Alcohol Abuse

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Treatment

Intoxication
In general, intoxication does not require treatment. After alcohol enters the body, the liver detoxifies the blood, the body excretes the alcohol, and the person sobers up.

In rare instances, excessive alcohol consumption can cause potentially fatal complications that require emergency medical treatment. Alcohol poisoning, or acute intoxication, can cause liver and/or respiratory failure, which may result in heart failure. For example, in drinking rituals or contests, participants (usually young males) consume large amounts of alcohol as fast as they can. The blood alcohol level rises so high and so quickly that the liver cannot metabolize the alcohol. The person may become comatose, may suffer cardiac and respiratory failure, and can die. In such cases, emergency medical support can be life saving.

Withdrawal
Mild withdrawal symptoms do not require treatment. More serious symptoms may require medical attention. Admission to a detoxification unit or a hospital can be lifesaving in cases of severe symptoms.

Physicians first assess the severity of symptoms, the existence of any coexisting medical or psychiatric conditions, and the risk for complications. A questionnaire, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar), is often used in assessing the potential for withdrawal symptoms and their intensity. A high score indicates a high risk of severe symptoms and these patients are typically treated on an inpatient basis, often with benzodiapines. A lower score indicates moderate symptoms, which require observation but no medication.

Treatment involves detoxification, hydration, and replenishing vitamins to prevent complications such as hallucination, convulsions, and delirium tremens (DTs). Without intervention, DTs have a 5% mortality rate.

Detoxification
Detoxification is a process in which the alcoholic becomes alcohol free. Detoxification must take place before treatment of dependence begins. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) questionnaire is often used to evaluate the potential for withdrawal symptoms and their intensity. Patients with a high score (i.e., at high risk for severe symptoms) are typically treated with medication in a controlled environment. A lower score indicates that treatment may require observation but no medication.

Severe symptoms usually occur in those with chronic alcoholism and a history of withdrawal symptoms. Cross-tolerant medications—drugs with effects similar to those of alcohol—may be given to control tremor, racing heart, and high blood pressure, and reduce the chance of seizure. Patients who take these medications, such as benzodiapines, must be closely monitored because they carry the risk for dependence. The physician gives a dosage sufficient to reduce symptoms, gradually tapers, and then discontinues the medication. Some patients need an antipsychotic to treat hallucinations.

Dependence
The severity of dependence, availability of facilities, insurance coverage, and other considerations factor into a patient's choice of treatment program. Inpatient and outpatient facilities have similar success rates, although outpatient facilities are sometimes the only option. Some facilities provide both detoxification and long-term treatment. Treatment modalities include education, behavioral approaches, and pharmacotherapy.

Inpatient
Inpatient treatment is provided in a residential program or a hospital. Patients admit themselves for treatment, which usually lasts a month. Alcohol education and different types of therapy, including group, individual, and sometimes family or couples therapy, are provided. Inpatient treatment is recommended for alcoholics who lack healthy social networks, have failed outpatient programs, or who suffer from serious medical or psychological conditions. These facilities administer medication when needed.

Outpatient
Outpatient treatment programs provide alcohol education and counseling (group and individual) several times a week. Alcoholics who have strong social networks and have no other psychiatric or medical conditions are good candidates for outpatient treatment. In addition, some find outpatient programs helpful after inpatient treatment. Patients must attend sessions regularly and abstain from alcohol and other substances. There are a variety of outpatient programs, ranging from community programs that provide only alcohol education to all-day programs in hospitals.

Intensive outpatient day programs in hospitals are becoming a common treatment option. Although they vary, most programs offer 8-hour treatment sessions during the week for adults who need a treatment plan that occurs frequently. Group therapy is the primary modality, with emphasis on preventing relapse, managing stress, and communicating with family.

Behavioral Therapy
In cognitive behavioral therapy (CBT), the patient and therapist work in one-on-one sessions to identify factors that cause relapse, called cues. The therapist provides strategies for defusing high-risk situations. The patient practices the techniques with the therapist, and when confronted by the cue outside the therapy setting, is better able to cope with the situation without drinking. Motivational enhancement therapy (MET) is a nonconfrontational therapy that focuses on motivating the patient to modify behavior. Therapists provide structured, positive feedback that enhances the patient's desire to change.

Alcoholics Anonymous
Alcoholics Anonymous (AA) is a self-help organization founded by alcoholics. Anyone is welcome to attend meetings. Members facilitate group meetings, which take place on a regular basis. Some AA chapters offer meetings 7 days a week. The framework of AA is a spiritual-based, 12-step program through which attendees admit their dependence on alcohol and seek to modify their behavior. Attendance is voluntary. AA uses a buddy system and group intervention to help members when they are tempted to relapse or when they do relapse. Alateen provides support for adolescents affected by alcoholism in the family, and Alanon helps adults affected by someone else's alcohol addiction.

Alcoholics Anonymous and other 12-step programs are considered interactional group therapy. Because of AA's commitment to anonymity and deliberate lack of professional guidance, research has been difficult to conduct. However, it is generally known as having helped more alcoholics than any other organization, and a recent study by the National Institute on Alcohol Abuse reports only slight differences in the effectiveness of cognitive behavioral therapy, motivational enhancement therapy, and AA.

Pharmacotherapy
A physician must prescribe and monitor treatment with medication. Pharmacotherapy alone has not been shown to be effective but can be beneficial when used as a part of a treatment plan. Two kinds of medication are used to treat alcohol dependence: aversive and anticraving.

• Disulfiram (Antabuse®), an aversive medication, has been used to treat alcohol dependence since the 1940s. This drug creates a chemical reaction with alcohol, and if the patient drinks within a 2-week period, he or she experiences vomiting, flushing, and increased blood pressure and heart rate. Disulfiram causes sensitivity to other forms of alcohol, such as aftershave and cooking wine, and mild reactions may occur. The drug has not been shown to increase the rate of abstinence, but it has reduced the number of days patients drink.

• Naltrexone (Revia®), an anticraving medication, has been shown to reduce the effects of alcohol and to reduce the amount of alcohol consumed when used with behavioral therapies. Short-term studies report that naltrexone cut the occurrence of relapse in half. Another anticraving medication, acamprosate (Campral®), also has shown promise.

Medication can also be used to treat co-occurring conditions such as depression, social phobia, or panic disorder.

Prognosis

Abstinence is necessary for successful treatment. Alcoholics cannot resume social drinking without risking a return to dependence. Many feel they are the exception to the rule; however, for every 10 people who say they will stop drinking, only 4 do. Motivation and intervention by family or friends can help the alcoholic achieve abstinence.

Recovery from alcohol dependence is possible. DSM-IV reports one study in which 65% of patients who abused or were dependent on alcohol abstained for at least a year following treatment. Another study showed 40% to 60% of alcoholics abstaining for longer than 1 year.

Over 700,000 people per day receive treatment for alcohol dependence. Approximately 20% of people with alcohol dependence achieve long-term sobriety without treatment.

Alcohol Abuse, Treatment, Prognosis reprinted with permission from mentalhealthchannel.net
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