written or unwritten contract on the conditions for using the car. • Discuss the rules about cars and drinking: (1) Do not drink and drive. (2) Do not get into a car with a driver who has been drinking. (3) Do call home to have parents come to get you and your friends, rather than driving home with someone who has been drinking. • Review how to say no to tobacco, drugs, and alcohol or other risky behaviors. • Teach children to ask questions before ingesting anything that is an unknown. • When in any uncomfortable situation, encourage the teenager to call home. Praise him or her for good judgment. e. Tips for helping teens to say “no” • Say it like you mean it. • You don’t have to give excuses. “No” is enough of a reason. • Suggest doing something different. • If you continue to get pressured, walk away.

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No family is immune to the effects of the alcohol and drug culture in our society. Some of the best children from the best homes can end up in trouble.

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No family is immune to the effects of the alcohol and drug culture in our society. Some of the best children from the best homes can end up in trouble. Be involved in your children’s lives. Parents should recognize when a child is having a difficult time so that the parents can support the child if needed. Seek additional help for the troubled child through participation in a drug program, counseling, or accessing other resources. Parents should elicit the school’s assistance and other community organizations to provide a healthy community in which to raise a child. A supportive family, school, and community environment working together is the best for tobacco, drug, and alcohol prevention.

79. I grew up in another country where alcohol was part of the culture and teenagers were allowed to drink. Why can’t I continue that tradition with my own children? Although the drinking age may vary between one culture and another, all cultures adhere to some restrictions, especially for teenagers. Countries that are ambivalent about drinking alcohol, such as the United States, are more rigid than are the more permissive countries. The countries where wine and beer are served regularly with meals in social settings are considered the more permissive countries. These generally include the Mediterranean countries such as Spain, France, Italy, and Greece. Most European countries, however, have a more relaxed attitude regarding teenage drinking compared with the United States, and the laws allow for drinking under the age of 21 years.

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Before one jumps to the conclusion that Europe’s relaxed attitude is actually “healthier,” consider the fact that rates of alcohol-related diseases are similar to or higher than the United States. The major concern with underage drinking is underage driving. Between 1970 and 1984 in U.S. history, when some states lowered their drinking age, alcohol-related motor vehicle fatalities increased among teenagers. This has never been as big a problem in Europe for two reasons. Europeans do not obtain their driver’s licenses until the age of 21 years, and Europeans rely more heavily on public transportation because of the higher cost of automobiles and fuel and also because the public transportation system is more accessible. When a person lives in one culture and then moves to another culture, culture adaptation must take place in order to survive in the new country successfully. In the United States, the drinking age is 21 years. Consequently, if you promote adolescent drinking by permitting your teenager to drink alcohol or by serving alcohol to your teen and his or her friends in your home, you are breaking the law. If the police catch you giving alcohol to minors, they will likely not be interested in your cultural history. Set an example for your children of how to be law abiding. You can still demonstrate how alcohol is used when you participate in a traditional celebration or festival. Thus, you can be a role model, showing the responsible use of alcohol. Discuss with your teen why it is not appropriate to drink under the age of 21 years in this culture, and share your ideas and values with him or her. Listen to the adolescent’s opinions and concerns (Question 78 discusses how to talk with your children).

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Parents often feel conflicted between wanting their children to spread their wings and be independent and their fears that their children are too young and naïve to be trusted. Parents are also wary of trusting how other people might influence their children. A potential recipe for disaster is the lenient drinking and drug laws in foreign countries and unsupervised groups of young people. The rising popularity of spring-break excursions has led to a growth in trip planners with websites specifically catering to this type of trip. Although the advertisers do not specifically condone the use of alcohol or drugs among students, they promote the use of these substances by advertising that anyone 18 years old or older can drink alcohol legally and that the liquor laws are rarely enforced in many of those countries. They also encourage students to check out Amsterdam, which is advertised as a “pot-smokers’ paradise” because of the liberal drug laws.

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80. My teenage child is taking a class trip to Germany where drinking is permitted. Is that a problem?

The concerns about your children drinking in a foreign country are valid. The risk of binge alcohol and drug use is high among teens. The accompanying high-risk behaviors that result from these activities can ruin a child’s future and may take a child’s life. The general feeling on the part of the child is “that won’t happen to me.” Part of the focus then is to explain that your child will be surrounded by a lot of people who will be out of control and who your child has no control over. We assume that if we are safe drivers our risk of having an automobile accident is very low. Although it is low, we still have no control

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over other people’s driving behavior, and those other people kill us at alarming rates. Exposing children to that concept may help to a certain degree. Here is some further advice to parents: • Do your homework, and know as much about the trip as you can. • Participate with school officials and the children in planning the trip. • Know how many chaperones there will be for the number of students who will be going. The suggested ratio is two adults to every seven or eight children. Each chaperone should be assigned to specific children who they are expected to accompany, even if it is late at night. Parents should get to know the chaperones before the trip so that they feel comfortable that these people will be accountable for each child’s welfare. The chaperones should assign each child to a buddy. Each buddy is responsible for the other. • Volunteer to be a chaperone. • Review with your child the safety rules about drinking and driving. • Warn them not go with strangers away from the student group. Students should stay close to the people they know and trust. • Tell your children to be cautious. Parents must be candid with their children about their worries and concerns. • Provide alternative activities or vacations for students, such as family trips or working for humanitarian organizations such as Habitat for Humanity as a volunteer. • If you are not comfortable with the school plan for a trip abroad, then just say no to your child. It may be difficult, but you probably will not regret it.

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First, here are some facts about marijuana and a comparison of the characteristics of marijuana and alcohol: Marijuana is the most common illegal drug used among adolescents. Even if it is the most commonly used drug, most teens have not used marijuana. Marijuana shares some of the same attributes and health consequences as tobacco. Both marijuana and tobacco are plants and are commonly smoked and consequently may damage the smoker’s lungs. Marijuana and alcohol both have social and economic consequences. Alcoholics often become poverty stricken and homeless. Chronic heavy marijuana users who smoked beginning in high school may have trouble graduating because of a combination of memory loss and a lack of motivation to complete their education. Consequently, young adults who smoked marijuana and/ or drank alcohol excessively while in high school are often unemployed.

Marijuana Effects Marijuana has sedative, analgesic, anxiolytic (antianxiety), and hallucinogenic effects. It can, however, also provoke anxiety and panic attacks, as it causes a rapid heart rate. Occasionally, paranoia, including frank paranoid delusions, may occur. Additionally, it may cause dizziness, giddiness, bloodshot eyes, and difficulty with short-term memory. Finally, it can either

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81. My teenager has a serious problem with marijuana. He constantly points out that I drink, and therefore, he doesn’t see the problem with his marijuana use. What do I tell him?

Chronic heavy marijuana users who smoked beginning in high school may have trouble graduating because of a combination of memory loss and a lack of motivation to complete their education.

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suppress or enhance appetite and suppresses nausea and vomiting in patients suffering from serious illnesses, such as cancer or AIDS. Adolescents use marijuana to achieve a mild, relatively short period of euphoric intoxication. Although it is not as addictive as alcohol or tobacco, it can still lead to dependency or addiction problems. Like alcohol, the individual effects of the drug on each person depend on how proficient the individual is at smoking, as well as its potency, the place where it is used, what the user anticipates will happen, and what other drugs it may be mixed with. Children at this age normally compare themselves with adults. Confronted with the teen’s marijuana use and the parent’s alcohol use, parents may need guidance as to how to steer the discussion in the direction that is not defensive but is helpful. Table 17, which compares alcohol and marijuana, may be used to guide the discussion. It is best for parents to stick to the facts without exaggerating them. One website called the Berkeley Parents Network provides advice in a newsletter that reviews parental comments in a weekly discussion. Parents’ advice to each other ranges from ignoring the child’s drug and/or alcohol use to being very punitive. The most cogent advice that one set of parents gave to the others was to keep discussions between the parents and their teens open and ongoing. It is particularly important to find out the underlying causes of why the teen feels the need to turn to drugs. Is it boredom, frustration with home and/or school, feeling isolated, peer pressure, the need for instant gratification, lack of self-confidence,

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Most teens do not drink alcohol. It is legal only for people over 21 to buy, drink, or sell alcohol in most states. It is illegal to buy or possess alcohol under the age of 21 years. Yes, alcohol is physically and psychologically addictive, but not everyone who drinks becomes addicted; 100,000 people die from alcohol addiction and its related causes each year. It is extremely dangerous and is the leading cause of death among teens. One teen is killed or maimed per hour from driving while impaired after drinking alcohol.

Most teens do not smoke marijuana. It is an illegal drug. The most important difference regarding the use of the two substances is the fact that it is illegal at any age to smoke marijuana. It may be psychologically addictive and possibly physically addictive. Not everyone who uses marijuana becomes addicted. Marijuana is less addictive than tobacco or alcohol, but it has serious, adverse side effects. It is extremely dangerous and is the leading cause of death among teens. One teen is killed or maimed per hour from driving while stoned on marijuana.

They last for 1 to 2 hours per drink.

One to four hours for the immediate effects. It takes 1 to 2 weeks to clear the body entirely. It may be dangerous, causing bodily harm.

What are the affects of drinking or smoking on driving a motor vehicle? What are the statistics of accidental deaths or injuries related to driving under the influence of alcohol or marijuana? After drinking alcohol or smoking marijuana, how long do the effects last? What are the effects of mixing alcohol or marijuana with other drugs?

It is extremely dangerous and can lead to death.

(continued)

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Is it addictive?

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The effects are slowed reflexes, distorted vision, memory lapses, and blackouts. They can eventually lead to brain damage. Judgment is impaired, and inhibitions lowered, leading to risky behaviors, including “at-risk” sexual behaviors. Depression may follow chronic use or abuse. Violence is frequently associated with alcohol use. Chronic use may lead to an organic brain syndrome. Yes. Alcohol can damage every organ in the body, risking a person for a variety of life threatening experiences, including cancer, liver disease, and so forth.

Marijuana has similar effects as alcohol, in terms of reflexes, coordination, and vision. The loss of memory and A-motivational syndrome are both serious consequences that adversely affect school performance. Marijuana enhances sexual feelings, which may lead to risky sexual behaviors, resulting in adverse consequences. Depression, anxiety attacks, paranoia, or psychosis, including hallucinations, may follow its use. A variety of chemicals in marijuana contain carcinogens. One joint contains four times as much cancer-causing tar as cigarettes. It affects the immune system leaving the body more vulnerable to a variety of illnesses. It has not been proven that using marijuana leads to using other drugs. It is a fact that most people who use illegal drugs did use marijuana first.

Can use of alcohol or marijuana cause cancer and other serious diseases?

Is alcohol or marijuana a “gateway drug,” thus leading to the use of other drugs that may be illegal?

Teens who smoke and drink are more likely to use marijuana. People who use all three substances are more likely to use other drugs.

Source: Adapted from the following sources: American Academy of Child and Adolescent Psychiatry, 2005; Anonymous Student, 2004; Focus Adolescent Services 2001; Hyde, 2006; Long, 2005; Parents, The Anti-Drug, 2006; Tips for Teens, 2003.

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What are the effects of using either substance on the brain and on the personality?

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It is illegal to buy, sell, or possess marijuana in this country, and doing any of these activities can lead to serious legal problems. Even a small amount may lead to fines or an arrest. Besides the issue of health, this is the main reason for teens to abstain from using marijuana. At the same time, drinking wine with dinner and drinking responsibly, as an adult, is legal.

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misinformation, or rebellion? After the underlying cause is determined, then the teen and the parents can work together toward a solution. A perfect example of this came from one set of parents who committed themselves to abstinence (they previously drank wine with meals at home) in order to support their child’s commitment to abstinence. Additionally, they entered family counseling and discovered that their teen used marijuana to relax. Consequently, healthy alternatives to marijuana for relaxation were pursued, and yoga and meditation classes were offered to learn more appropriate relaxation techniques.

It is illegal to buy, sell, or possess marijuana in this country, and doing any of these activities can lead to serious legal problems.

This may smack the teen as societal hypocrisy, and you need to be aware that teens are ever alert to that notion and often use it as an excuse for their continued behavior. Society as represented by the law, however, has no regard for such allegedly ethical distinctions, and part of maturity is coming to grips with that simple fact. Continued use could place the teen’s future in jeopardy if caught by the police with an illegal substance.

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82. My daughter refuses to take the medication prescribed and continues to abuse drugs and alcohol. She repeatedly points out that she doesn’t see any difference between a drug that the doctor prescribed to help her moods and the more “natural” approach that she chooses. How do I counter that? One of the most common rationales teens give for their continued noncompliance is that they regard a prescribed psychotropic medication as synthetic and therefore unsafe and marijuana as natural and therefore safe. Additionally, because of that, they regard the psychotropic effects of marijuana as a reasonable alternative to continue to “medicate” their mood or anxiety disorder. How much of this is a lame excuse for continued use as opposed to a legitimate concern depends on the teen making the claim. As mentioned in Question 81, teens are ever on the prowl for what they consider hypocritical thinking and behaving on the part of adults, and this can be just another example of that. First, the notion that because a drug is “natural” as opposed to “artificial” makes it healthier is rampant in our culture. Marketers have capitalized on this, and alternative medicine, herbal, and vitamin stores thrive on it. What makes something natural as opposed to artificial is often completely arbitrary, and the FDA has no control over this type of labeling. Second, even when we are able to distinguish clearly between compounds found in nature from those synthesized in a laboratory, there is absolutely nothing about any particular compound that makes one safer than the other for that rea-

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son alone. A compound is safe or dangerous based on its actions on the body and not based on where it comes from. Before the development of organic chemistry and our ability to synthesize chemical compounds, plenty of naturally occurring compounds were available that were well known to be either health giving or toxic. Many of the earliest poisons such as arsenic and strychnine are natural. Many opiates and hallucinogens are natural. Others are manmade. The earliest antibiotics were natural compounds. Many of the latest and most effective antibiotics are now synthesized. Second, because an intoxicating substance is immediately pleasurable, it should therefore be used to aid with one’s mood or anxiety is a notion discussed in previous questions (see Questions 67 and 68). Any immediate effects create a vicious cycle leading to addiction and long-term negative effects as previously outlined—including the underlying mood or anxiety disorder that the teen is now arguing can be treated with only marijuana. It is a paradox that the very substance that one claims to be helping his or her mood and/or anxiety is actually perpetuating it. Trying to remind the child of this fact can often be an exasperating experience. One’s memory for events preceding the drug use and resulting mood swings is often lacking because of continued use. Medications used to treat the underlying mood or anxiety disorder, alternatively, have the opposite effect on mood from marijuana or alcohol. They have little to no immediate effects and are not immediately rewarding. They have potentially long-term benefits; they serve to stabilize mood and anxiety over time so that the issues of drug addiction can be dealt with more effectively. One has greater emotional resources to draw on when one’s mood and anxiety level are stable.

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Often, the issues of compliance have nothing to do with previous reasons. If your daughter is angry with you, what better way to express her anger than to refuse to comply? Teen rebellion is common at this age and may be part of the reason for her noncompliance. You and your daughter can explore why she feels the need to self-medicate with drugs or alcohol. Listen carefully without judging her. Ask her how you could best help her so that she does not have to turn to illicit drugs to deal with her distress. Speak to her physician about the problem, and elicit his or her cooperation in working with you to address her noncompliance. Ask the physician to discuss in greater detail the medicine he or she is prescribing, including what it is for, how it is expected to be helpful, and how long it may take to reach its maximum effectiveness. Side effects and drug interactions should also be addressed. Let an alliance form between her physician and her so that she owns the decision. Help her to begin to assume greater responsibility for her medication and psychotherapeutic care so that the issue of noncompliance is less likely to be viewed as a rebellious act against you. If, however, she still cannot comply, then a different, more comprehensive approach is needed. The search for a drug and alcohol program for teens should be the next step.

83. I experimented with drugs and alcohol as a teen and grew out of it without the need for treatment. So why are they telling me that my daughter needs treatment? Each person’s makeup includes the genes from both the mother and the father that are amalgamated in a unique way; therefore, a child might have a greater

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Other factors, including other social, psychological, and historical factors, may also increase the chance that your child is at greater risk for addiction than you. Social factors may include immediate family issues, such as conflict, or environmental differences, such as neighborhood or school. If your family gave you emotional support and provided the opportunities to substitute drug use with more appropriate stress releasers or you did not experience a lot of peer pressure to do drugs or if you had specific goals that you wanted to accomplish as a teen that were hindered by the use of drugs and alcohol, then it probably was easier for you to “grow out” of using drugs and alcohol than it might be for someone else. Peers play a critical role in the choices that children make in their lives. Psychological factors include depression, low self-esteem, dependency needs, inability to cope with overwhelming feelings of psychological pain, and a history of ASPD or hyperactivity. These traits may explain why the experts are telling you that your daughter needs treatment. Finally, historical forces cannot be ignored. During the 1960s, one marijuana cigarette contained 10 mg of the active ingredient tetrahydrocannabinol. Today, a marijuana cigarette contains 150 to 200 mg. The higher dose may lead to a stronger addiction; a stronger chance of addiction most likely means that the craving is worse, making it harder to stop using. Thus, your

Each person’s makeup includes the genes from both the mother and the father that are amalgamated in a unique way; therefore, a child might have a greater genetic predisposition to addiction than either one of the parents may have had.

Special Populations

genetic predisposition to addiction than either one of the parents may have had. Although there is a strong genetic predisposition to alcohol and drug abuse, it does not mean that a child definitely will or will not become addicted as an adolescent or adult. Just because you did not succumb to an addiction after experimenting with drugs as a teen does not necessarily protect your child from a substance-use disorder.

Tetrahydrocannabinol the psychoactive ingredient to marijuana that gives it its hallucinogenic and appetite effects. It is also pharmaceutically synthesized and released under the trade name Marinol and is prescribed as an appetite stimulant for cancer and AIDS patients.

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daughter and her genetic, psychological, environmental, and historical makeup are different from yours and are not to be discounted.

84. I am concerned that my teenager is drinking. I have heard about parents having “key parties” in their homes to ensure that the teens don’t drive home drunk. What are they? A key party is a teenage drinking party that the teens host with parental consent; the parents also closely supervise the teens.

A key party is a teenage drinking party that the teens host with parental consent; the parents also closely supervise the teens. For example, in 2004, a parent was presented with a request from his child for permission to celebrate his senior prom at an all-night beer blast with his fellow classmates. The intended party was to be at a beach, which was 40 minutes by car from their home in Rhode Island. The parents were alarmed, particularly at the thought of a group of inebriated teens driving home from the beach. The family carefully weighed the options: to say no and alienate their son, to ignore the teen’s plans and jeopardize his safety and that of the other teens, or to negotiate a compromise. The parents knew that drinking among teenagers in their town was common. They also knew that if they had a party that allowed drinking they would be breaking the law. In an effort to keep the teens safe, however, the parents developed a compromise that was against the law but prevented the teens from drinking and driving. The parent’s inherent dilemma was safety versus legality. The parents proposed the following: Their son could have the party at his home under specific circum-

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stances: (1) The son’s friends would agree to give up their car keys after entering the parent’s home (hence the term, key party). (2) The guests would have to remain at the home all night with their parent’s permission. (3) During the entire night, the father would be available to collect the keys from everyone who attended the party, stand by the door to prevent any one from leaving after the drinking began, and monitor the party so that no one did anything untoward or dangerous. The parents did not participate in buying the beer nor did they know how the teens obtained the beer. A young person of drinking age brought the two kegs of beer. Tents were pitched in the backyard so that the teens could spend the night. On the morning of the party, the father stopped by the local police station to warn the police about the party; however, the neighbors complained about the noise sometime after midnight. Consequently, the police went to the home and noticed the two kegs. Of the roughly 35 teens who were at the party, most were under 18 years old. The father was arrested for breaking the law because alcohol was served to minors in his home. According to researchers, many parents think that drinking among teenagers is unstoppable and the choices they must make unbearable. Many teens see drinking as a “rite of passage to adulthood.” The parents may or may not agree with this, but more importantly, they want to keep their children safe. Do they risk losing their teen in a tragic motor vehicle accident or risk violating the law? Consequently, parents make compromises. The following results from a survey of several thousand parents and teens illustrate these compromises. The parents often, but not always, supply the alcohol to teens.

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Harris Interactive Survey of Parents • Forty-six percent of adults believed that teens should not be allowed to drink under any circumstances. Seven of 10 parents of children 12 to 20 years old disapprove of underage drinking. • Three of four parents think that teens obtain alcohol with parental knowledge and/or permission. • One of four parents with children 12 to 20 years old have thought that teens should be able to drink at home with a parent present. • One parent of four indicated that they allow their teens to drink under their supervision. One parent of every two has served his or her teenager’s friends an alcoholic beverage in his or her home under parental supervision. • One parent of 10 believes that it is acceptable to have graduation or prom parties in high school where alcohol is served, if parents are present to supervise the party.

Survey of Teens • Nearly half of all teens surveyed reported having obtained alcohol somewhere at some point in time. • Two to three teens say it is easy to obtain alcohol from their parents without their parents knowing it. • One third of the teens surveyed said that they can get alcohol from their own parents. One of five teenagers reported that he or she could get alcohol from their friend’s parents. Source: Adapted from Grand, L. (2004). Centre for Addiction and Mental Health, Ontario, Canada.

The downside of allowing the teen to drink at home or hosting a “key party” is that parents are sending a dan-

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If you are hosting a teen party, make your policies about no drugs and no alcohol clear to your children up front. Ask them to inform all potential guests. Invite an open discussion.

Special Populations

gerous message that obeying the law is an option and not a mandate. By allowing such parties, parents are risking not only their own welfare but also their children’s by conveying the message that it is okay to drink alcohol under the legal age.

Help your teen plan the party. Develop an invitation list and invite only a specific number of people. Avoid “open” parties, and turn away uninvited guests. Invitations should be personal and not sent by e-mail. Put your phone number on the invitation, and invite other parents to call you. Include directions about parking. Set the rules ahead of time: no alcohol, drugs, or tobacco. Establish a starting and an ending time. Provide the refreshments; plan them with your teenager. Let guests know that if they leave the party, they may not return. If they arrive at your house intoxicated or with alcohol or drugs, inform them that you will call their parents or the police. Plan activities such as music, games, movies, and Karaoke in advance. Avoid dangerous activities, such as skateboarding. Let the neighbors know ahead of time that there will be a party. Reassure them that you will be there to supervise. Make regular and unobtrusive visits to the room where the party is taking place. Invite other parents to help chaperone, especially when a large number of teenagers will be present. Provide an atmosphere in which teens can have fun without alcohol or drugs. If your child has been invited to a teen party, call the parents to find out about their plans for the party. Volunteer to help chaperone the party. Share your concerns

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with the parents. Tell your teenager that you will be available so that if the party is not alcohol or drug free, you are just a phone call away. Reassure teenagers that you want them to have fun but that more importantly your main concern is safety. Parents’ first responsibility is to ensure that their children are safe.

85. How are men and women different in their responses to alcohol?

Today, women represent a growing number of drinkers who either have alcohol problems or are dependent on alcohol.

Traditionally, men who were the breadwinners were also the drinkers; women did not drink in polite society, which has kept female drinking and alcohol abuse away from public discussion. Traditionally, conventionality characterized female roles; however, throughout the ages, women have used alcohol for medicinal purposes. Alcohol was used during childbirth. Women were encouraged to drink beer to enhance breastfeeding. Hot toddies and various fruit tonics have been used for menstrual cramps. A rise of alcohol consumption in women accompanied the rise of feminism. Changes in women’s roles that involve exposure to traditionally masculine environments have provided women with opportunities to drink more openly. Today, women represent a growing number of drinkers who either have alcohol problems or are dependent on alcohol. Among younger women, the number of drinkers is approaching the number of men who drink. Despite the growing numbers of women drinkers, continued differences remain between the two genders. Women prefer wine, whereas men prefer beer. Men prefer to drink in bars and ballparks, whereas women prefer to drink in restaurants or lounges. Men have more social

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problems than women due to drinking, such as having trouble with the law and DWIs, damaging property, and getting into fights. Alternatively, women tend to use either prescription drugs or over-the-counter drugs with alcohol. Women often take sedatives or tranquilizers with alcohol, whereas more men use cannabis and tobacco with alcohol. Women who use alcohol and drugs are more often involved with a drug-dependent partner and/or come from drug abusing and disorganized families than men. Men tend to become more aggressive with alcohol, whereas more women suffer more depression and anxiety, which may partly explain their increased use of sedatives and hypnotics with alcohol. Despite these differences, one alarming problem for both genders equally is driving a car knowing that he or she has had too much to drink. Although men seem to have more social problems from drinking, women have more adverse physical effects as a consequence of alcohol use. They are more susceptible to organ damage than men. This is because women absorb and metabolize alcohol differently. Men, pound per pound, contain more water than women, whereas women have a higher proportion of body fat than men. Alcohol is water but is not fat soluble. The more water that is available, the more diluted the alcohol becomes and thus the less toxic it is to the brain and other organs in the body. In summary, as a result of drinking, more negative social responses occur in men, whereas women experience more physically toxic effects, possibly leading to serious health problems, such as heart disease, osteoporosis, high blood pressure, breast cancer, ulcers, and liver disease. Gender is a strong factor in understanding the use and abuse of alcohol.

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86. My spouse just returned from the service over seas. He refuses to talk about the time over there. He says he needs to drink because he has nightmares and trouble sleeping. I am worried that he is an alcoholic. What can I do? Posttraumatic Stress Disorder (PTSD) a mental/emotional disorder that is characterized by persistent distressing symptoms lasting longer than 1 month after exposure to an extremely traumatic event.

Studies have demonstrated that individuals seeking treatment for PTSD have consistently had a high prevalence of drug and/or alcohol abuse, and the symptoms of the two disorders interface to the point that they feed off one another.

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Many soldiers returning from overseas are reluctant to talk about their combat experiences, making it difficult for wives to comfort or support them. Veterans often think that their wives might not understand if they talk about their experiences. Talking about it invokes bad memories and feelings of helplessness, severe anxiety, and distress. Many veterans are afraid that they may lose control of their feelings by talking about the injuries and deaths of their buddies. When they do talk about it, many cry, and some fear not being able to stop crying. The most frequently diagnosed disorder among soldiers returning from active duty is PTSD. PTSD is a reaction to a traumatic event, characterized by intense emotions that can exert a feeling of “going crazy.” Studies have demonstrated that individuals seeking treatment for PTSD have consistently had a high prevalence of drug and/or alcohol abuse, and the symptoms of the two disorders interface to the point that they feed off one another. PTSD is associated with a number of symptoms, including numbness, avoidance, and re-experiencing. The symptoms feed on each other so that one intensifies the other. Numbness often occurs immediately after the trauma and may persist. Some returning veterans feel numb, and if they do not feel numb, they want to suppress whatever feelings they might have by drinking alcohol or using other substances. Most veterans suffering from PTSD have few friends. Some fan-

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tasize living the life of a hermit in which they do not have to be around people. To avoid their feelings, many further retreat from close relationships, and normal marital relationships, which are often the closest, suffer the most. Consequently, there is a clinically significant disturbance in family relationships. Re-experiencing traumatic memories can be triggered by everyday seemingly trivial stimuli, such as helicopters flying overhead, the smell of urine, the smell of diesel, or the popping sound of popcorn. These stimuli provoke anxiety, stress reactions, depression, and anger. Thoughts about their combat experiences may intrude at any moment, making it difficult to concentrate. They are always on the alert. Consequently, they can rarely relax and enjoy themselves in a crowd. Very few who suffer from PTSD fall asleep easily, and then once asleep, they have recurrent dreams or nightmares that are related to their combat experiences, startling them awake. People suffering from PTSD suffer from periods of anxiety and chronic depression. Frequently, many veterans self-medicate their symptoms using drugs or alcohol. Data from a 1988 study demonstrated that between 60% to 80% of treatment-seeking Vietnam combat veterans with PTSD also met the criteria for alcohol and or drug abuse. The assumption is that PTSD patients use alcohol and drugs to self-medicate their distressing symptoms. In a 1996 study, alcohol, marijuana, heroin, and benzodiazepines did help to control the severity of the symptoms, but cocaine made the symptoms worse; however, over time, as the drinking and drug using continues and tolerance develops, the symptoms not only increase but also return with the additional problems associated with chronic substance abuse.

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Both conditions need to be addressed, or the chance of treatment success is minimal. Medication can assist in coping with the uncomfortable symptoms. The medication used most often is an antidepressant medication. Occasionally, it may be one of the medications used in the treatment of alcohol dependence to deter compulsive drinking. Benzodiazepines are rarely, if ever, used because of their addictive qualities. Other treatments include cognitive behavior therapy (assists patients to reframe stressful experiences and negative thoughts into more positive thinking), hypnotherapy (hypnosis) and behavior therapy (interventions that reinforce more desirable behaviors), desensitization (incremental exposure to stressful events as tolerated), relaxation therapy and guided imagery (both techniques to handle anxiety), and counseling (individual, group, and family therapy). Couples therapy is especially important for PTSD veterans and their wives in order to reverse the effects of the strained marital relationship. A wife’s support and understanding of her husband is very effective in helping him to cope better with the debilitating symptoms of PTSD. The Veterans Administration (VA) has treated thousands of veterans and has studied and published numerous articles related to PTSD and substance abuse. The VA provides specialized treatment for veterans suffering from PTSD with co-occurring substance abuse disorder and has done so since the 1960s. Besides providing the traditional approaches to substance abuse and mental illness, they also provide outpatient groups for veterans and support groups for wives. Seek help with your husband at the closest VA hospital or outpatient center or

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look up services that might be available at a local mental health center. The earlier you seek treatment the better the prognosis.

87. Does alcohol affect older persons differently? The aging process alters a person’s response to drugs of all kinds. Metabolism is slower because of the reduced size of the liver. Declining kidney function delays the elimination of drugs. Vulnerabilities to drug sensitivities and drug interactions are due to the decline in the aging body’s water content, increased fat content, decreased lean body mass, and a diminished hepatic blood flow. There is a greater sensitivity to lower drug levels and a greater vulnerability for drug–drug interactions and toxicity in older adults. Consequently, a standard dose of alcohol in an older person will result in a higher blood alcohol level because the alcohol clears the body more slowly in a 60 year old than it does in a 20 year old. The aging brain is also more susceptible to the effects of alcohol. Concurrent use of drugs and alcohol can significantly change a drug’s actions that may lead to toxicity. The greater variety of drugs, both prescription and over-the-counter, that are used with alcohol, the greater potential there is for adverse reactions. Table 18 reflects some age related changes in response to drugs and alcohol. Statistically, alcohol and drug abuse among older persons has reached epidemic proportions and remains underreported, undiagnosed, or ignored. The prevalence of older

Consequently, a standard dose of alcohol in an older person will result in a higher blood alcohol level because the alcohol clears the body more slowly in a 60 year old than it does in a 20 year old.

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Table 18 Age-Related Changes in Response to Drugs and Alcohol Physiological Changes

Response to Drugs

Less total body fluid

Higher blood levels of water-soluble drugs Greater accumulation of fat-soluble drugs (diazepam, barbiturates) Reduction in absorption

Increased adipose tissue Decreased secretions in the gastrointestinal tract and lower gastric pH Reduced liver size and decreased hepatic metabolism Reduced kidney functions Drier oral mucosa

Slower metabolism results in a longer half-life of some drugs Slower elimination of drugs Difficulty swallowing tablets and capsules

people who have a problem with alcohol ranges from between 2% and 10%. Studies of older hospitalized patients have demonstrated much higher rates of alcoholism, ranging from 8% to 70%. Nearly half of the older persons who are hospitalized for a medical problem are abusing alcohol, which has compromised their health. Older men outnumber older women alcoholics by 4 to 1, although women are more likely to start drinking heavily in mid to late life. Few are dependent on illicit drugs, although they are more likely to misuse or even abuse over-the-counter and prescription medications. The epidemiological literature examining the risk factors as predictors for late-onset alcohol problems is extremely limited. Several studies reported that lateonset alcoholics are not likely to have family histories of alcohol abuse, and only a few have legal or social problems as compared with early-onset alcoholics. Evidence shows that late-onset alcoholism is more likely to be the result of maladaptive responses to stressors that are com-

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mon during the aging process, including social, psychological, and physical changes.

Special Populations

Factors Associated With Drinking and Older Persons • Social factors: social isolation, poor housing or residential changes, reduced finances, loneliness, loss of social support systems • Psychological factors: depression, grief and loss of a spouse and close friends, loss of self-esteem associated with unemployment, anxiety, fears either warranted or unwarranted, fear of crime • Physical factors: loss of youth, loss of mobility and strength, decreased acuity of the senses, loss of health because of either chronic or acute illnesses, such as heart disease, hypertension, diabetes, lung disease, or arthritis Suicide among older persons is a big problem. Twentyfive percent of those who commit suicide are older than 65 years. The rate of suicide for older adults is five times the general population. Alcohol use is involved in one third of older-persons’ suicides. No age group is immune to the problems associated with the misuse of drugs, alcohol, over-the-counter drugs, and prescription drugs, but older people have problems that are unique to their age group.

No age group is immune to the problems associated with the misuse of drugs, alcohol, overthe-counter drugs, and prescription drugs, but older people have problems that are unique to their age group.

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88. We are thinking about moving to a rural area to avoid the drug and drinking problems that our children are exposed to in the city. Do rural Americans, especially teens, have similar problems with alcohol or drugs?

Higher rates of substance abuse, including alcohol, tobacco, and other drugs, actually exist among rural teens.

A move to a rural area will not insure that teenagers will escape the influences of alcohol and drugs. Higher rates of substance abuse, including alcohol, tobacco, and other drugs, actually exist among rural teens. There are also higher rates of traffic violations, such as DWIs, in rural areas. There is speculation as to whether the higher numbers of DWIs in rural areas have to do with the distances traveled or the number of intoxicated drivers. Certain rural areas in the northeast, such as New Hampshire and Vermont, and the west (Nevada and California) have higher rates of alcohol and substance abuse among teenagers than in the south. It is speculated that the number of individuals in the south with strong Christian values has kept the incidence of alcoholism low. Here are some surprising statistics: Eighth graders living in rural America are more likely to do any one of the following than their urban counterparts: • Smoke marijuana (34.5%) • Drink alcohol (29.9%) • Use tobacco (chewing and smoking) (50%) Factors that may contribute to the higher rates of substance abuse among rural teens are as follows:

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Not only is the rate of alcoholism and drug abuse higher, but there are barriers to accessing health care resources for a number of reasons, including cultural beliefs and attitudes. Stigma is associated with seeking help for mental illness and substance abuse. Rural Americans believe that individuals should take care of themselves. A “pull-yourself-up-by-the-bootstraps” mentality exists. Maintaining confidentiality in a small town is also difficult because there are no secrets. There is fear that everyone will know, resulting in shame for the entire family. Other barriers to accessing care include a lack of qualified health care and substance-abuse professionals, fewer AA meetings and other substance-abuse treatment programs per square mile, long distances to get to health and mental health programs, and a lack of transportation to those services.

Special Populations

• Higher rates of unemployment • Limited after-school activities because of distance, weather events, and so forth • More uneducated families living below the poverty line

If you are concerned about the influence of the drug culture at your child’s school in the city, discuss your concerns with the teachers, the principal, other parents, and your child. Insist that your children attend drug-education programs. Moving to a rural area may be peaceful and quiet and may be beneficial for your family, but it will not make your children any safer from alcohol and drugs. No such thing as a “geographical cure” exists. Where and when you move, troubles will be packed in your luggage along with your clothes and other belongings.

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89. I have heard the term “impaired professional.” Do professionals have similar problems with alcohol or drugs as others? If I suspect that a professional is impaired, what should I do? During the past few years, a body of literature has been growing on the impaired physician, as well as other health care professionals, because of alcohol or drug abuse; however, the impaired professional may include college professors, lawyers, and even congressmen, besides doctors and nurses. The impaired health care professionals are used as a model for this discussion because physicians and nurses have easier access to drugs and are thus at a greater risk for being impaired. A frequently mentioned rate of alcoholism and drug abuse among physicians is that physicians have a greater risk of addiction by 30 to 100 times that of the general population. Some authors dispute that figure, however, claiming that no sound data are available. Other authors speculate that the rate of addiction among health care professionals is equal to the general population. What is similar to the general population is that men outnumber women in terms of excessive drinking or drugging. Some of the risk factors are the same as the risk factors for the general public, as are the therapeutic interventions. One factor other than an easy access to drugs is the stress that is associated with the work of caring for others, which increases the risk of professional impairment; however, each professional role has its unique stressors associated with the job. All professionals have a greater sense of being invulnerable because of their ability to control their own destinies. Precisely because professionals are independent, however, they are also more

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vulnerable because of the lack of formal controls or supervision to monitor their job performance.

Special Populations

Since the late 1970s, programs have been developed to assist professionals in becoming drug and/or alcohol free. The American Medical Association has published a number of articles about impaired professionals, including doctors, nurses, social workers, and lawyers. AA has developed groups that specifically target professionals. Both the American Medical Association and the American Nurses Association have established programs that are based on AA principles for the impaired health care professional. The National Nurses Society on Addictions has two goals: advocacy and education. During the 1980s and 1990s and today, many corporations, including hospitals, have established employee assistance programs to promote early identification and intervention for employees, enabling them to receive rehabilitation and still maintain their job status in the future after completion of a substance abuse program. Impaired professional programs serve as follows: • Liaisons with hospitals, professional organizations, and licensing boards • Educators about impairment among professionals • A registry of programs for recovering professionals • Investigators related to reports of impairment • Advisors regarding financial aid during treatment, while away from the job State licensing boards are available to the general public to respond to concerns of the possibility of an impaired professional. They will conduct an inquiry,

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and if the concern is valid, they will initiate measures for rehabilitation. The only down side of the investigations that state professional licensing boards conduct is that some boards have become overly zealous, acting like tribunals that accuse a suspect of being impaired and presuming guilt without due process. State boards, however, see their mission as protecting the public and they take that mission very seriously.

The prognosis for recovery of professionals is good, especially if the intervention is started early in the disease process.

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The prognosis for recovery of professionals is good, especially if the intervention is started early in the disease process. Treatment entails close monitoring by a peer in the work situation, usually designated by the treatment team or the licensing board, maintenance of health promoting activities by the professional, random urine screens, regular checkups with a designated substance-abuse professional, and attendance at a 12step program. Finally, nurses may not work nights where there is less supervision, nor can they pass out narcotic medications or have access to the medicine keys, at least during the first year of recovery. Support from fellow employees, family, and a 12-step program is essential for a successful recovery.

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PART VII

Surviving Alcoholism Will I ever be able to drink again?

I was arrested for a DUI. What should I do?

What are my rights to privacy?

More . . .

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90. Will I ever be able to drink again? Moderation Management (MM) founded in 1993 as an alternative alcoholic treatment program to the traditional AA 12step program.

AA’s goal is absolute abstinence over the remainder of a person’s lifetime, and any drink constitutes either a “slip” or relapse. MM, alternatively, allows the individual to decide whether to drink or maintain abstinence.

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This will forever be the most controversial issue, particularly with the growth of Moderation Management (MM) and its founder’s eventual jump to AA, followed by her causing the deaths of two people while driving intoxicated. MM’s primary book, Moderate Drinking, shares some important points in common with AA’s Big Book. Notably, it makes clear distinctions between problem drinkers and alcoholics: Problem drinkers may be able to control their drinking, whereas alcoholics need to maintain abstinence (see Question 44). This is exactly the claim that the Big Book makes. Where the two organizations differ is on who makes the determination that someone is a problem drinker versus an alcoholic. Because AA focuses on denial as a major problem with alcoholics, then clearly an alcoholic is incapable of deciding for himself or herself whether he or she is a problem drinker or an alcoholic. Only an outside observer can determine that. MM, on the other hand, allows its own members to make the determination. Thus, according to AA, MM’s members are merely alcoholics in denial. AA’s goal is absolute abstinence over the remainder of a person’s lifetime, and any drink constitutes either a “slip” or relapse. MM, alternatively, allows the individual to decide whether to drink or maintain abstinence. MM members are more likely than AA members to be female, younger, and employed. Additionally, most MM members have never sought treatment for their alcohol problem. They reported animosity toward AA and had no desire to participate in such a program. A number of individuals in MM still have evidence of alcohol dependency, and many of those who are unable

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to moderate their drinking do move toward a goal of abstinence with some measure of success. One of the criticisms is that, aside from inappropriately promoting continued alcohol use among alcoholics, morbidity and mortality will rise as a result of this type of program. Despite this criticism, the continued morbidity and mortality among AA members remains an everpresent issue, as slips and relapses are high in this group as well. Remember that the founder of MM left MM for AA in order to achieve abstinence the month before her tragic accident. Moving away from the controversial rhetoric that various groups engage in hinges on one simple question: Is alcohol reeking havoc in your life in any way? Are you using alcohol despite all evidence that it is destroying your personal and professional relationships and/or your health? If the answer is yes, then you are an alcoholic. If you are an alcoholic you need to stop drinking, period; otherwise, your life and/or someone else’s life are in jeopardy. Whether you can moderate your alcohol use will quickly become apparent to you and all who you affect. You may be able to deny the obvious, but the obvious will not deny you!

91. I was arrested for a DUI. What should I do? Everyone agrees that traffic-related fatalities resulting from alcohol intoxication are terrible tragedies that evoke a great deal of anger, rage, and a need for retribution. In 2005, as a result of active lobbying efforts of Mothers Against Drunk Driving (MADD), the U.S. Congress passed a federal law requiring all states to

Mothers Against Drunk Driving (MADD) an advocacy group of women who have lost someone, usually a child, because of a drunk driver.

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In 2005, as a result of active lobbying efforts of Mothers Against Drunk Driving, the U.S. Congress passed a federal law requiring all states to enforce a legal limit for blood alcohol level of 0.08.

enforce a legal limit for blood alcohol level of 0.08. Overall, this has been a success in reducing the incidence of traffic related fatalities. The penalties for such a violation are left up to the state. They can include sanctions such as jail, detention, and/or probation, impounding of the vehicle, license suspension, license plate confiscation, enforced use of ignition interlock mechanisms that require one to blow into a breathalyzer for the key to function, and rehabilitation programs ranging from education classes to inpatient rehabilitation programs. States often modify their laws to change behavior. For example, Minnesota found that 80% of drivers who lost their licenses as a result of a DWI continued to drive. This law obviously did not achieve its goal. Thus, they began impounding their vehicular license plates with much greater success in getting alcoholics off the roads. Eighteen states have mandatory jail time for first-time offenders. Additionally, some states have the leeway of charging someone for driving under the influence with any amount of alcohol in their system, even if the blood alcohol level is less than 0.08, if they fail a field test and/or are on other prescription or nonprescription medications that might influence their driving ability. What should you do? First, get yourself a good lawyer in the state where the incident occurred. Because each state’s laws are different, you must find a credible lawyer who knows the laws specific to your state. Second, stop drinking, and join a recovery program immediately. If you can show the court that you admit to needing rehabilitation, the sentence might be lighter than if you deny that you are having problems with alcohol or drugs.

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92. What are my rights to privacy?

Long-standing laws in all states and at the federal level protect a patient’s right to privacy and the health care provider’s obligation to maintain confidentiality. Sharing information about a patient’s health and health care without his or her permission involves legal sanctions against those who have breached confidentiality. During the 1980s, the President’s Commission on Mental Health recommended to Congress that there should be a federal law that protects a patient’s right to privacy, especially patients who are extremely vulnerable, such as the mentally ill, substance abusers, and the mentally retarded. Public Law 99-319 legally guarantees a patient’s right to privacy. No information can be released without the written authorization of the patient. The patient must knowingly and specifically

American Hospital Association founded in 1898 to represent and serve all types of hospitals, health care networks, and their patients and communities.

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Every patient has the right to privacy, which is 1 of 12 patients’ rights that the American Hospital Association adopted in 1973 and revised in 1992. A corollary of the patient’s right to privacy is the professional’s obligation to protect that right, which is confidentiality. Health care professionals have always honored the ethical principle of confidentiality; therefore, the patient may disclose personal information to his or her health care professional without fear of it being revealed to others, including to family members and other professionals. Traditionally, mental health care providers, as well as those involved with the care of the alcoholic or drug addict, have been extremely protective of their patients’ rights to privacy. Maintaining an individual’s privacy is both an ethical and legal obligation.

Health care professionals have always honored the ethical principle of confidentiality; therefore, the patient may disclose personal information to his or her health care professional without fear of it being revealed to others, including to family members and other professionals.

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request psychiatric and/or drug and alcohol information to be released before it can be.

Health Insurance Portability and Accountability Act (HIPAA) the American Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. Congress in 1996 and was put into effect on April 14, 2003.

A recent law that governs the right to privacy is the Health Insurance Portability and Accountability Act (HIPAA).

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In 1997, professionals from nine organizations who serve the mentally ill worked together to develop a Mental Health Bill of Rights, which further addressed a patient’s right to privacy and patient confidentiality. A patient’s right to privacy includes not only his or her personal information, but it also includes the relationship with his or her mental health and/or substance abuse provider, except as laws dictate. Exceptions where private information may be disclosed include (1) a threat to harm others; (2) issues involving mandatory reporting, such as communicable diseases, impaired driving, child abuse or neglect, or any other requirement that is mandated by a particular jurisdiction; (3) in some states, a court-ordered or court-subpoenaed record that may be released to the court without the patient’s written permission; (4) hospitals and medical offices that may release minimally necessary health care information without the patient’s written permission for the purposes of diagnosis, prognosis, type of treatment, time, length of treatment, and cost, particularly in emergency situations. An additional exception has been mandated under the recent Patriot Act, whereby health care providers may disclose information without the patient’s permission to authorized officials conducting security investigations. A recent law that governs the right to privacy is the Health Insurance Portability and Accountability Act (HIPAA). This went into effect April 14, 2003, and provides stringent legal penalties for health care institutions or professionals breaching confidentiality. The initial intent of HIPAA was to allow people to main-

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tain their healthcare insurance after termination of employment and to decrease the exclusions for preexisting conditions. HIPAA also mandated that patients have the right to make informed decisions about their health care, which is another ethical principle called informed consent. The law provided further controls over Medicare fraud and abuse and standardized the electronic claims system between providers and third-party payers. Patients also have the right to view and amend their healthcare information by submitting a written request. Patients not only have the right to access their medical records, but they also have the right to know who else has access to them. In addition, over time, HIPAA has become known for protecting patient’s privacy. Before being seen each time by the health care provider, the patient is issued a notice of privacy that must be read and signed. If your right to privacy may have been violated, you can contact the privacy officer of the institution where you believed the violation occurred. You can also contact the Center for Mental Health Services, who can provide information about the protection and advocacy agency in your state.

93. I am worried about my employer finding out about my treatment. How can I prevent his or her finding out? All employees need to know that they are under no obligation to disclose medical information, whether they are seeking employment or are currently employed. Many job application forms request information about mental illness. The employers may request information about a gap in employment, and because

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many employers pay the medical bills, employers frequently feel that they have a right to know an employee’s medical history. If treatment requires time away from work, some medical information may need to be released in order to justify the time off. The information given to an employer is strictly at the employee’s discretion. If a health care professional or health care institution shares information with the employer without permission, legal sanctions may be invoked that will penalize the provider. The threat of legal sanctions should prevent the employer from finding out about your health status. The legal sanctions are described Question 92.

American Disabilities Act title I of the Americans with Disabilities Act of 1990 took effect July 26, 1992. It prohibits private employers, state and local governments, employment agencies, and labor unions from discriminating against people who have physical or mental disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms, conditions, and privileges of employment.

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Many patients fear that they will be fired if an employer finds out about their history of alcoholism or drug addiction. The American Disabilities Act is a federal law that was passed to protect patients with disabilities from being fired because of a specific disability. The American Disabilities Act of 1990 makes it unlawful to discriminate against an employee if he or she is a qualified individual with a disability. A disability is defined as “a person who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment or is regarded as having such impairment” (U.S. Equal Employment Opportunity Commission, 1991). This law also applies to people with mental disorders, including addictions. If the disabled person is the most qualified person among all of the applicants, then accommodations must be made, such as job restructuring, modifying work schedules, and acquiring or modi-

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Current laws protect employees from unwanted disclosures to employers, which should prevent the employer from finding out about your alcoholism or drug addiction. In this case, the law prevents your employer from finding out about your medical status.

94. My employer ordered me into treatment or risk getting fired? What are my rights? Employees need to know that disciplinary actions may occur, including dismissal, if the employee’s job performance has been compromised as a result of alcohol or drug abuse. Employers may offer time off to seek treatment and a return-to-work agreement. The Family Medical Leave Act (FMLA) may also cover the employee’s ability to take a temporary leave of absence to seek treatment for alcohol and drug addiction. You are eligible to take time off without pay to get treatment under these circumstances: 1. Your employer has 50 or more employees. 2. You have been employed at least 12 months or worked in excess of 1,250 hours.

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fying equipment. According to the American Disabilities Act, employers cannot discriminate in their hiring and firing practices based on medical information. The law specifically prohibits an employer from asking questions about a person’s disability during an employee’s job interview unless the questions are directly related to job requirements. The same principle remains true after the prospective employee is hired.

Family Medical Leave Act (FMLA) the U.S. Congress passed this act in 1993 with the goal of providing employees with a balanced life between family and work.

The Family Medical Leave Act (FMLA) may also cover the employee’s ability to take a temporary leave of absence to seek treatment for alcohol and drug addiction.

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3. Your employer must continue your health insurance coverage, but you must pay your share of the premium. 4. You may or may not return to the same job, but it should be an equivalent position. 5. You must give notice 30 days in advance of your intention to go on medical leave. 6. You do not have to reveal a great deal of confidential information, but the employer has the right to know enough of the facts in order to discern that your reason is covered by FMLA. 7. The health condition must be serious enough to warrant inpatient care in a hospital, hospice, or residential medical facility or continuous treatment by a health care provider. 8. You may be required to provide a physician’s certification that you are in need of continuous treatment, with the date on which the condition began, its probable duration, and the pertinent medical facts. If written notification has been given to the employee, the employer also has the right to require a fitness-forduty exam before the employee returns to work. If your employer ordered you to get treatment or be fired, you have the following rights: • • • •

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The right to not be unfairly dismissed The right to refuse treatment The right to privacy The right to be absent from your job, while seeking treatment, under the FMLA guidelines, if you and your employer qualify

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It is also your right not to tell your employer whether you are receiving treatment and still remain on the job. Your job performance, however, must meet the required standards. If your addiction is interfering with your job performance, take your employer’s offer to seek treatment rather than be fired. Employers have the right to take disciplinary action based on job performance problems that result from an employee’s alcohol or drug abuse. Negotiate with the employer on the amount of time away that you will need to get the required treatment. Determine what you must change in order to meet his or her expectations regarding your job performance. Take the offer: Save your job, and save your life!

95. What is co-dependency? How do I know if I am co-dependent, and what can I do about it? Co-dependence is a concept that developed after the disease model of alcoholism took hold in the 1960s. Until then, the focus of treatment was on the alcoholic patient and excluded the family. At that time, the spouse was labeled as the chief enabler, which included trying to control the alcoholic’s behaviors, picking up the pieces from the adverse consequences of the alcoholic’s behaviors, or rescuing the alcoholic from the adverse consequences. It was discovered in addiction treatment centers that not only did the individual suffering from the addiction need treatment, but his or her family members needed treatment as well. In treating the alcoholic or drug addict, the clinicians noticed

Co-dependence a maladaptive coping pattern in family members who are closely related to a substance abuser or experience a prolonged exposure to the behaviors of the alcoholic- or drugdependent person(s).

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that the family members had specific characteristics and behaviors in common.

The characteristics of codependency include low self-esteem, self-defeating behaviors, distorted thinking, problems in expressing feelings, difficulties with relationships, and the disowning of one’s own needs in order to respond to external demands (being a martyr).

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The co-dependent is not sick because of the alcoholic’s behaviors but because he or she is attracted to the alcoholic. The attraction is because of the codependent’s own defense mechanisms that were developed during childhood. These behaviors may be either passive or aggressive and are reactions to childhood trauma. The characteristics of co-dependency include low self-esteem, self-defeating behaviors, distorted thinking, problems in expressing feelings, difficulties with relationships, and the disowning of one’s own needs in order to respond to external demands (being a martyr). People who are at risk for co-dependency include spouses of addicts, recovering addicts, adult children and grandchildren of addicts, professionals in caretaker roles, such as nurses, families with a secret, and people raised in a co-dependent family. Codependent families have unwritten rules that encourage self-deception and manipulation. The rules include the following: • • • • • • •

Don’t feel—just smile. Always be perfect. Don’t embarrass the family. Loyalty is everything. Don’t have fun. Don’t ask for help. Don’t tell family secrets.

If you are a spouse of an addict, come from an alcoholic family, are a professional caretaker, or come from a family who has a secret that family members hide

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• Express your feelings and own up to your own reality. • Acknowledge your needs and wants. • Grieve the past and accept your family’s dysfunctional behaviors, while seeing their assets. • Identify your strengths and build on them to enhance your self-esteem. • Develop healthy relationships. • Refrain from rescuing other people, especially at one’s own expense. • Learn to communicate clearly and directly.

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from themselves and each other but everyone knows about, you may be at risk for being a co-dependent. Treatment for codependency includes helping the codependent do the following:

Many programs for co-dependents also follow the AA’s 12 steps. Many books about co-dependency are available to the general public. Recovery from codependency involves an increased self-awareness, as well as more open and honest expression of feelings, recognizing one’s own needs with a focus on self-care and self-nurturing. Individual psychotherapy and/or counseling may help the codependent accomplish this. Joining a 12-step program is also beneficial. Developing healthy relationships with others and with a higher power, as in all of the 12-step programs, can provide a greater sense of self during the recovery process. If you think you may be a co-dependent and you tend to rescue others at your own expense, deny your own thoughts and feelings, and feel that your life has become unmanageable because of the unhealthy relationships that you are involved in, seek out a support

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group. Support groups include Al-Anon, Alateen, CoDependents Anonymous (CoDA), and Adult Children of Alcoholics Organization (ACoA), which are 12-step programs in the tradition of AA but are designed for the family and friends of alcoholics. They offer the necessary support for these individuals regardless of whether their loved one is recognizing their problem and is in treatment. In fact, these programs are especially beneficial to those whose family member remains in denial, as they are especially in need of support and guidance during these initial stages of intervention. There are obvious overlaps between AA, CoDA, ACoA, Alateen, and Al-Anon. Try them all out before deciding which group has the strongest fellowship and the most frequent meetings in your community.

96. My family member is an alcoholic and refuses to get help. What should I do? Aside from joining a support group, you may wish to take several steps to help your loved one. The real challenge will be to broach the subject of the use of alcohol or drugs in a nonthreatening and nonjudgmental way. First, you may wish to consider alternative ways of discussing the problem. Second, discuss with your family member his or her experiences with alcohol during the past, including childhood. What were his or her parents drinking habits? Describe various strategies for coping with stressful situations, both in the past and now. Talk about alcohol as a way of coping, which may have worked initially but is currently leading to unacceptable behaviors. When linking his or her alcohol use with negative coping behaviors, use

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open-ended questions so that you do not seem accusatory or threatening. These allow for discussion and do not end with yes or no answers. If he or she acknowledges that alcohol use may be a means of dealing with an emotional problem, such as depression, then suggest that your spouse seek counseling or the care of a psychiatrist. Third, if your spouse does not acknowledge a problem, you may leave pamphlets from various alcohol treatment organizations around the house for his or her information. Next, if he or she still refuses to get help, you may need to suggest a separation or propose some other drastic measure, which may be interpreted as coercion. It is not coercion in so far as you are giving that person a choice, albeit with specific consequences that impact on both of you. The issue is you and your loved one’s health and safety or chronic illness and potential death. Do not threaten! Be prepared to set up a set of consequences and then follow through with them. When you lay out the consequences, be sure to use “I” messages, which convey less blame. The following is an example of an “I” message: When you become verbally abusive after you have had a couple of drinks (the behavior), I feel helpless, and my feelings are hurt; then I get depressed (your feelings). If you continue to verbally abuse me and do not stop drinking or get help for yourself, then I will have to leave for the sake of my own mental health (the consequences). The formula for “I” messages: When you _____ (describe the behavior). Then I feel ______ (describe how you feel). Consequences ___ (describe what the consequences will be).

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If repeated attempts to talk to one’s family member about the problem have failed, it is then time for action. Remember that ultimately one individual has little control over the behavior of others. Someone suffering from alcoholism cannot be coerced into treatment. In that context, separation is a legitimate measure to protect yourself from the dangers of continued heavy drinking. It is critically important to stop bailing the person out from alcohol-related problems. This only strengthens the denial and perpetuates the problem, as the person never fully appreciates what dangers his or her alcohol or drug use is causing.

Many clinicians think that addiction is a family illness because it affects each and every member of a family; therefore, individual and family therapy are essential ingredients to recovery as well as attending support groups.

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Many clinicians think that addiction is a family illness because it affects each and every member of a family; therefore, individual and family therapy are essential ingredients to recovery as well as attending support groups. Recovery takes a lifelong commitment on the part of the individual and the family. The prognosis is better if family members also participate in treatment. Finally, consider doing an intervention. Many of these organizations have resources that can help you conduct a group intervention. It is best to use a professional intervention specialist to guide the process and support your family in confronting the alcoholic’s denial. In a private meeting with family members, friends, employers, and coworkers, along with an intervention specialist, confront the abuser about the problem that drinking and/or drugging are causing him or her personally at home and at work, as well as the effects on his or her body. The facts and the objective evidence are presented in a calm nonemotional manner. During the intervention, the family and others also identify the consequences that will occur if the behavior continues

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and the addicted family member refuses to get help (see Question 46 for further information).

97. What is the impact of alcoholism on children? Most co-dependents are children of alcoholics, but not all come from alcoholic families. Some may have grown up in dysfunctional families who had other problems, such as poverty or a mental or physical illness. Adult children of alcoholics grow up physically— but emotionally, psychologically, and spiritually, many still function on a developmental level that is appropriate for a young child. ACoAs have never learned a “normal” way of thinking, feeling, or reacting. Their parents never grew up to be responsible, integrated adults. Consequently, ACoAs have never had appropriate role models to emulate. Frequently, childhood trauma has compromised their adult relationships, career trajectories, and marriages. For example, because they have never seen a functional parental partnership in action, they tend to have poor parenting skills, and often the cycle of alcoholism continues from generation to generation unless it is broken by an intervention.

Characteristics of Alcoholic Families • Low levels of cohesion • Lack of the expression of love and caring for each other • Poor communication • High degree of conflict • Inconsistent parenting • Lack of routine, such as meal and bed times

Adult children of alcoholics grow up physically— but emotionally, psychologically, and spiritually, many still function on a developmental level that is appropriate for a young child.

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• Lack of traditions and rituals, such as celebrating Easter or 4th of July • Chaotic family systems with loose boundaries between family members, often with role reversals such as a child parenting the alcoholic parent • Rigid boundaries between the family and the community to hide the alcoholism and maintain a façade of normalcy

Young Children of Alcoholics Young children have a tendency to blame themselves and feel guilty for their parents drinking. They worry about their parents, fearing that they might get sick or injured and get anxious when their parents fight. They may perpetuate the lie that their family life is normal and are ashamed of their parents, thus avoiding having friends play at their homes. Because of the many promises that are broken by inconsistent parenting, they do not trust other people. Other characteristics may include the following: • Failure in school or truancy and poor high school gradation rates • Lack of friends and withdrawal from classmates • Difficulty having fun • Judging one’s self mercilessly, resulting in poor selfesteem • Delinquent behavior, such as stealing or violence • Frequent physical complaints, such as headaches or stomachaches • Abuse of drugs or alcohol • Anger and aggression toward other children • Impulsivity, risky behaviors, and a lack of selfdiscipline • Mistrusting adults and authority figures

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Adult Children of Alcoholics The roles that children assume are sometimes functional within an alcoholic family system, but the danger is that ACoAs will continue these same behavior patterns, enacting roles that are no longer functional as adults. ACoAs often stay in abusive relationships because of their own lack of self-esteem, their comfort with chaos, their fear of abandonment, and/or their sense of unfailing loyalty. They frequently remain loyal even in the face of evidence that the loyalty is undeserved. Because of their past experiences with their parents who disappointed, hurt, or abused them, ACoAs often perceive themselves as victims and may continue to play the roles of martyr or victim as adults. ACoAs learn other roles in order to adapt to chaotic family patterns. The following are some of the roles that are identified in the literature on alcoholism. The behaviors associated with each role may persist into adulthood. Table 19 provides a list of roles that children adopt in order to cope within alcoholic families.

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• Being super responsible or very irresponsible • Depression, suicidal thoughts, or attempts

Each family member plays a role in order to keep the family system in balance, which is true in all families. The difference between a “normal” family and an alcoholic family is that the roles in the dysfunctional family tend to be rigid and not interchangeable. Therefore, dysfunctional behavior problems persist into adulthood; thus, the enabler continues to rescue others. The hero continues to excel at all costs to himself or herself. The scapegoat continues to set himself or herself up as the victim of abuse or follows in his or her parents’ footsteps by drinking or drugging. The mascot

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Table 19 Adopted Roles to Cope Within Alcoholic Families • The Enabler. The family member who helps, supports, and allows the substance abuse to continue by “saving” the abuser from the consequences of his or her behavior and then covering up the mistakes. The enabler may deny the alcoholism, but the child or spouse may feel angry and helpless to control the situation. He or she makes excuses for the alcoholic’s behaviors. The enabler has learned to be a rescuer. • The Hero. The sibling who excels in academics and sports in order to compensate for feelings of inadequacy and guilt and to create the illusion of a successful family. The hero may also be the super responsible family member who takes care of both the parent(s) and the other children in the family, thus assuming the adult parental role. • The Scapegoat. The sibling who acts out his or her anger by displaying unacceptable behaviors. The behaviors may include delinquency or substance abuse. This person allows the rest of the family to believe that the family problems are because of his or her acting out behaviors. The scapegoat may be the child who brings attention to the family so that family may be required by the school or law enforcement to seek help for this child. They are inadvertently discovered to be an alcoholic family. • The Mascot. This child is the comedian who diverts the attention away from the alcoholic and the family to himself. His or her diversionary tactics defuse the anger that everyone in the family feels by providing comic relief. • The Lost Child. This child is the family member who never causes a problem and is relatively invisible. The lost child has also been labeled the placater because he or she is sensitive to the needs of others and is often sympathetic to the alcoholic parent. The lost child may not only be a placater, but also an adjuster who easily follows directions and doesn’t draw attention to him or herself. This child is protected from the family’s anger and blame because the lost child is the unnoticed child who avoids the family’s hostility.

plays the comedian as an adult, and the lost child tends to remain isolated as an adult, under everyone’s radar. The impact of having an alcoholic parent has lasting effects on children, as they continue to play out their assigned family roles. The good news is that if you are a child of an alcoholic, a number of self-help groups are available, as mentioned in the previous question. Sometimes depression hampers progress. If that is the

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98. What resources are available for women whose spouses are alcoholic and abusive? Spousal abuse as well as child abuse is highly correlated with alcoholism. Domestic violence occurs in all cultures, races and ethnicities, religious, and socioeconomic groups. Many clinicians and researchers believe that violence is a learned behavior, role modeled by the parents and perpetuated in the next generation. A child raised in a home with physical abuse is much more likely to be abusive as an adult or to tolerate an abusive spouse. Women are more likely to be the victims than men and when attacked by men, their injuries are more severe. Men, however, can also be victims of spousal abuse, but are less likely to report abuse or to seek help. Another alarming fact is that 50% of men who assaulted their wives also abused their children. Seventy-five percent of spousal abuse reports stated that the offender had been drinking. A study of spousal abuse by male U.S. army soldiers found that domestic violence was more prevalent in families where the soldier drank heavily. A large percentage of women who abuse alcohol or drugs are reported to have been abused either physically or sexually as children. The result of early childhood abuse is poor and inadequate coping skills and severe psychological problems such as chronic anxiety, depression, or PTSD.

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case, psychotherapy and/or antidepressant medications may give the ACoA the boost in energy to work on his or her lifelong problems.

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There is no one explanation as to why women stay with their abusers. Usually these relationships start out loving and down the road the first incidence of violence occurs, leaving the woman stunned and the man apologetic; however, the cycle frequently is repeated, and the spouse is ashamed, begins to blame himself or herself, and feels trapped. There are some things you can do if you find yourself in a cycle of violence. Plan ahead when you may or may not need an escape route. Pack a bag and hide it from your spouse. Include in the bag a change of clothes, a set of car and house keys, bank account numbers, birth certificates, insurance policies and numbers, marriage license, valuable jewelry, important telephone numbers, and money. Try to contact resources ahead of time. Seek support from 12-step programs for wives of alcoholics. Get support from multiple sources, Al-Anon, Crises Centers, the clergy, and other community organizations. This will empower you to do what is best for you and your children. Treatment for alcoholism and drug abuse is most often done in the community, except for detoxification from a substance, which usually takes place in a hospital.

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99. What are my rights to refuse treatment? Treatment for alcoholism and drug abuse is most often done in the community, except for detoxification from a substance, which usually takes place in a hospital. Hospitalizations occur when either the patient’s life is threatened during the withdrawal period or because of some other threat to safety, such as threatening violence, as in child abuse or spouse abuse. Unlike most hospitalizations where the issues of safety trump autonomy (the right to self determination), the right to refuse treatment is sacrosanct in all of health care.

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Informed Consent When a patient agrees to treatment, he or she must be able to sign a form regarding informed consent that states that he or she understands the proposed treatment plan and the reasons for it. The process of obtaining informed consent includes the following:

Surviving Alcoholism

In general, patients have the right to refuse medical or psychiatric treatment, short of emergency hospitalizations for reasons of safety.

• Assessment of the patient’s capacity to make medical decisions • The absence of coercion • The patient who has been fully informed of the diagnosis, prognosis, risks, and benefits of the treatment and who has been informed of alternative treatments as well as the risks versus benefits of no treatment The health care provider should test the patient’s understanding of the explanation in order to be certain that he or she clearly understands it. All relevant factors, including what was disclosed, the patient’s competency, and the agreement to treatment, plus the actual consent form, should be stored in the patient’s medical record. Exceptions to informed consent do exist, however. • Emergencies, such as alcohol withdrawal syndrome or impending DTs • Court-ordered evaluations • Therapeutic privilege waiver

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• A patient who is unconscious and in need of lifesaving treatment • A patient who is incompetent • Child abuse proceedings Therapeutic privilege occurs when the physician withholds information from the patient because he or she believes that informing the patient will cause more harm than good. Occasionally, patients waive the right to know. It is a good idea for the health care provider to enlist the aid of a family member to make decisions when the patient refuses to participate in his or her health care decisions. Consent is implied when he or she actively participates in the treatment; for example, the patient offers his or her arm to have blood drawn (Albrecht & Herrick, 2006). When refusing medication or treatment, it is important that the patient understands the potential consequences.

The Elements Necessary to Refuse Treatment If you are refusing a lifesaving treatment, your physician is responsible for ascertaining that you clearly understand the refusal. He or she may request a capacity determination. This entails a psychiatrist’s formal evaluation of your capacity to make such a decision. The capacity to refuse treatment requires four elements: • The ability to express a choice • The ability to understand the treatment options and their consequences • The ability to appreciate the information as it applies to one’s specific situation • The ability to make reasonable judgments regarding the information

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Surviving Alcoholism

These four elements must be met for a patient to have the capacity to decide on medical or psychiatric treatment or to refuse it. It is important for the health care provider to sort out each of these elements. An emergency conservatorship may be required to help make the necessary decisions to save the patient’s life if it has been determined that the patient lacks capacity to make decisions regarding his or her health and/or finances. Usually a family member is appointed as the conservator.

Life-Threatening Conditions A few life-threatening situations occur in the treatment of alcohol and drug abuse. Severe symptoms from the sudden and untreated withdrawal of a drug or alcohol, and DTs can be life threatening. Another life-threatening situation may be when someone’s behavior is out of control and he or she is threatening violence—the patient is a danger to self or others. If safety is at stake—to the patient, someone else, or society—then hospitalization or treatment may be required without the patient’s permission. At this point, the patient may not be capable of making an informed decision, particularly if he or she is still in denial that there is a problem and is threatening harm to self or others, is intoxicated, or has the DTs. Under these circumstances, the decision to treat or hospitalize the substance abuser will be made in the best interests of the patient, the family, and society. If safety remains a concern even after a patient is no longer intoxicated or in active alcohol withdrawal, the health care provider or physician may turn to the courts for guidance. The court can order treatment for an unwilling patient to be admitted to a hospital and/or to be treated. The legal procedures for this vary from state to state. In most states,

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treatment can be provided without a patient’s consent only if the patient remains an immanent threat to self or others. After this threat has resolved, then only a court can intervene to order a patient into a rehabilitation center and generally only after the patient has broken the law and the matter involves an alternative to sentencing. Otherwise, no state allows a patient to be civilly committed to a drug or alcohol rehabilitation program. In summary, you have the every right to refuse treatment. The right to refuse treatment is a valued ethical principle that all of the health professions honor. It is one of many of the rights that the American Hospital Association’s Patient’s Bill of Rights lists. The rights of psychiatric and substance abuse patients are posted in most treatment settings. If you refuse treatment, you must consider the consequences to you and to your family. Study the risk/benefit ratio carefully before making the decision. Also, be aware that if your behavior or medical condition is life threatening, physicians have an obligation to admit you to the hospital for observation and treatment, especially if the treatment is life saving.

100. Where can I get more information? Many resources are available through organizations, websites, and publications. A partial list is included in the appendix.

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Appendix Organizations http://alcoholism.about.com/ www.nlm.nih.gov/medlineplus/alcoholism.html www.aca-usa.org/ www.alcoholismtreatment.org/ www.naadac.org/ www.medicouncilalcol.demon.co.uk/ www.collegedrinkingprevention.gov/ www.soberrecovery.com/ www.substancereview.com/ www.mentalhealth.com/dis/p20-sb01.html www.ModerateDrinkingPrograms.com www.aarecovery.com/alcoholism.html www.recoverymd.com/ www.drunkdrivingdefense.com/alcoholism.htm www.aa.org/ www.ncemi.org/cgi-ncemi/edecision.pl http://www.whitehousedrugpolicy.gov/ http://www.streetdrugs.org/ http://www.drugsense.org/html/ http://www.alcoholpolicymd.com/alcoholpolicymd/index.htm http://www.mentalhealthchannel.net/alcohol/diagnosis.shtml http://www.alcoholconcern.org.uk http://www.nida.nih.gov/ http://www.codependents.org/

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http://www.projectmainstream.net/ http://historyofalcoholanddrugs.typepad.com/ alcohol_and_drugs_history/ www.asam.org/ http://www.aahistory.com/ http://www.pamf.org/teen/parents/risk/alcohol.html http://www.madd.org/under21/4254 http://parents.berkeley.edu/advice/teens/marijuana.html www.theantidrug.com/

Organizations and Helplines The National Center for Victims of Crime: 1-800-FYI CALL (394-2255) National Domestic Violence Hotline: 1-800-799-7233 or SAFE (1-800-787-3224) National Organization for Victim Assistance: 1-800-TRY NOVA (1-800-879-6682)

Al-Anon, Alateen, and Other Resources Al-Anon P.O. Box 862 Midtown Station New York City, NY 10018 Phone: 1-800-344-2666 Alateen (For teens who are worried about someone else’s drinking) P.O. Box 862 Midtown Station New York City, NY, 10018 Phone: 1-800-344-2666 Alcoholics Anonymous (AA) General Service Office P.O. Box 459 Grand Central Station New York City, NY 10163 Phone: 1-212-870-3400

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Families Anonymous P.O. Box 528 Van Nuys, CA 91408 Phone: 1-800-736-9805 or 1-818-989-7841

Appendix

Hazelden Center for Youth and Families 11505 36th Avenue North Plymouth, MN 55441-2398 Phone: 1-800-257-7800 Narcotics Anonymous (NA) World Service Office P.O. Box 9999 Van Nuys, CA 91409 Phone: 1-818-780-3951 National Council on Alcoholism and Drug Dependence, Inc. 12 West 21st Street, 8th floor New York, NY 10010 Phone: 1-212-206-6770

References Albrecht, A. T., Herrick, C. 100 Questions and Answers About Depression. Sudbury: Jones and Bartlett, 2006. D’Alesandro, D., Huth, L. (April 2002). Kids and Alcohol: Common Question and Quick Answers. Virtual Pediatric Hospital. Retrieved February 20, 2006. Available from: http://www. virtualpediatrichospital.org/patients/cqqa/alcohol.html Hazelden Foundation. Parents Can Help Kids Stay Alcohol-Free: Parents Can Take Advantage of “Teachable Moments.” Retrieved February 20, 2006. Available from: www.hazelden.org/ servlet/hazelden/cms/ptt/hazl_alive_and_free.html Higher Education Center. (n.d.). Eight Points for Parents. Retrieved February 20, 2006. Available from: www.edc.org/hec/parents/8points.html Homeier, B. P. (March 2005). Kids and Alcohol: Kids Health for Parents. Retrieved February 20, 2006. Available from: http://kidshealth.org/parent/emotions/behavior/alcohol.html Homeier, B. P. (May 2005). Talking to Your Child About Drugs. Kids Health for Parents. Retrieved February 20, 2006. Available from: http://kidshealth.org/parent/positive/tlk/talk_about_ drugs.html

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How to Talk to Children About Alcohol and Drugs. (n.d.). Retrieved February 20, 2006. Available from: www.tcda.state.tx.us/ issues/straigttalk/hml Kuhn, C. (2002). A Scientific Approach to Talking With Kids Alcohol. Contact source: [email protected]. Retrieved February 20, 2006. Available from: dukemednews.duke.edu/av/medminute. php?id=5332 Leadership to Keep Children Alcohol Free. (n.d.). Retrieved February 20, 2006. Available from: www.alcoholfreechildren.org/ gs/pubs/html/Prev.htm Palo Alto Medical Foundation. (2004). Teens and Alcohol. Retrieved February 20, 2006. Available from: http://www. pamf.org/teen/parents/risk/alcohol.html Set Rules: How Strict Should Parents and Caregivers Be? Talking to Your Children About the Dangers of Alcohol, Tobacco and Illegal Drugs. (n.d.). Retrieved February 20, 2006. Available from: family.smhsa.gov/set/moreArticles.aspx Stephens, D., Dudley, R. (December 2004/January 2005). “The Drunken Monkey Hypothesis.” Natural History. Talk to Your Kids as Families Watch TV Together. Tips for Parents. (n.d.). Retrieved February 20, 2006. Available from: www. texasdwi.org/kids.html Talking to Your Kids About Alcohol. (n.d.). Retrieved February 20, 2006. Available from: www.adhl.org/clearinghouse Teach Your Children Well. (n.d.). Retrieved February 20, 2006. Available from: http://www.madd.org/under21/4254 What Can Parents Do to Help Their Children Be Drug Free? (February 20, 2006). Retrieved February 20, 2006. Available from: http://www.yic.gv/drugfree/whatparent.html

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GLOSSARY

Glossary Acetylcholine: The first neurotransmitter discovered. It is found in both the peripheral nervous system and the central nervous system. In the peripheral nervous system, it is involved in both muscle contraction as well as that part of the involuntary nervous system involved with “rest and restoration.” In the central nervous system, it is involved with memory function. ACTH: Adrenocorticotropic Hormone. A hormone released by the pituitary gland, which stimulates the adrenal glands to release adrenalin. Adrenalin is a stress response hormone that has a multitude of metabolic effects including alterations in blood pressure, heart rate, and muscle metabolism involved in the “fight or flight” response in the involuntary or autonomic nervous system. It also reverses inflammatory reactions. Agonist: A drug capable of combining with a receptor on a cell and initi-

ating a reaction or activity. The drug may produce the same biological effect as the neurotransmitter itself. Alcohol: an organic chemical that consists of carbon, oxygen, and hydrogen. Alcohol dehydrogenase: An enzyme that is a biological catalyst that accelerates the breakdown of alcohol into aldehyde, responsible for many of the negative effects of alcohol. Alcohol-related neurodevelopmental disorder (ARND): A disorder in the development of the nervous system in a fetus. It is related to the exposure of the fetus to alcohol. Alcohol withdrawal delirium: A syndrome that occurs after the amount of alcohol that is usually consumed has decreased, or upon abstinence, after prolonged and heavy use of alcohol which leads to the following: changes in the individual’s vital

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signs and adverse gastrointestinal and central nervous system symptoms. Aldehyde dehydrogenase: An enzyme that accelerates the breakdown of aldehyde into acetic acid, a nontoxic chemical that is easily eliminated from the body. ALT (Alanine Aminotransferase): See AST. The ratio of AST to ALT (AST:ALT) can sometimes help to determine whether the liver or another organ has been damaged. Both ALT and AST levels are reliable indicators of liver damage. American Board of Psychiatry and Neurology: The governing body that oversees clinical standards for both psychiatrists and neurologists and the various subspecialty fellowships such as child and adolescent psychiatry and addiction psychiatry. American Disabilities Act: Title I of the Americans with Disabilities Act of 1990 took effect July 26, 1992. It prohibits private employers, state and local governments, employment agencies, and labor unions from discriminating against people who have physical or mental disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms, conditions, and privileges of employment. Although alcoholism is included as a disability, the law does not shield employees who drink on the job or employees who cannot perform the job up to the required standards. American Hospital Association: Founded in 1898 to represent and

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serve all types of hospitals, health care networks, and their patients and communities. The American Hospital Association provides education for health care leaders and is a source of information on health care issues and trends. Close to 5,000 hospitals, health care systems, networks, and other providers of care and 37,000 individual health care professionals form the American Hospital Association, which is located in Chicago. American Nurses Association: The American Nurses Association is a professional organization of nurses to advance the profession of nursing. Its mission includes public education, establishing standards for nursing practice and guidelines for ethical health care practices, lobbying state and federal lawmakers to advance the practice of nursing. The American Nurses Association keeps their members informed of current issues regarding health care economics and the general public’s health. American Society of Addiction Medicine (ASAM): Established in 1989 and was the first American medical society to focus on drugs and alcohol. Its mission is to train medical students, faculty, and residents to provide better treatment and rehabilitation and to develop strategies for prevention of alcoholism. The organization has established a uniform credentialing process for psychiatrists and other physicians who demonstrate their expertise by examination

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in substance-use disorders and other behavioral health issues.

Anemia: A deficiency of red blood cells. Antabuse: A drug given to alcoholics that produces nausea, vomiting, dizziness, flushing, and tachycardia (a fast heart rate) if alcohol is consumed, thus it is a deterrent to drinking and acts as a negative reinforcer. Antagonism: The mechanism that causes the blocking of the biological responses at a given receptor site, due to a drug or other chemical. Anterograde amnesia: Loss of memory where new events are unable to be transferred to long-term memory. Amnesia refers generically to memory loss and usually refers to memory loss for previously remembered events. Antibodies: Occur in response to an antigen as larger numbers of proteins that have high molecular weights. Antibodies are a normal immune response to fight infection. Anticonvulsant: A drug that prevents seizures from occurring. Antiemetic: A drug known for its antinausea and antivomiting qualities. Antisocial personality disorder (ASPD): An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the

Glossary

Amygdala: Attached to the tail of the caudate structure of the brain that is considered a part of the limbic system.

culture is pervasive, inflexible, and most often has an onset in late adolescence. It may be preceded by the diagnosis of a childhood conduct disorder. The antisocial person exhibits a disregard for and violates the rights of others, lacks empathy for others, is unremorseful when hurting others, fails to conform to social norms, including participating in criminal and other high risk behaviors, lies or is deceitful, impulsive, and aggressive. The disorder is more prevalent in adolescents whose parents also have the disorder. Aqua vitae: Latin for “the water of life.” AST (Aspartate Aminotransferase): See ALT. A liver enzyme present in liver cells but also in red blood cells, cardiac tissue, and pancreatic tissue. When there is acute liver disease, this enzyme is released into the blood stream leading to its elevation on laboratory testing. AST can help determine the cause of the liver damage. An AST:ALT ratio > 2.0, a value rarely seen in other liver diseases. Atrophy: A decrease in the size of an organ or muscle, or a wasting away of a body part or tissue. Attention deficit hyperactivity disorder (ADHD): A persistent pattern of inattention and/or hyperactivity and impulsivity that is seen more frequently in children with ADHD than in children at comparable developmental levels. Other features associated with ADHD are low frustration

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tolerance, temper outbursts, stubbornness, excessive and frequent insistence on their own requests, labile mood swings, dysphoria, rejection by peers, and poor self-esteem. Academic achievement is often impaired because the children are distractible. Conflicts with authority figures, both parents, and school personnel are common. Many of these children also have oppositional defiant disorders. These children may have been exposed to drugs or alcohol in utero. Many ADHD children exhibited low birth weights as newborns. Some teenagers who have ADHD selfmedicate with drugs or alcohol. Aura: A subjective sensation of voices or colors prior to a seizure. Axon: That part of the neuron or nerve cell that is a long tube conducting signals away from the cell body. Barbiturates: A class of drugs that effect GABA to prevent seizures from occurring. They were used for anxiety disorders until the discovery of benzodiazepines, which were found to be much safer. Beriberi: From Sri Lankan for “I cannot, I cannot.” A condition caused by thiamine deficiency, leading to damage to the central nervous system and causing memory and emotional disturbances (Wernicke’s encephalopathy), weakness and pain in the limbs, and periods of irregular heart beats. Swelling of bodily tissues is common. In advanced cases, the disease may cause heart failure and death.

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Bipolar disorder: A mental illness defined by cyclic episodes of mania or hypomania, classically alternating with episodes of depression; however, the condition can take various forms, such as repeated episodes of mania only or only one episode of mania and repeated episodes of depression or rapid cycling between mania and severe depression. Bupropion: Generic for Wellbutrin, marketed as an antidepressant, and Zyban, marketed as a smoking cessation medication. Campral: A drug used to maintain alcohol abstinence. Its mechanism is not well understood but it is believed to restore the normal balance between neuronal excitement and inhibition. Carbohydrate-deficient transferrin: A protein found in blood involved in transferring iron to cell tissues. It is elevated with heavy alcohol consumption. The performance of carbohydratedeficient transferrin as a screen for alcoholic liver disease has a sensitivity of 80% and a specificity of 92%; however, carbohydrate-deficient transferrin is not routinely tested, is expensive, and is not reimbursed by Medicare. Centers for Disease Control: A federally mandated program that was established in 1973 to monitor the nation’s health. The overarching goal is to protect the health and safety of U.S. citizens. Central pontine myelinolysis: Disintegration of the myelin sheath in the pons that is associated with rapid re-

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tially more toxic to the nervous and cardiac systems.

Cerebellar system: The part of the nervous system that has to do with coordination of muscles and the maintenance of equilibrium.

Co-dependence: A maladaptive coping pattern in family members who are closely related to a substance abuser or experience a prolonged exposure to the behaviors of the alcoholic- or drug-dependent person(s). It may also refer to people who are not associated with an alcoholic family but may come from families that are dysfunctional for whatever reason, including poverty or mental illness.

Cerebral edema: Swelling of the brain because of an abnormal accumulation of fluid. Cirrhosis: A liver disease where there is widespread disruption of normal liver functions. It is a chronic progressive condition that may eventually leads to death. Classical conditioning: A type of learning that results when a conditioned and unconditioned stimulus are paired together, resulting in a similar response to both stimuli. Pavlov, who paired a bell tone with the delivery of food to dogs, developed this learning model. The salivation in response to the food (unconditioned stimulus) became associated with the bell (conditioned stimulus) over time, such that the food was no long needed to cause salivation in the presence of the bell tone. Clotting factors: A group of proteins specifically designed to interact together to cause blood to clot and stop bleeding. Cocaethylene: A chemical produced by the liver when processing cocaine and alcohol (ethanol) simultaneously that has many pharmacological properties similar to cocaine except that it stays in the body longer and is poten-

Glossary

placement of low sodium, most often due to alcoholism.

Cognitive behavior therapy: A therapeutic intervention that reinforces “positive thinking” and extinguishes “negative thinking” (i.e., changing undesirable cognitive functioning). Concordance rates: The rate at which genetically related individuals share with one another a particular trait. For example, identical twins have 100% of their genes in common, whereas fraternal twins have only 50% of their genes in common. Confabulation: Filling in the memory gaps through fabrication (i.e., making up stories to cover the loss of memory). This is opposed to lying, which is deliberate story telling to hide real (remembered) events from someone to achieve some other gain other than merely filling in memory gaps. Congestive heart failure: The heart is unable to maintain adequate circulation of blood to the body’s tissues and is unable to pump out blood via the circulation system.

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Coronary artery disease: The build up of plaque in the coronary arteries constricting blood flow to the heart muscle, leading to chest pain (angina) and the potential for muscle death (myocardial infarction). Cortisol: Also called hydrocortisone. It is derived from cortisone and is also used to treat inflammatory conditions, including arthritis. Cystic fibrosis: An inherited disease found in Caucasians that appears early in childhood. It involves a functional disorder of the endocrine system. Symptoms include faulty digestion because of a lack of pancreatic enzymes, difficulty breathing because of the accumulation of mucus in the lungs, and excessive salt in the sweat. At one time, these children only lived to be 4 or 5 years old. Now they live to be adults. Delirium tremens (DTs): An acute withdrawal syndrome from alcohol that frequently occurs in alcoholics who have a 10-year (or more) history of heavy drinking. Tachycardia, sweating, hypertension, tremors, and delusions characterize it. Vivid hallucinations that are usually visual in nature and wild agitated behavior, however, define it. Dexedrine: A psychostimulant that is prescribed to treat ADHD. Dipsomania: An uncontrollable urge or craving for alcohol. This is an old expression for an alcoholic.

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Disulfiram: Generic name for Antabuse, which is the most widely used medication for alcoholism in this country. It inhibits aldehyde dehydrogenase, thereby preventing the metabolism of alcohol, which leads to a variety of unpleasant side effects if the person takes a drink. These effects include nausea, vomiting, flushing, palpitations, and overactivity of the sympathetic nerves; however, it is only effective if the person is motivated to stop drinking and continues to take the drug as a support for not drinking. Dopamine: One of the brain’s major neurotransmitters, it is responsible for attention, alertness, decision making, reward, pleasure, and mood. Double-blind study: A drug study that consists of an experimental group of patients/volunteers who receive the experimental drug, medical device, or treatment and a control group who receives a placebo or the current and standard drug, medical device, or treatment. Neither the investigator nor the patient/volunteer knows who is getting the experimental drug, treatment, medical device, or placebo. Downregulation: The process by which a cell decreases the number of receptors to a given hormone or neurotransmitter to decrease its sensitivity to this molecule. An increase of receptors is called upregulation. Down’s syndrome: A person with Down’s syndrome is mentally delayed

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Drosophila: A type of fruit fly that is commonly used to test genetic influences to various physical and behavioral traits. Drunken monkey hypothesis: An evolutionary theory as to why having a taste for alcohol may convey some survival advantage by allowing animals to choose fruit that is the ripest. DWI: A legal acronym for driving while intoxicated. Some states use the term to mean driving while impaired. it is also known as driving under the influence or DUI. Some states define DUI as referring to drugs other than alcohol, whereas DWI refers specifically to alcohol and typically involves a moving violation. Other states define DUI as driving under the influence of any substance even when not intoxicated and not having made a moving violation. For example, a minor is caught behind the wheel of a car with alcohol on his breath, but his blood alcohol level is under the legal limit. States define these terms based on issues of burden of proof. For example, some states regard driving while intoxicated as requiring a greater burden of proof on the part of the state than driving under the influence or driving

while impaired. Refer to your own state definitions for further information. Dysphasia: The loss of the ability to use or understand language as a result of an injury to the brain or a disease. Electrochemical: The means by which a nerve conducts signals through the body and axon. This causes a release of chemicals.

Glossary

and has characteristic facial features. The risk factors for having Down’s syndrome include family history of Alzheimer’s disease, a family history of Down’s syndrome, and advanced maternal age at the time of the pregnancy.

Eliciting stimuli: Plural for eliciting stimulus. It is a trigger that elicits an involuntary or automatic response. Traditionally, in Pavlovian conditioning, pairing a bell with the presence of food stimulated the dog to salivate. After repeated pairings, the bell alone would elicit salivation from the dog. The bell became the eliciting stimulus. Such repeated pairings occur frequently in an addict’s pursuit and use of a drug. Therefore, a bar, a friend, even an innocent but frequently used word can act as an eliciting stimulus to prompt intense craving or even feelings of withdrawal. Endogenously: Functional causes occur from internal factors in the mind or the body. An example may be depression if there was no external event that might have precipitated the depression. Endogenous opiates: Opioids that develop or originate within the body. Endorphins: Short for endogenous morphine. See enkephalin or endogenous opiate.

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Enkephalins: Greek for cerebrum. An endogenous opioid made up of amino acids, the building blocks of proteins also known as peptides, which are produced in the brain that have an affinity for opiate receptor sites and act similarly to analgesics and opiates, providing pain relief and a feeling of wellbeing. Enzyme: A biological molecule that catalyzes or accelerates a chemical reaction. Most enzymes are proteins. Epidemiological: The basic science of public health, having to do with epidemiology, which is the study of patterns of disease distribution in time and space that focuses on the health status of population groups or aggregates, rather than on individuals, and involves quantitative analysis of the occurrence of diseases in population groups. Epileptogenic: Causing epileptic attacks or seizures. Epistemological: The study of the nature and grounds of knowledge especially with reference to its limits and validity. Euphoric: A happy and elated mood. Excitotoxicity: The pathological process by which neurons are damaged and killed by the overactivation of receptors for the excitatory neurotransmitter glutamate, such as the NMDA receptor. Excitotoxins, such as NMDA, which bind to these receptors, as well as pathologically high levels of glutamate, can cause excitotoxicity by allowing high levels of calcium ions to enter the cell. These calcium

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ions lead to neuronal cell death also known as apoptosis. Executive functions: Brain functions involving planning and decision making. Such functions require thinking and postponing of more immediate wants or needs thus suppressing impulsive action. Executive functions are located in the frontal lobes of the brain. Extinction: Elimination of a classically conditioned response by the repeated presentation of the conditioned stimulus without the unconditioned stimulus. It is also the elimination of an operantly conditioned response by no longer presenting the reward immediately after the response. Family Medical Leave Act (FMLA): The U.S. Congress passed this act in 1993 with the goal of providing employees with a balanced life between family and work. The law only pertains to companies with 50 or more employees. The employee must have worked with the company for at least 1 year. The law mandates up to 12 weeks of leave for various medical emergencies, such as birth or adoption of a child or the illness of a family member. The old job or an equivalent position must be provided when the person returns to work. Fetal alcohol syndrome disorder (FASD): A disorder that is found in infants whose mothers ingested alcohol during pregnancy, resulting in the infant being mentally retarded along with having other distinguishing features.

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Fluoxetine: The generic name for Prozac, which is an SSRI. It is also effective with obsessive compulsive disorder, posttraumatic stress disorder and other anxiety disorders. GABA: Gamma-amino butyric acid, the brains major inhibitory neurotransmitter. This neurotransmitter dampens all brain activity, essentially calming the brain down at every level. Gabapentin (Neurontin): An anticonvulsant medication that may be used as an adjunct treatment with other drugs for seizures for adults and children over 12 years old. The mechanism of action is unclear. Gene: A specific sequence of nucleotides in the DNA and RNA, which is a unit of inheritance that controls the transmission and expression of specific traits in people and other living organisms. Scientists and clinicians believe that alcohol dependence and abuse is influenced by genetic factors. GGT (Gamma Glutamyl Transpeptidase): A liver enzyme that when elevated is associated with alcoholic liver disease (among other diseases). Glial: Cells that support and nourish the brain’s neurons. Glutamate: The brain’s major excitatory neurotransmitter. This neuro-

transmitter activates all brain activity, essentially stimulating the brain and “lifting” it up at every level. Gray matter: The part of the brain that contains the nerve cell bodies, including the cell nucleus and its metabolic machinery, as opposed to the axons, which are essentially the “transmission wires” of the nerve cell. The cerebral cortex contains the gray matter.

Glossary

Flumazenil (Romazicon): A benzodiazepine antagonist that is used to reverse the sedative effects of benzodiazepines in the management of an overdose.

Growth hormone: Secreted by the pituitary gland and regulates growth. Half-life: The time it takes for half of the blood concentration of a medication to be eliminated from the body. The half-life determines the time to achieve equilibrium of a drug in the blood and determines the frequency of dosing to maintain that equilibrium. Hallucinogen: A classification of drugs that produces hallucinations, euphoria, an altered body image, distorted or sharpened visual and auditory perceptions, confusion, loss of motor coordination, and impaired judgment and memory. Health Insurance Portability and Accountability Act (HIPAA): The American Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. Congress in 1996 and was put into effect on April 14, 2003. Hematocrit: Measures of the proportion of blood volume that is occupied by red blood cells—a measure of the amount of blood one has. When this is low, one is known to have anemia.

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Hepatitis: A liver disease due to a viral infection. Drug users are at high risk for developing infectious diseases, such as hepatitis, because drug users share injection equipment with other users, are immunosuppressed, and have poor hygiene. There are several types of hepatitis viruses: A is usually transmitted by fecal-oral contact; B is often acquired through sexual contact, frequently among drug users; C is transmitted among drug users by injection; and D also is spread by drug users and their sexual contacts. Hypertension: High blood pressure, which can appear without an apparent cause. Hypertension can damage other organs in the body and is frequently the cause of strokes. Hypocalcemia: Low blood calcium. Hypokalemia: Low blood potassium. Hypomagnesemia: Low blood magnesium. Hyponatremia: Low blood sodium. Hypophosphatemia: phosphorous.

Low

blood

ICD (International Classification of Diseases): This is the World Health Organization’s manual for classifying all diseases, including mental illness and substance abuse. It is very similar to DSM. Immunosuppression: Involves an act that reduces the activation or effectiveness of the immune system. A person who is immunosuppressed is said to be

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immunocompromised—more susceptible to infections and cancer. Intensive outpatient treatment program (IOP): A program usually run by inpatient personnel, as part of the discharge plan for continuing followup treatment for their inpatients, upon discharge. It may be at a hospital or in a community setting. It frequently includes any of the common treatment modalities, including cognitive behavioral therapy, motivational enhancement therapy, and the 12-step AA program. The interventions are usually group rather than individually oriented. Intermittent reinforcement: The reinforcement of a behavior (the reward) that occurs some of the time as opposed to continuous reinforcement that occurs every time after the behavior occurs. The behavior tends to reoccur when followed by a positive reinforcer (e.g., a good grade for a written paper) or by eliminating the negative reinforcer (e.g., a spanking). Kindling: An effect on the brain whereby repeated electrical or chemical stimulation of the brain eventually induces seizures. This may explain why cocaine and alcohol previously did not lead to seizures but after repeated use now do. Kudzu (Pueraria lobata): A plant used in alternative medicine to reduce alcohol cravings. Lamotrigine: Generic name for Lamictal, an anticonvulsant also approved for the treatment of bipolar

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tion is not exclusive to alcoholics of Italian origin.

Learning theories: Theories that have to do with the acquisition of knowledge and skills and modifying behavior to learn new behaviors through behavior modification interventions (positive and negative reinforcement, extinction) and cognitive behavior interventions.

Mean corpuscular volume: A measure of the size of the red blood cells. When this number is high and the hematocrit is low, this is known a macrocytic anemia.

Leukopenia: A condition in which the number of leukocytes (white blood cells) circulating in the blood stream is low, commonly due to a decrease in the production of new cells in conjunction with various infectious diseases, drug reactions, other chemical reactions, or radiation therapy. Macrocytic: From “macro” for large and “cytic” for cell. Primarily in reference to large red blood cells from thiamine deficiency (pernicious anemia) that is common in chronic alcoholics whose nutrition is poor. Malabsorption: Faulty absorption of nutrients from the alimentary canal. Marchiafava-Bignami Syndrome: Named after the two Italian pathologists who first discovered the condition. A syndrome first identified in alcoholics of Italian origin who died after suffering from seizures resulting in a coma. Autopsy results demonstrated degeneration of the area of the brain known as the corpus callosum, the major pathway connecting the left and right hemispheres of the brain. It now appears that this very rare condi-

Mellanby effect: Impairment from alcohol is greater at a given blood alcohol level when the amount of alcohol in the blood is increasing as opposed to decreasing. This also explains the differences in feeling “hung over” as opposed to “buzzed” at the same alcohol level depending on a falling or rising level. This is why taking “the hair-of-the-dog” or another drink “cures” a hangover.

Glossary

depression, particularly with respect to relapse prevention.

Mendelian: The central tenets of genetics developed by Gregor Mendel. They relate to the transmission of hereditary characteristics from parent organisms to their children; they underlie much of genetics. Metaphysical: Relating to a reality not investigated by the natural sciences or perceptible to the normal senses. Metronidazole: Generic name for Flagyl, an antibiotic medication that rarely can have an Antabuse-like effect for patients taking it and drinking alcohol. Microcephaly: An abnormally small head with associated mental retardation. Microvascular: The part of the circulatory system made up of minute vessels or capillaries measuring less than 0.3 millimeters in diameter.

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Mitigate: To soften or become less harsh. Modeling: Learning through pervasive imitation. One person tries to be like another person, who is a role model, who is admired. The second person identifies with the role model in order to imitate what they observed the role model doing. Modeling is a strategy used to form new behaviors, learn new skills, or enhance existing skills. The theory of modeling was also named by Bandura as “Social Learning Theory.” Moderation Management (MM): Founded in 1993 as an alternative alcoholic treatment program to the traditional AA 12-step program. MM requires each person to plan to limit their drinking rather than requiring complete abstinence. MM includes nine steps, which does include abstinence for the first 30 days. There must be the desire to moderate one’s drinking behavior and to accept responsibility for one’s own behavior. Attendance at MM meetings is also required. Its goal is prevention and its hopes to support persons at the onset of the disease of alcoholism. Monoamine oxidase inhibitors: An antidepressant that is not used as frequently as other antidepressants, namely because of the side effects, which include anticholinergic effects, such as a dry mouth. Additional side effects are adverse reactions, including a hypertensive (high blood pressure) crisis when eating certain foods,

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such as aged cheeses, casseroles made with cheese, pizza, dry sausage, pepperoni, and alcoholic beverages (especially beer, including nonalcoholic beer and wine, especially red wine). Patients must adhere to low tyramine diets, which are sometimes difficult to follow. This diet should be adhered to even after the drug has been stopped for a period of 2 weeks. Mothers Against Drunk Driving (MADD): An advocacy group of women who have lost someone, usually a child, because of a drunk driver. The purpose of the group is to educate the public about the dangers of alcohol and driving while under the influence of an intoxicating substance and to lobby legislators at the federal, state, and local levels to pass laws that will get intoxicated drivers off the road. Motivational enhancement therapy: Cognitive interventions are used to enhance the substance abuser’s desire to stop using. The therapy integrates a combination of humanistic treatment and enhanced cognitive– behavioral strategies. Motivational enhancement therapy was designed for the specific purpose of treating the substance abuser, particularly the opiate addict who uses euphoric enhancing drugs. The focus is on the negative implications of substance abuse, for each individual, encouraging the client to articulate his or her own need for change. It has been used with alcoholics but less effectively. Often, motivational enhancement therapy has been combined

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Motivational interviewing: A brief treatment approach designed to produce rapid internally motivated change in addictive behavior and other problem behaviors. The core principles are (1) to express empathy, (2) develop discrepancy, (3) avoid augmentation, (4) roll with resistance, and (5) support self-efficacy. Motivational interviewing assumes that ambivalence and fluctuating motivation occur during substance abuse recovery. Motivational enhancement therapy and motivational interviewing are based on similar assumptions, especially the belief that change will not occur unless the individual is motivated to change. Motor cortex: An area on the outer part of the brain that is responsible for voluntary motor control. Muscular dystrophy: A group of heritable diseases characterized by the progressive wasting of muscles. Myopathy: A disorder of the muscle tissue, typically causing wasting and weakness. Naloxone: Generic for Narcan. It is an opioid antagonist and competes with opioids at the opiate receptor sites. It is used as an antidote when

there is respiratory depression induced by opiate intoxication. Naltrexone: Generic for ReVia. It is an opioid antagonist that competes with narcotics at opiate receptor sites, blocking the opioid analgesics. It is used primarily to treat various addictions.

Glossary

with biological interventions such a methadone. The underlying message is that drug misuse is a choice and it is the individual’s choice to change his or her own behavior. It is an individually-oriented program conducted by a skilled therapist rather than a group program. Consequently, it is expensive.

Narcan: See Naloxone. Narcotic analgesic: An opioid used to control pain. National Organization of Fetal Alcohol Syndrome: An organization to educate young women about the dangers of drinking while pregnant, hopefully to prevent the incidence and prevalence of fetal alcohol syndrome. Neurochemical: A broader name for neurotransmitter. Any chemical that has effects on nerve cells. Neuron: A nerve cell made up of a cell body with extensions called dendrites and the axon. Neuroprotective: A protection of the nervous system against toxic substances. Neurotoxic: Toxic or lethal to the nerve and/or nervous tissue. Neurotransmitters: Chemicals released by nerves that communicate with other nerves causing electrochemical changes in those nerves to continue to propagate a signal. NMDA (N-methyl-D-aspartic acid): An amino acid derivative acting as a specific agonist at the NMDA receptor and therefore mimics the action of glutamate at that receptor. In contrast

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to glutamate, NMDA binds to and opens the above receptor only, but not other glutamate receptors. Nonsteroidal anti-inflammatory drugs (NSAIDs): An extremely diverse group of anti-inflammatory and analgesic drugs that inhibit the enzyme cyclooxygenase and reduce the synthesis of prostaglandins. Aspirin and ibuprofen are examples. Norepinephrine: A neurotransmitter in the brain as well as a stress hormone released by the adrenal glands, also known as noradrenaline or adrenaline. As a stress hormone, this compound affects the “fight or flight response,” activating that part of the involuntary nervous system known as the sympathetic nervous system to increase heart rate, release energy from fat, and increase muscle readiness. As a neurotransmitter, it increases alertness and helps in elevating mood, but it can also increase anxiety and cause tremors. Off-label: Prescribing of a medication for indications other than those indicated by the Food and Drug Administration. Ondansetron: Generic name for Zofran, an antiemetic drug that acts on specific serotonin receptors. Open-label: A term used to describe the type of study where both the researcher and the volunteer/subjects know the drug or treatment that the subjects are receiving. An open-label study is the opposite of the doubleblind study. In the double-blind study,

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neither the researcher nor the participant know whether the subject is receiving the experimental drug, device or treatment, or a placebo. Operant conditioning: A type of learning that is concerned with the relationship between voluntary behavior and the environment. If behavior is followed by a reward, it will reoccur. It was developed by B. F. Skinner. Opiate: A type of opioid. An opioid is any agent that binds to opioid receptors. Found principally in the central nervous system and gastrointestinal tract. There are four broad classes of opioids: endogenous opioid peptides, produced in the body; opium alkaloids, such as morphine (the prototypical opioid) and codeine; semisynthetic opioids such as heroin and oxycodone; and fully synthetic opioids such as pethidine and methadone that have structures unrelated to the opium alkaloids. Although the term “opiate” is often used as a synonym for opioid, it is more properly limited to the natural opium alkaloids and the semisynthetics derived from them. Opioids/ Opiates have addictive qualities. Parathyroid hormone: A hormone produced by the parathyroid gland that is next to the thyroid. This hormone regulates calcium and phosphorus. Partial agonist: A chemical (e.g., drug) that can both block and stimulate a receptor depending on the relative amount of neurotransmitter present in the synaptic cleft. If the amount of neurotransmitter is great, the chem-

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ical acts as an antagonist; if the amount of neurotransmitter is low, the chemical acts as an agonist.

Peripheral neuropathy: Peripheral refers to the nerves outside of the central nervous system. Neuropathy is the degeneration of the nervous system. Peripheral neuropathy is the degeneration of the peripheral nerves. Phenobarbital: A barbiturate currently used as an anticonvulsant. Phenylketonuria: An inherited metabolic disease that causes mental retardation because of the inability to oxidize the metabolic product of phenylalanine. Physician’s Desk Reference: A compendium of all of the drugs available to legal prescribers (MDs, DOs, and NPs) in the United States and Canada, along with guidelines about their actions, how each drug is generally used, the drug interactions, side effects, and contraindications. Placebo: A drug, medical device, or treatment that looks similar to the

Platelets: Also known as thrombocytes. A type of blood cell involved in the cellular mechanisms of the formation of blood clots. Low levels or dysfunction predisposes for bleeding, whereas high levels, although usually asymptomatic, may increase the risk of the development of a thrombus or clot.

Glossary

Partial hospital program (PHP): A program usually run as part of the discharge plan for their inpatients. Patients attend 2 to 3 days per week. Partial hospital programs for alcoholics frequently include AA meetings and are based on the 12 steps of AA. The interventions are focused on group work rather than individual psychotherapy. It provides an opportunity to monitor the patient’s progress and serves as a therapeutic bridge between the hospital and the community.

experimental drug, medical device, or treatment, but it is in fact an inactive drug, liquid, device, or treatment and will not affect the volunteer’s health or illness.

Posttraumatic Stress Disorder (PTSD): A mental/emotional disorder that is characterized by persistent distressing symptoms lasting longer than 1 month after exposure to an extremely traumatic event. Potable: Drinkable. Potentiates: To make more active or effective, to augment, and to make more potent. Prolactin: A hormone found in the anterior lobe of the pituitary that induces and maintains lactation during the postpartum period in a female. Prophylaxis: Preventing the occurrence of something. Proximate cause: In evolutionary theory, the initial cause that changes the behavior of a biological system. Pulling one’s hand from a fire is caused by a reflex arc in the nervous system and would be an example of a proximate cause. Prozac: See fluoxetine.

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Pseudobulbar: A condition that simulates paralysis of certain cranial nerves caused by lesions in the medulla oblongata, a part of the brain. Pseudobulbar palsy: Condition caused by damage to the cranial nerve pathways that can lead to unprovoked outbursts of laughing or crying along with other neurological deficits. Psychosis: A state in which an individual experiences hallucinations, delusions, and disorganized thoughts, speech, and/or behaviors. An inability to distinguish reality from fantasy. Psychosocial theory: A theoretic viewpoint that developed in the early 1900s that the cause of mental illness pertains to environmental circumstances that impact on one’s psychological well-being. Mental disorders result from environmental and social factors, including social and environmental deprivation. Psychostimulant: “Psycho” pertains to the brain and its cognitive functions. It is an agent or drug that increases the functional activity or efficiency of an organ. A psychostimulant enhances the functional capacity and efficiency of the brain and its cognitive functions temporarily during a brief span of time. Psychotropic: A drug that has an effect on the psychic functions of the brain, behavior, or experience. Rapid eye movement (REM): Rapid eye movements that occur during a stage of sleep that appears on EEG as if the subject is awake. During this

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time the subject is actively dreaming. Also known as dream sleep. Receptors: Specific areas of protein on a neuron that are configured to respond only to specific neurotransmitters. Receptors act like locks, which can only be opened by specific keys that are the neurotransmitters. Reinforcers: The stimuli that are coupled with a behavior in operant conditioning so that the reward is either applied or removed to elicit the desired response. Reliability: The ability to reproduce the same outcomes upon repeated testing. Reuptake: The process by which neurotransmitters return to the presynaptic cells after being released into the synaptic cleft and attaching receptors on the postsynaptic cells. Reverse agonism: A chemical (drug) that has reverse activity on the receptor rather than just merely blocking the receptor. ReVia: Trade name for naltrexone. A medication used for narcotic and alcohol addictions thought to control craving. It is an antagonist and blocks the effects of opioids. Ritalin: The trade name for methylphenidate. It is used to treat ADHD. Selective serotonin reuptake inhibitors (SSRI): A class of antidepressant/antianxiety medications that works by blocking the serotonin transporter, thereby increasing the amount of serotonin in the synaptic

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Self-medication: Taking medications that are not prescribed by a physician or nurse practitioner, including alcohol or other drugs, to cope with emotional distress (e.g., drinking alcohol or smoking marijuana to calm down when one is feeling anxious). Sensitivity: Probability of a positive test among patients with a particular disease. The more sensitive the test the better it is at detecting the presence of disease. Sensory cortex: An area on the outer part of the brain that is responsible for organizing sensory input into a coherent perception at the level of consciousness. Serotonin: One of the brains major neurotransmitters. It is responsible for “vegetative functions,” that is sleep, appetite, sex drive (libido), anxiety, and mood. Sleep architecture: A predictable pattern during a night’s sleep that includes the timing, amount, and distribution of rapid eye movement (REM) sleep and non REM. REM and NREM occur approximately in 90 to 110 minute cycles over the course of an 8-hour period during a person’s night sleep. There are four stages in sleep architecture. Slow-wave sleep: A state of deep sleep that occurs regularly during a normal period of sleep with intervening peri-

ods of rapid eye movement (REM) sleep. At this stage, there is a low rate of autonomic physiological activity. Specificity: Probability of a negative test among patients without disease. A very specific test rules out disease. Status epilepticus: A state in a person whereby seizures occur in rapid succession without recovery of consciousness.

Glossary

cleft. These medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).

St. John’s Wort (Hypericum perforatum): A plant used in alternative medicine as an alternative to antidepressant medications. Synaptic cleft: The gap between nerves where neurotransmitters are released that allow nerves to communicate with one another. Teratogen: An agent, such as a virus, drugs or alcohol, or radiation, that causes malformations in a fetus or embryo. Tetrahydrocannabinol: The psychoactive ingredient to marijuana that gives it its hallucinogenic and appetite effects. It is also pharmaceutically synthesized and released under the trade name Marinol and is prescribed as an appetite stimulant for cancer and AIDS patients. Tetrahydroisoquinolone (THIQ): A chemical compound that can be formed by combining acetaldehyde (the toxic breakdown product of alcohol) and dopamine (the neurotransmitter). It is thought to be specific for alcoholics and has opioid-like activities causing euphoria, thereby explaining their increased propensity

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toward addiction when compared to the normal population. Therapeutic communities: The environment on an inpatient unit that is developed to be a healthy milieu for staff and patients and that facilitates the development and implementation of treatment. A therapeutic community is described as a group of patients and professionals that adhere to cultural norms for behavior, value the individual, and provide activities for patients to teach them skills for healthy interpersonal relationships, as well as activities for daily living. Thiamine: Vitamin B1. It plays an important role in converting carbohydrates and fat into energy. Deficiency can lead to conditions known as Beriberi and Wernicke/ Korsakoff’s syndrome. Thrombi: Plural for thrombus or blood clot. If the clot detaches and moves, it is known as an embolus. Thrombocytopenia: The presence of relatively few platelets in blood. Topamax: The trade name for topiramate. An anticonvulsant. Topiramate: Off label, it may be used as an adjunctive mood stabilizer, especially in bipolar disorders. Trade name: The name given to drugs by the company that has the patent rights to the drug, either through purchasing the patent rights from another company, or having discovered or designed them. The trade name is the company name.

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Transporter: Also known as a transport pump. Transporters are made up of proteins that act as “vacuum cleaners,” taking up leftover neurotransmitters from the synaptic cleft and transporting them back into the nerve cell that originally released them. Transport pump: See transporter. Ultimate cause: In evolutionary theory, the ultimate cause for why a particular behavior evolves to serve an evolutionary purpose that has survival value. A reflex arc is a more efficient system for conferring survival value than having the signal go to the level of consciousness before one pulls one’s hand out of the fire would, as with the ultimate cause. Ultimate causes are often theoretical in nature because they are difficult to prove. Upregulation: The process by which a cell increases the number of receptors to a given hormone or neurotransmitter to improve its sensitivity to this molecule. A decrease of receptors is called downregulation. Valerian (Valeriana officinalis): An alternative medicine that is used in place of sedative drugs. Validity: The accuracy of the outcome of a test or instrument (i.e., the extent to which a test or instrument measures what it intends to measure). Valproic acid: An anticonvulsant medication that acts on GABA and is FDA approved for use in bipolar disorder (manic depression) and seizure disorders.

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White matter: Tracts in the brain that consist of sheaths (called myelin) covering long nerve fibers. Zofran: Trade name for ondansetron. It is an antiemetic that prevents nausea and vomiting by blocking serotonin peripherally, centrally, and in the small intestine.

Glossary

Vascular dementia: A cognitive disease with mental and emotional impairments, plus neurological signs and symptoms. The disease is the result of multiple vascular lesions. Vascular dementia may be seen with or without delirium, delusions, and depression and may be with or without behavioral disturbances. As in most dementias, there is memory loss and other cognitive impairments. Vertigo: Dizziness, as in the room is spinning around. This is a brain effect as opposed to lightheadedness or feeling faint, which is often also described as dizziness but is due to low blood pressure. Vivitrol: An injectable, long acting form of naltrexone.

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta): These are all sleep-enhancing or sleep-inducing medications that are not benzodiazepines but do act on one of the GABA receptors in a manner similar to benzodiazepines. Zyban: See bupropion.

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Index

Index A AA. See Alcoholics Anonymous (AA) Abilify, 144 Abstinence Acamprosate and, 127 alcohol-related dementia and, 165 defined, 113 internal struggles and, 20–21 as key to treatment, 24 loss stage, 86 Abuse, of alcohol, 47–48, 64. See also Alcoholism Acamprosate, 126–128, 128t Acamprosate calcium, 115 Acetaminophen, 181–182 Acetylcholine, 15 Addiction, 43–46, 207t addictive behaviors, 21 addictive qualities of alcohol, 26–30 defined, 20–22 as family illness, 246 genetic predisposition to, 213 historical forces, 213–214 learning theory, 27 pattern of use associated with specific environments, 29–30 social factors for, 213 Addiction counselors, 94–95 Addiction treatment specialization, 94 Adolescents. See also Children; Teenagers alcohol treatment for, 115–116 communication with, 199–200 Adoption studies, 68–70 Adult Children of Alcoholics Organization (ACoA), 244 Advil, 182 African Americans, alcoholism risk and, 72, 75 Aggression, 81–82

Aging brain atrophy and, 164 effect of alcohol in, 223–225 factors associated with drinking, 225 physiological changes, 224t suicidal tendencies and, 225 Agonism, 121 Agonist, 122 Al-Anon, 244, 258 Alaskans, 76 Alateen, 244, 258 Alcohol addictive nature of, 26–30 defined, 2 discovery of, 4–6 evolution of human use of, 6–9 health benefits of, 7–8 religious/spiritual associations, 9 safe level of consumption of, 84–85, 84t Alcohol abuse, 47–48, 64. See also Alcoholism Alcohol amnestic disorder, 164 Alcohol dehydrogenase, 7, 59 Alcohol dependency, 43–46 Alcoholic cirrhosis, 177–178 Alcoholic families, 247–251 adopted roles to cope within, 250 adult children of alcoholics, 249 characteristics of, 247–248 young children of alcoholics, 248–249 Alcoholic(s). See also Alcoholism determining if individual/self fits criteria of, 48–50 family members who refuse to get help, 244–247 offspring of, 68 and problem drinkers compared, 232 type I vs. type II, 58–59

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100 QUESTIONS & ANSWERS ABOUT ALCOHOLISM Alcoholics Anonymous (AA), 98–101, 258 dry drunk concept, 85–87 and rehabilitation compared, 104–105 sponsors, 99 12-step approach, 99, 100t 12 traditions, 101t Alcoholism alternative treatments/herbal remedies, 152–154 biological effects of, 59–62 cause of, 37–40 costs of, 65 debate over nature of, 34–37 defined as a disease, 22–26 link to mood disorders, 173–174 medications, 117–119 phases of (Jellinek), 58 prevalence of, 64–65 quantitative vs. qualitative differences, 48–49 risk of inheriting, 65–70 screening tools, 51–58 violence and, 80–82 voluntary and involuntary aspects of, 30–34 Alcohol-related dementia, 163–166 Alcohol-related neurodevelopmental disorder (ARND), 191 Alcohol-related psychosis, 172 Alcohol withdrawal delirium, 136 Aldehyde dehydrogenase, 7, 119 ALT (alanine aminotransferase), 61 Altered states, of consciousness, 8–9 Alternative treatments, 152–154, 210 Alzheimer’s disease, 165 Ambien, 151 American Board of Psychiatry and Neurology, 94 American Disabilities Act, 238–239 American Hospital Association, 235 American Hospital Association Patient’s Bill of Rights lists, 256 American Medical Association, 229 American Nurses Association Credentialing Center, 97 impaired health professional program, 229 American Society of Addiction Medicine (ASAM), 20, 43, 101–104 Patient Placement Criteria, 101–102 specialty certification, 94

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use of Dilantin in alcohol withdrawal, 169–170 Amsterdam, 203 Amygdala, 70 Analgesic properties, of alcohol, 8 Anemia, 61, 62, 153 Anglo-Americans, 81 Anhedonia, 133 Antabuse, 115, 119–120, 120t Antagonism, 122 Anterograde amnesia, 164 Antibodies, 154–155 Anticonvulsant medications, 14, 45, 140, 169–170 off-label use, for anxiety, 145 Antidepressant medications, 16, 45–46, 175 Antiemetic, 16, 17 Antihypertensive medications, 45 Antisocial personality disorder (ASPD), 80–81 Anxiety alternatives to benzodiazepines, 144–145 benzodiazepines and, 143–144 disorders, 114 following detox, 141 medications, 146–147t posttraumatic stress and, 221 Aqua vitae, 8 Aripiprazole, 144, 147t ASAM. See American Society of Addiction Medicine (ASAM) Asian Americans, alcoholism risk and, 72, 77 Asian societies, 81 AST (aspartate aminotransferase), 60–61 Ativan, 138, 139–140 Atrophy, of brain, 164–165 Attention deficit hyperactivity disorder (ADHD), 114–115, 191 Atypical antipsychotics, 144 AUDIT (Alcohol Use Disorders Identification Test and shorter versions of), 51–53, 56 Auditory hallucinations, 171–172 Aura, 169 Axon, 11f

B Barbiturates, 14 Beer, 4–5

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C CAGE screening tool, 53, 56 Calcium, 62 Campral, 115, 126–128 Cancer/cancer treatment, 16, 78 Capacity determination, 254 Carbamazepine, 140, 145, 147t Carbohydrate-deficient transferrin, 61 Carcinogen exposure, 78 Cardiovascular disease, 78 Cardiovascular system, 159–160 Catholicism, alcohol use and, 75

Caucasians, 72 Celebrities, 28–29 Centers for Disease Control, FASD criteria, 192, 193t Central pontine myelinolysis, 163, 166 Cerebellar system, 166 Cerebral edema, 163 Chief enabler, 241 Children abuse of, 80, 252–252 abuse of alcohol/drugs by, 82–83, 192–196 age 5-7, 198 age 8-12, 198–199 age 13-17, 199–200 alcohol discussions with, 194–201 of alcoholics, 65–70 binge drinking/drug use, 203 birth defects/fetal alcohol syndrome and, 189–192 cultural differences in alcohol consumption, 201–202 giving alcohol to minors, 202 impact of alcoholism on, 247–251 marijuana use by, 205 preschoolers, 197–198 rationales for noncompliance, 210 traveling to country where drinking is permitted, 203–204 Chinese traditional medicine, 153 Chlordiazepoxide, 138, 142 Cholesterol, 183 Christian temperance movements, 98 Chronic insomnia, 150 Chronic phase, 58 Cirrhosis, 79, 177–178 CIWA-A, 137, 138t Classical conditioning, 27, 32 Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A), 137 Clinical trials, 134–135, 155 Clotting factors, of liver, 61 Cocaethylene, 186 Cocaine, 75, 76, 82, 186 Co-dependency, 241–244 characteristics, 242 children of alcoholics, 247 treatment for, 243 Co-Dependents Anonymous (CoDA), 244 Cognitive behavior therapy, 109 Cognitive deformities, 188 Communication, 195

Index

Behavior modification, medication and, 117–118, 119–120 Benadryl, 150 Benzodiazepines, 139–141, 142–144, 168, 169, 222 Berkeley Parents Network, 206 Beta-blockers, 140 Betaendorphin, 17 Bible, 74–75, 75 Big Book, 99, 232 Binge drinking, 79–80, 176, 203 Biological effects, of alcoholism, 59–62 Biopsychosocial model, 38–39 Bipolar disorder, 118, 134–135, 145, 172, 174–175, 191 Bipolar II disorder, 175 Birth defects, 188, 190–192 Black Death, 5 Blackout, 163 Blacks, alcoholism risk and, 75–77 Blood alcohol levels, 18, 234 Blood pressure, 183 Brain, 9–13, 10f effect of alcohol on, 13–19 gray and white matter, 10 injury, 79 limbic areas involved with mood/reward, 17f neurons, 10 neurons and neurotransmitters, 11–13, 11f studies, 70 Breast cancer, 79 “Brewers droop,” 183 Britain, 65 Brühl-Cramer, 34–35 Bupropion, 27 B vitamins, 61, 153, 164

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100 QUESTIONS & ANSWERS ABOUT ALCOHOLISM Co-morbid substance abuse, 87 Concordance rates, 68 Confabulation, 164 Confidentiality, 235–237 Controlled drinking therapy, 112–114 Coronary calcification, 79 Costs, of alcoholism, 65 Couples therapy, 222 Court-ordered treatment, 255–256 Crisis plan, 90 Cross-tolerance, 184 Crucial phase, 58 Cubans, in South Florida, 76 Cultural differences, in alcohol consumption, 201–202 Cystic fibrosis, 66

D Delirium, 171–172 Delirium Tremens (DTs), 34, 136, 167–169 Dementia, alcoholism-related, 153, 163–166 Demographics, of alcohol use, 64 Depakote, 145 Dependence, on alcohol, 43–46, 64–65 Dependence syndrome, 43–44 Depression, 87–89, 191 in alcoholics, 173 following detox, 141–142 posttraumatic stress and, 221 sobriety and, 110 Desyrel, 151 Detoxification, 102, 136–137, 252 alcohol withdrawal syndrome, 137–139, 138t anxiety/insomnia/depression and, 141–149 benzodiazepines, 139–141 levels of care, 103 Dexedrine, 115 Diagnosis, 42–62 clinician requirements for, 94–98 DSM-IV, 42–43 dual diagnosis, and treatment, 110–111 of mood disorders, 173–174 Diagnostic and Statistical Manual of Mental Disorders, 42–43 alcohol abuse criteria, 47 alcohol dependence criteria, 44 Diazepam, 142 Diet, 78 Dilantin, 141, 169–170

284

Diphenhydramine, 147t, 150 Dipsomania, 34–35 Disabled employees, 238 Discontinuation syndromes, 145–149 medication-specific, 148 withdrawal, 145, 148 Discrimination, based on medical information, 239 Disease alcoholism seen as, 22–26 germ theory of, 24 related to alcohol abuse, 78–80 Distilled spirits, 2, 5 Disulfiram, 115, 119–120, 120t Domestic violence, 251 Dopamine, 13, 14, 17–18, 19t, 26–27, 89 Dose titration, 83 Double-blind, placebo-controlled studies, 134 Downregulation, 168 Down’s syndrome, 66 Doxepine, 146t, 151 Drosophila, 7 Drug, alcohol viewed as, 2–4 Drug-induced hepatotoxicity, 180 Drug research and development, 131–132 Drunken monkey hypothesis, 6–7, 26 Dry drunk concept, 85–87 DSM-IV, 42–43, 44 DUI (driving under the influence), 219, 233–234 DWI (driving while intoxicated), 50 Dysfunctional families, 249 Dysphasia, 166

E Electrochemical, defined, 11, 12 Electrolyte deficiencies, 169 Eliciting stimuli, 32, 34 Emergency conservatorship, 255 Emergency room visits, alcohol-related, 64 Emotion, extremes of, and relapse, 90 Employee assistance programs, 229 Employment compromised job performance, 239–241 medical disclosure, 237–239 Enabler role, 250 Endocrine system, 162 Endogenously available neurotransmitter, 122 Endogenous opiates, 13, 14 Endorphins, 17, 18

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F Faith-based programs, 99, 107–108 Families Anonymous, 259 Family Medical Leave Act (FMLA), 239–241 Federal Drug Administration (FDA), 118, 131–132 Federal law, against DUI, 234 Female-male alcohol response compared, 218–219 Fetal alcohol syndrome disorder (FASD), 188–192 Five-shot screening tool, 53–55, 54t, 56 Flumazenil, 134 Fluoxetine, 16, 18, 129, 146t Folate, 61, 141 Foreign countries, lenient drinking/drug laws, 203–204 France, 65 Fruit, alcohol content of, 7

G GABA (gamma-aminobutyric acid), 13, 127, 142, 168 Gabapentin, 15, 134, 145, 147t, 151 Gabatril, 145 Gamma-aminobutyric acid. See GABA (gamma-aminobutyric acid) Gastrointestinal system, 159 Gateway drug concept, 82–83, 208t Gender differences, in alcohol response, 218–219 Genes, 65–66

Gene Theory, 66 Genetic tendency, for alcoholism, 65–70 Genetic variation, in taste for alcohol, 7–8 Genitourinary system, 162 Geodon, 144 Germ theory, 5–6, 24 GGT (gamma-glutamyl transpeptidase), 60 Glial cells, 165 Glutamate, 13, 14–15, 168 Glutamate receptor blocker, 126–127 Grief and loss stages, 86 Group treatment, 111–112 Growth retardation, 193t

Index

Enkephalins, 16–17, 18 Environmental exposure, to carcinogens, 78 Environmental factors, in alcoholism, 66–67 Enzymes, 7–8 Epidemiological studies, 80 Epileptogenic, 170 Epistemological, 9 Esophageal cancer, 79 Eszopiclone, 151 Euphoric aspects, of alcohol, 8 Euphoric feelings, 90 Europe, children’s alcohol consumption in, 202 Excitotoxicity, 15 Executive functions, 81 Experimentation with drugs/alcohol, 212–214 Extinction, 28

H Haldol, 141, 175 Half-life, 139 Hallucinations, 171–172 Hallucinogens, 15, 211 Haloperidol, 141 Hazelden Center for Youth and Families, 259 Health benefits, 7–8, 83–84 Health care providers, substance abuse by, 228 Health Insurance Portability and Accountability Act (HIPAA), 236–237 Heart attack risk, 165 Heart defects, 188 Helplines, 258 Hematocrit, 61 Hematologic system, 61, 160–161 Hemorrhagic stroke, 79 Hepatitis, 60, 177 medications to avoid, 180–182 types of, 178 Herbal remedies, 152–154 Heroin, 89 Hero role, 25 HIPAA, 236–237 Hispanics, alcoholism risk and, 72, 76 Homicide, 79, 80, 81 Hypericum perforatum, 154

I ICD (International Classification of Diseases), 44 “I” messages, 245 Immune system, 160–161 Immuno-suppression, 61, 62 Impaired professionals, 228–230 Inderal, 140

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100 QUESTIONS & ANSWERS ABOUT ALCOHOLISM Individual treatment, 111–112 Information, 256–260 helplines, 258 organizations, 257 support groups, 258–259 Informed consent, 237, 253–254 Inhalant use, 76 Inheritance, 65–70 environmental factors, 66–67 Gene Theory, 66 nature vs. nurture, 67–68 twin and adoption studies, 68–70 Inpatient program, 102, 108–109 Inquiry into the Effects of Ardent Spirits on the Human Mind and Body, An (Rush), 35 Insomnia chronic, 150 following abstinence, 149–152 medications, 146–147t sleep architecture, 149–50 treatment, 150–152 Institutional review boards, 135 Insulin sensitivity, 162–163 Insurance plans, 106 Intensive outpatient treatment, 102, 104 Intermittent reinforcement, 28 Interventions, 116–117, 246 Intoxication, at cellular level, 13 Involuntary deliberation, 30–34 Irritability, 86–87 Islam, use of alcohol in, 74 Italians, and Marchiafava-Bignami Syndrome, 166 Italy, 65

J Jaundice, 177 Jellinek, E.M., 35, 58 Judaism, use of alcohol in, 74

K Key parties, 214–216 Kindling, 172 Koran, 74 Korean-Americans, 77 Korsakoff’s dementia, 164 Kubler-Ross, Elizabeth, 85, 86 Kudzu, 153–154

286

L Lamictal, 145 Lamotrigine, 14, 15, 145, 147t Learning theory, 27–29 Libido, 182–183 Librium, 138, 139–140, 142 Lifestyle issues, 37–38, 78 Lippich, Franz, 35 Lithium, 175 Liver alcohol effect on, 60–61 cancer, 79 disease, 153 transplant, 178–180 Lorazepam, 138, 146t Lost Child role, 250 Low birthweight, 188 Lunesta, 151 Lung cancer, 38–39 Lyrica, 145

M Macrocytic, 61 Magnesium, 62 Malabsorption, intestinal, 164 Manic depression, 172, 174–175 Mantle, Mickey, 178 Marchiafava-Bignami Syndrome, 166 Marijuana, 13, 82, 205–209 and alcohol issues compared, 207–208 effects of, 205–206, 209 rationales for, 210 Mascot role, 250 MAST (Michigan Alcohol Screening Test), 55 Mead, 4–5 Mean corpuscular volume, 61, 62 Medical consequences, of alcoholism, 158–163 Medically managed intensive inpatient treatment, 103 Medical records, access to, 237 Medicare, 237 Medications, for alcoholism, 117–155 Antabuse (disulfiram), 119–120 benzodiazepines, 143–144 Campral (acamprosate), 126–128, 128t detoxification meds, 137–141 drug research/development, 131–132 off-label treatment, 128, 131–134 ondansetron, 129–130 Prozac (fluoxetine), 129

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N Naloxone, 122 Naltrexone, 115, 122–126, 123t Narcan, 122 Narcotic analgesics, 16, 18 Narcotics Anonymous (NA), 259 National Council on Alcoholism and Drug Dependence, Inc., 259 National Institute on Alcohol Abuse and Alcoholism, 47 National Nurses Society on Addictions, 229 National Organization of Fetal Alcohol Syndrome, 191 Native Americans, alcoholism risk and, 72, 76–77 Natural recovery, 65 “Natural” substances, 210–211 Nature vs. nurture, 67–68 Neurochemical effects, 83. See also Dementia, alcoholism-related Neurodevelopmental disorders, 193 Neurological efffects, of alcoholism, 166–167 Neurontin, 15, 134, 145, 151 Neuroprotective effect, 127 Neurotoxic effects, 164 Nicotine, 184–186 NMDA, 15 NMDA glutamate system, 19t Non-steroidal anti-inflammatory drugs (NSAIDs), 182 Norepinephrine, 15 NSAIDs, 182 Nurse practitioners, 96–97 Nurses, substance abuse impairment and, 228–230

Index

ReVia (naltrexone), 121–125 Topamax (topiramate), 129, 130 Vivitrol (naltrexone), 125–126 Zofran (ondansetron), 129 Medications, vs. drugs, 2–3 Medication-specific discontinuation syndromes, 148 Mediterranean societies, 81 Melatonin, 152, 154 Mellanby effect, 18–19, 20 Mendel, Gregor, 66 Mendelian (Gene) Theory, 66 Mendelian patterns of inheritance, 66 Mental disorder(s), 42–43. See also Mental illness Mental Health Bill of Rights, 236 Mental health specialists, 94 Mental illness dual treatment of, with alcoholism, 110–111 stigma, 227 Metabolism, 162 Metaphysical, 9 Metronidazole, 120 Mexican Americans, 76 Microcephaly, 190 Microvascular changes, 165 Middle Ages, 5 Military service, and PTSD, 220–223 Milk thistle extract, 153 Mind altering, 3 Mirtazepine, 146t, 151 Modeling, 28–29 Moderate Drinking, 232 Moderate drinking therapy, 112–114 Moderation Management (MM), 232–233 Monamine oxidase, 132 Mood disorders, 87–88, 172–174 Mood swings, 174–177 Morbidity and mortality, 78–80 Mothers Against Drunk Driving (MADD), 233–234 Motivational enhancement therapy, 109 Motivational interviewing, 113 Motor cortex, 10, 11 Motor vehicle accidents, 18, 20, 81, 202 Motrin, 182 Mouth cancer, 79 Multivitamins, 141 Muscular Dystrophy, 66 Musculoskeletal system, 161–162 Muslims, alcohol use and, 74

O Off-label treatment, 128, 131–134 Olanzapine, 144, 146t Ondansetron, 16, 17, 129–130 One-stepper. See Dry drunk concept Open-label studies, 134 Operant conditioning, 28, 32 Opiate antagonist, 122 Opiate receptors, 89 Opiates, 13, 16–17, 18, 45, 121, 211 Opioid peptide system, 19t Organizations, 257 Oropharyngeal cancer, 79 Outpatient treatment, 102

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P Pain medications, prescribed, 16, 45 Pancreatic disease, 153 Parental guidelines, for alcohol discussions, 194–195 Partial agonist, 122 Partial hospital programs (PHPs), 105–107 Pathogenic phase, 58 Patient’s Bill of Rights, 256 Patriot Act, 236 Pavlov, 27 PAWS (post acute withdrawal syndrome), 141 Per capita alcohol consumption, 64 Peripheral neuropathy, 167, 184 Personality disorder, 175 Personality types, and alcoholic tendencies, 39 “Pharmakos,” 4 Phenobarbital, 14 Phenylketonuria, 66 Phenytoin, 141 Phosphate, 62 Physical assault, 183 Physical deformities, 188 Physicians, drug/alcohol abuse by, 228 Physician’s Desk Reference, 132 Placater, 250 Platelets, 62 Polygenic diseases, 67 Post Acute Withdrawal Syndrome (PAWS), 141 Posttraumatic Stress Disorder (PTSD), 39, 114, 220–223 symptoms, 220–221 treatment of, 222 Potassium, 62 Potentiate, 15, 16 Pregabalin, 145, 147t Pregnancy, 188–189 Premature birth, 188 Prepathogenic period, 58 Preschoolers, alcohol discussions with, 197–198 President’s Commission on Mental Health, 235 Prevalence, of alcohol use/alcoholism, 64–65 Prison population cocaine and, 75 violent offenders, 81 Privacy, rights to, 235–237

288

Problem drinkers, and alcoholics compared, 232 Prodromal phase, 58 Prohibition, 35 Prometa treatment protocol, 134–135 Propanolol, 140 Prophylaxis, 170 Proteins, 65 Protestantism, alcohol use and, 75 Proximate cause, 26 Prozac, 129 Pseudobulbar palsy, 166 Psychiatric clinical nurse specialists, 96 Psychiatric disorders, 42–43 Psychiatrists, 97–98 Psychological dependence, 58 Psychologists, 94, 96 Psychosis, 172 Psychosocial theory, 27 Psychostimulant medications, 115 Psychotherapy, 142 Psychotropic effects, of alcohol, 8–9 Psychotropic substances, 3–4 PTSD. See Posttraumatic Stress Disorder Public Law 99-319, 235 Pueraria lobata, 153 Puerto Ricans, 76

Q Quetiapine, 144, 146t, 151

R Ramelteon, 146t, 152 Rapid eye movement (REM) sleep, 149 Rebound, 148 Receptors, 11, 12 Recovery abstinance required for liver transplant, 179 detox and rehab settings/levels of services, 102–103 dry drunk concept, 85–87 family commitment to, 246 impaired professionals and, 230 support and persistence, 88–89 12 steps, 86, 99, 100t Recurrence, 148 Rehabilitation, 102 Reinforcers, 20 Relapse, 90–91, 112–113 Remeron, 151

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S St. John’s Wort, 154 Scandinavians, 81 Scapegoat role, 250 Schizophrenia, 72, 145, 174–175 Screening tools, 51–58 AUDIT, 51–53, 56 CAGE, 53, 56 difficulty in incorporating, 55 Five-shot screening tool, 53–55, 54t, 56 influence on patient behavior, 57–56 MAST, 55 sensitivity and specificity of, 51 validity and reliability of, 51 Seizures, withdrawal, 169–170 Selective serotonin reuptake inhibitors (SSRI), 16, 17, 144 Self-medication, 173–174 posttraumatic stress and, 221 teenagers and, 212 Sensory cortex, 10, 11 Seroquel, 144, 151

Serotonin, 13, 14, 15–16, 19t Sexual assault, 80, 81, 82, 183 Sexual problems, 182–184 Shakespeare, 36 Shame, 227 Sinequan, 151 Sleep architecture, 149–150 Slow-wave sleep, 149 Smoking, 38, 78, 82–83, 85, 184–186 Sobriety. See Recovery Social factors, for addiction, 213 Social support networks, 99 Social workers, 94, 95 Sociopathy, 58, 80 Sonata, 151 Sponsors, 99 Spousal abuse, 252–252 SSRIs. See Selective serotonin reuptake inhibitors Status epilepticus, 169 Steroids, 45 Stigma, 24–25, 227 Stress hormones, 19t Stroke risk, 165 Suicide, 79, 81, 225 Support groups, 244, 252, 258–259 Synaptic cleft, 11, 12, 13f

Index

Research Council on Problems of Alcohol, 35 Residential program, 102 Respiratory system, 158–159 Reuptake, 12, 13 Reverse agonism, 121–122 ReVia, 115, 121–125 Reward, immediacy of, 30 Risk, alcoholism and aging, 73–74 genetic variations in ADH2, 72–73 inheritance of alcoholic tendencies, 65–70 knowledge of, 71 lifestyle choices and, 37–38 males vs. females, 73 modifiable, 72 for other addictions when addicted to alcohol, 89–90 poverty/lack of education, 72 race, 72–73, 73t, 75–77 religious and cultural differences, 74–75 Risperdal, 144 Risperidone, 144, 146t Ritalin, 115 Role models, 28–29, 99, 195 Romazicon, 134 Rozerem, 152 Rural areas, alcohol/drug use and, 226–228 Rush, Benjamin, 35

T Tea drinking, 8 Teenagers, 199–200. See also Adolescents; Children; Underage drinking alcohol use by, 207t drinking seen as “rite of passage,” 215 key parties and, 214–216 marijuana use by, 206 peer pressure and, 213 rationales for noncompliance, 210 rebellion and, 212 substance abuse in rural areas, 226 Tegretol, 140, 145 Teratogen, 190 Tertiary syphilis, 24 Testosterone, 183 Tetrahydrocannabinol, 213 Tetrahydroisoquinolone (THIQ), 89 Therapeutic communities, 108 Therapeutic privilege, 254 Therapy, individual and family, 246. See also Recovery; Treatment Thiamine, 61, 141, 153, 164 Thrombi, 165

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100 QUESTIONS & ANSWERS ABOUT ALCOHOLISM Thrombocytopenia, 61–62 Tiagabine, 145, 147t Tobacco, 78, 82–83, 85, 184–186 Tolerance syndrome, 44–45, 184 Topamax, 129 Topiramate, 129, 130 Trade name, 129 Traffic fatalities, alcohol-related, 64 Transporter/transport pump, 12 Trauma, alcohol-related, 55–56 Traumatic brain injury, 166 Trazadone, 146t, 151 Treatment of adolescents, 114–116 alternative/herbal remedies, 152–154 benzodiazepines and, 143–144 clinician requirements for, 94–98 court-ordered, 255–256 detoxification, 102–103, 136–137 of DTs, 168 for dual diagnosis, 110–111 elements necessary to refuse, 254–256 faith-based programs, 107–108 individual vs. group, 111–112 interventions, 116–117 life-threatening conditions, 255–256 medications, 117–119 moderate drinking programs, 112–114 Moderation Management, 232–233 partial hospital programs, 105–107 post-detox, 142–143 Prometa treatment protocol, 134–135 rehabilitation, 104–105 rights to refuse, 252–254 success of types of options, 109–110 thiamine, 164 of withdrawal symptoms, 169–170 Triggers, 90 Trotter, Thomas, 34 12-step approach, 99, 244 12 traditions, 101t Twin studies, 68–70 Tylenol, 181–182 Type I/Type II alcoholics compared, 58–59

teen survey, 216 Upregulation, 15, 168

U

Zaleplon, 151 Ziprasidone, 144, 147t Zofran, 129 Zolpidem, 146t, 151 Zyban, 27, 186 Zyprexa, 144

Ultimate cause, 26 Underage drinking Harris Interactive Survey of Parents, 216 key parties, 214–216 planning a non-alcohol party, 217–218

290

V Vaccines, 154–155 Valerian, 154 Valeriana officinalis, 154 Valium, 142 Valliant, George, 72, 113 Valproate, 147t Valproic acid, 14, 15, 145 Vascular dementia, 165–166 Vertigo, 18 Veterans Administration (VA), 222–223 Vietnamese-Americans, 77 Violence, 80–82, 208t, 252 patient a danger to self/others, 255 Viral hepatitis, 178 Visual hallucinations, 171–172 Vitamin deficiencies, 61, 141, 153, 164 Vivitrol, 125–126 Voluntary deliberation, 30–34

W Water, potable, 8 Wellbutrin, 186 Wernicke’s encephalopathy, 164 WHO, 35, 43, 65 Wine, 5 Withdrawal seizures, 136, 169–170 Withdrawal syndrome, 44–45, 117 Women with alcoholic/abuse spouses, 251–252 vs. male response to alcohol, 218–219 World Health Organization (WHO), 35

Z