Cadabam's Blog

By Biju George

Psychiatric Nurse

“I will not take or knowingly administer any harmful drug.”

Nightingale Pledge

People with addiction seek the help of medical professionals in time of crisis. Does this mean that no medical professionals need help? The answer is they too sometimes need help. Both doctors and nurses are susceptible to drug addiction and they may even be more vulnerable than the general population. Surveys say that 15 % of medical professionals will abuse drug or alcohol some time in their career.

The research says that 8 to 15 % of the medical professionals are physically dependent to some addictive drugs. The risk is high in anaesthetic department and the emergency department as they have easy access to medicines. However, general physicians or paediatricians too can get addicted to various substances.

Why is there an increasing risk of drug abuse in medical professionals?

• Medical professionals seem to be particularly susceptible to prescription drug abuse. This is likely because they have access to prescription products that the general population does not. The nurses usually steal prescription pads and forge their own prescriptions.
• Medical professionals have the knowledge of drug and its effect and may feel as if they are not going to be addicted as they fully understand the effects if the medicine.
• The medical students may be curious about the medicines and its effect and it may lead to addiction.
• They have practice and knowledge about injections and it will help them self-administer the injections/ injectables.
• Doctors and nurses often get more seriously ill than their patients because they take higher quality drug than other people. For example, some pain killer drugs such as fentanyl are more potent than morphine and heroin.
• For medical professionals it is easier to hide the signs and symptoms of the substance abused for longer time.
• Professionals within this community frequently work in the higher pressured environment for longer hours with little or no support.
• While more studies on this subject are being conducted, it could be said that just the constant presence of the substance near the person could easily drive them to try it.

Types of Drug Abuse in Medical Professionals:

-The addiction in medical professionals varies from common painkillers to anaesthetic medicines. Some of them are as follows:

• Depressants:

1. Barbiturates (Amytal, Neurbutal, phenobarbitone, etc.)
2. Benzodiazepines (Lorazepam, Librium, Diazepam)
3. Flunitrazepam

• Dissociative anaesthetics:

1. Ketamine
2. Propofol

• Opioids and Morphine derivatives:

Codeine, Fentanyl, morphine, opium, other opioid pain relievers like oxycodone, meperidine, hydro morphine.

• Stimulants :

*    Amphetimine, cocaine, methamphetamine, methylphenidate

*    Anabolic Steroid: Anadrol, oxandrin

*    Antihistamines – CPM

*    Antitassive or cough syrups

Signs and symptoms of drug abuse in health professionals:

It seems to be very difficult to identify the signs and symptoms of drug abuse in medical professionals because they have knowledge about the medicines and its side effects, and it helps them to hide the signs and symptoms for longer time. But the common signs and symptoms include:

• Reclusive behaviour: Long periods spent in self imposed isolation
• Long unexplained absence
• Lying and stealing, especially money and medicines
• Involvement in the wrong side of law
• Deteriorating relationship with family and friends
• Obvious intoxication, deliriousness, incoherence or unconsciousness
• Erratic mood disturbances
• Decreased performance at work
• Pricking marks in body

Drug Addiction as a occupational Hazard:

In medical profession drug addiction is considered as occupational hazard, since there is a high risk to get addicted to the drugs in their career. So the hospital authority and occupational health team should take all precaution to avoid drug abuse.

How to prevent drug addiction in medical professionals:

The hospital authorities should take care to avoid or to prevent the addiction in the medical staffs. The precautions include

1. The addictive medicines should require greater storage security and should have proper stock counting.
2. Some hospitals have measures in place to catch drug abuse among staff including urine drug tests and strict monitoring of controlled substance being taken out of stock.
3. Education and training include addiction awareness and stress reduction practices helpful in controlling drug abuse.

May all our medical professionals be free from drug abuse, so that they can serve the society in a better ways.

By Jinna Bordoloi, Rehabilitation Counsellor

An addiction is defined as a persistent, chronic intense focus on a single behaviour pattern that feels or is out of control. Almost everyone has some kind of addiction-if not to drugs or alcohol then to gambling, cigarettes, risky behaviour, exercise, television, computer games, internet, adult videos, work, shopping and so on. The symptoms of addiction to drugs or any other activities are:

• Persistent and frequent thinking about the activity throughout the day.
• Significant interference with enjoying other important aspects of life.
• Inability to control, cut back or stop the behaviour even after becoming aware of the debilitating effects.
• Restlessness or irritability when attempts are made to cut back the behaviour.
• Feelings of anxiety or agitation if behaviours is stopped for a period of time.
• Use of the addiction to escape and to avoid other responsibilities.
• Engaging in high risk behaviour that jeopardizes emotional or physical safety.
• Intense mood swings associated with the activity ranging from euphoria to shame, guilt or depression.

Among the various addiction alcohol or drug abuse are the most challenging. Drug can be any substance ingested into the body that produces an altered state of consciousness or change in body chemistry. Once the need of drug has been established in order to maintain effective functioning, addiction and physiological dependence prevail. The most widely used drugs are those that happen to be legal – coffee, cigarettes, chocolates and cola beverages. All contain sufficient quantities of amphetamine to create full fledge addictions.

Drug Use:

Occasional Use                            Habit Formation

◄────|──────────|──────────|──────────|─────►

Psychological                                          Physiological

Dependency                                             Addiction

There are many negative physical effects that results from the drug abuse. Disturbances of sleep are common results of introducing artificial stimulants or depressants into the blood stream. Through neglect, disinterest and distraction, the diet of a drug abuser often suffers. Many drugs tend to stifle the appetite or lead the user toward malnourishment. Some problems are the result of the ways in which the drugs are introduced into the body. For example, nasal damage results from repeated snorting of cocaine, lung damage has been reported in marijuana smoker and skin disorder occur in those who inject heroin, variety of musculoskeletal, respiratory gastrointestinal and central nervous system disorders are possible. In addiction almost every system of the body is affected, example nerves are destroyed, neurotransmitters are side-tracked, genetic material is altered etc.

Death is placed on the top of the list of the effects. Death due to drug overdoses, suicide in altered state of consciousness, death during the convulsions while withdrawing from barbiturates are very common.

Preventions programmes for addiction can be classified into two types. The primary prevention programmes are designed for adolescents with little or no experience with substances. Secondary prevention targets the beginner and tertiary programme work with the experienced, highly abuser or dependent abuser. The alcoholics anonymous/ narcotics anonymous (AA/NA) model, motivational intervening, relapse prevention and pharmacotherapy is widely used for addiction process.

The form of addiction has been increasing with time. Internet surfing became as havoc for the rising generation. Internet addicts may spend forty to eighty hours a week on the net, and abuse in various forms. For example, online game addiction, compulsive internet shopping, seeking, pursuing and possibly masturbating to online pornographic imagery etc.

Many a treatment protocol has been invented by various psychologists to prevent the user to become an abuser.

Job P. J.

De-addiction Counselor

Alcoholism is a family disease which affects not only the alcoholic but also each and every member in the family who stays with him. It affects the children with the same intensity with which it affects the spouse, infact even more.

One in four children in our country is exposed to alcoholism and drug addiction in the family. This means that in your house, your neighbourhood or among your children’s friends one in four might be hiding their embarrassment, confusion, hurt or shame about what’s going on at home.

When does a child lose his childhood? When he lives with an alcoholic parent; to others he looks like any other child, dresses like any other child and walk about like any other child. Until they get close enough to notice that edge of sadness in his eyes, or the worried look on his brow.

He behaves like a child but he is not really enjoying, he just carries on. He does not have the same spontaneity that other kids have; but nobody really notice it. Even if they do they probably do not understand it.

The fact remains that he never feels like a child. He has never known what a child feels like. Any normal child is an innocent, beautiful, delicate being bubbling with energy, offering and receiving love easily, playful, doing work for approval or for reward, but always doing as little as necessary. The most important fact is that he is always carefree.

In contrast, the child of an alcoholic is not a carefree little one. He is often a withdrawn child who never gives trouble to anybody. He hides himself in a corner. Though he does not really want to be hiding, he always instantly hides in a shell, hoping to be noticed sometimes by the others. But he is powerless to do anything about it.

Children in family with alcoholism syndrome are generally ignored because all the attention is directed either towards the alcoholic parent or towards his alcoholism. The self-centered, uncooperative, destructive behaviour of the alcoholic gains all the attention that the child longed for. At the same time the child learns not to rock the bout, not to develop any desires or needs, not to make demands.

Children of alcoholic as a group, have a higher incidence of emotional problem like anxiety, stress and depression. They also have lots of school problem such as difficulty in concentration and conduct problems. They experience all sort of adjustment problems.

Children of alcoholics shows an increased predisposition of alcohol or other drugs when they enter adulthood.

Children who live with alcoholism or drug addiction need models of what a happy home looks and feels like; so that they will have something to look forward to. They need to spent time not worrying about their parents and what might be going on their houses that is going to hurt blow up or disintegrate. They need to be around peaceful rhythms and routines.

KARTHICK CHANDRAMOHAN

Psychiatric Counselor – Cadabams’ Psycho-Social Rehabilitation Centre

Bangalore

CONSUMPTION OF TOBACCO

In India, Tobacco Consumption is most popular form of both smoke and smokeless. Global cigarette consumption has been rising steadily since James Bonsack invented the first cigarette-rolling machine in 1881. By the 1960s, the incontrovertible health consequences of smoking had become apparent. The total number of smokers is increasing mainly due to expansion of the world’s population. Unless smoking prevalence rates decline dramatically, the absolute number of smokers will continue to increase (WHO).

In Tobacco Consumption, the male percentage is 20 – 29.9%, according to the estimate of WHO in the year of 2008 & according to Global Adult Tobacco Survey (GATS) 2009 – 2010, the male percentage of tobacco consumption is 47.9%. The Female Percentage in tobacco consumption is below 20% according to the estimate of WHO in the year of 2008 & according to Global Adult Tobacco Survey (GATS) 2009 – 2010, the female percentage of tobacco consumption is 20.3% (WHO, 2008; GATS 2009 -2010).

Tobacco Consumption harms nearly every organ of the human body. The tobacco consumption may give rise to adverse health effects such as cancer, respiratory diseases, cardiovascular diseases, reproductive diseases & other diseases.

In India, everyday 2500 people per day were dying due to tobacco consumption & every year 9 lakh people were dying due to Tobacco Consumption. A man who consumes tobacco may increase their risks of dying from bronchitis by nearly 10 times, from emphysema by nearly 10 times and from lung cancer by more than 22 times.

A woman who consumes tobacco may increase the risk of dying to heart disease and lung cancer by nearly 12 times. The people who are consuming more number of tobacco in any form is to be taken seriously and immediately tobacco cessation programme is to be evaluated on them through various assessments.

Since the consumption of tobacco is increasing day-by-day, this study aims to bring awareness about harmful effects of tobacco consumption & suggests suitable measures to prevent people from consuming tobacco and to promote tobacco cessation counseling.

India is second among top 20 countries with highest male smoking populations. In India, 229, 392, 725 male smokers are using all tobacco products according to Global Tobacco Survey of 2008 estimate. India is third among top 20 countries with female smoking populations according to Global Tobacco Survey of 2008. In India, 11, 908, 517 female smokers are using all tobacco products.

STUFFS OF TOBACCO

Cigarettes contain 4,000 chemicals which causes various sorts of diseases. The some of the important chemicals are:

Carbon Monoxide       -           Poisonous Gas                                                             Ammonia                    -            Used in fertilizers                                                                    Formaldehyde             -           Poison used to preserve dead animals                         Nicotine                      -           Addictive Drug                                                                       Cyanide                       -           Poisonous Gas                                                             Tar                               -           Used to make roads                                                                Arsenic                        -           Poison used to kill weeds & insects                           Phenol                         -           Toilet Cleaner

HEALTH RISKS OF TOBACCO

Compared with non-smokers, smoking is estimated to increase the risk of

• Coronary heart disease by 2 to 4 times
• Stroke by 2 to 4 times
• Men developing lung cancer by 23 times
• Women developing lung cancer by 13 times
• Dying from chronic obstructive lung diseases (such as chronic bronchitis and emphysema) by 12 to 13 times.

Smoking causes the following cancers:

• Acute myeloid leukemia
• Cancer of the esophagus
• Kidney cancer
• Cancer of the larynx (voice box)
• Lung cancer
• Cancer of the oral cavity (mouth)
• Cancer of the pharynx (throat)
• Stomach cancer

Smoking is associated with the following adverse health effects:

• Infertility
• Preterm delivery
• Stillbirth
• Low birth weight
• Sudden infant death syndrome (SIDS).

TOBACCO CESSATION PROGRAMME

Tobacco Cessation is an effort to quit tobacco use at an individual level that may or may not be supported by external help i.e., family, community or health professionals. It can be described as an act, requiring good deal of will power to overcome immediate discomforts that accompany the withdrawal of Nicotine.

Tobacco cessation (colloquially quitting) is the process of discontinuing the practice of inhaling a smoked substance. Tobacco cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop using due to the development of strong physical addictions or psychological dependencies resulting from their habitual use. This study focuses mainly on cessation of Tobacco smoking. However, the methods described may apply to cessation of smoking other substances.

A person with Tobacco addiction along with some manifest diseases such as cancer, cardio vascular disorder, peripheral vascular diseases, diabetes, mellitus, lung disease, psychiatric conditions etc.

The available treatment formats are:

1. Self-help Treatment: Self-help strategies may include written materials, audio or videotape, computer programs and telephone hotlines. Materials can be tailored to particular populations such as different ages or ethnic groups, or to individual smoker characteristics.

1. Nicotine Replacement Therapy: Nicotine replacement therapy (NRT) is available in gum, transdermal patches, intranasal spray, inhaler devices and sublingual tablet. The total duration of treatment was examined and the use of patches beyond eight weeks was no more effective than stopping treatment at eight weeks. Gum was found to be least effective in the hospital setting. The results for patches were more consistent between settings suggesting that patches may be more suitable in the hospital setting.

1. Other Medications: A range of anxiolytic and anti-depressant medications has been tested for effectiveness in smoking cessation. Of these, only bupropion was found to be effective when compared with placebo or NRT.

It is believed that very few smokers can successfully quit the habit in their very first attempt. Many studies indicated that many smokers find it difficult to quit, even after they get afflicted with tobacco related diseases. A serious commitment and resolve is required to arrest nicotine dependency. For that Tobacco Cessation Counseling is needed.

The stages of Tobacco Cessation Counseling are:

• Pre-Contemplation Stage: The person has never thought of quitting or has never listened attentively to smoking/chewing tobacco and health information.
• Contemplation Stage: The person is thinking about stopping and it thinking about harmful effects of continued tobacco use as well as thinking about the ways to stop.
• Preparation Stage: The person has already worked out ways to stop tobacco use.
• Action Stage: The person is no longer using tobacco & has managed without any form of tobacco for up to 6 months.
• Maintenance Stage: The person not only has stopped using tobacco for over 6 months but had made changes towards long-term abstinence. This is called maintenance. The person returns to a regular tobacco use after a period of abstinence. Once relapsed, the person may go to any of the previous 4 stages. This process is called relapse.

The Intervention techniques used in this Tobacco Cessation Counseling are:

1. Behavioral Counseling
2. Ventilation
3. Psychological Support
4. Motivation

CONCLUSION

This Study reviews the current status of tobacco related problems and suggests that Tobacco Cessation Programme as an effective method to quit the habit of consuming tobacco and provides an information about Tobacco Cessation Counseling. The persons who receive Tobacco Cessation Counseling training were significantly more likely to intervene with persons who use tobacco in any form.

Mrs. Renuka Rajshekar Hiremath

Consultant Clinical Psychologist

Cadabam’S Group

The concept of addiction to a drug or to alcohol is widely understood. The concept of behavioral addiction is less immediately obvious. Behavioral or ‘process’ addictions operate in very similar ways to substance addictions, and can be just as life-destroying for the addicted person and their family members. Behavioral addictions may involve a dependency on certain behaviors in relation to other people – as in the case of co-dependency or sexual/ relationship addictions – or compulsive behaviors engaged in for excitement, emotional release, achieving a sense of self or chasing the promise of control, such as gambling or self-harming.

Behavioral addictions are patterns of behavior, which follow a cycle similar to that of substance dependence. These are dependency disorders linked to various human activities, often pleasurable and not related to taking chemical substances. This begins with the individual experiencing pleasure in association with a behavior and seeking out that behavior, initially as a way of enhancing their experience of life, and later, as a way of coping with stress. The process of seeking out and engaging in the behavior becomes more frequent and ritualized, until it becomes a significant part of the person’s daily life. When the person is addicted, they experience urges or cravings to engage in the behavior, which intensify until the person carries out the behavior again, usually feeling relief and elation. Negative consequences of the behavior may occur, but the individual persists with the behavior in spite of this.

There are many types of behavioral addictions. Addictions to screens include videogames, mobile phones and internet (online games, cyber-sex and social networks). There is also compulsive shopping (called oniomania), addiction to sex, addiction to work (workaholic), body-building (Adonis complex), emotional dependency and dependency on groups who use psychological manipulation such as coercive sects, as well as interpersonal dependency (on one person in particular).

Videogames: We talk about addiction when videogames become the central focus of the person’s thoughts, affect sleeping patterns, lead to isolation from family and friends and replace the usual or enjoyable activities the person used to take part in.

Internet: Internet is the instrument or medium which can lead someone to develop one of the following behavioural addictions:

Online games: These are the so-called role games, successors to the game Dungeons and Dragons. Internet is the means of access and there is a monthly charge to be able to play. People from all over the world participate in large numbers in this form of group game. A virtual person is created (avatar) who evolves so as to be able to reach certain levels.
The characteristics of the game make it very attractive and for this and other reasons, it favors players who are persistent and who can develop a behavioural addiction. Furthermore, the sense of interaction the player feels can lead, in fact, to social and family isolation. Among teenagers it can be a reason for absenteeism from school.

• Cybersex: Excessive uncontrolled behavior in the search for sexual activity without physical contact. Sexual excitation is obtained through the creation of fantasies produced by images, text messages, web cameras, etc., and internet is also used as a means of communication.
• Social networks: Loss of control over time spent connected to social networks such as Facebook, MySpace, Twitter, etc. The activity occupies the person’s thoughts and affects family and social relationships, school performance, etc. The person presents problematic or addictive behavior.

Mobile telephone: A person can be described as dependent on mobiles when he becomes isolated socially or from the family and has difficulties with ‘face to face’ contact, loses control over the use of mobiles and the time spent and continues with the behavior despite negative consequences (work, family, economic, etc.).

Compulsive shopping (oniomania): Unplanned shopping accompanied by an uncontrollable impulse. The action of buying is paramount, rather than what is bought. Before shopping, the person becomes agitated and anxious, this state being relieved temporarily when a purchase is made. Feelings of guilt follow which do not impede repetition of the problem behavior despite negative consequences. It is a circuit which cannot be interrupted without treatment. 80% of ‘shopaholics’ are women and the age of onset of the problem is around 18 years of age. The level of general education among sufferers is medium or high.

Addiction to sex: Uncontrolled sexual activity. This dependency is one of the least admitted and visible. Sexual relations generally take place with strangers (anonymity) and do not always have obtaining pleasure as their aim, but rather the relieving of a temporary discomfort experienced if such behavior cannot be carried out.

Addiction to work: Addiction to work is defined as excessive dedication to work activities without control or limits. More and more time is spent working and other activities are forgotten. This excessive dedication is not due to real work demands placed on the person but to the person’s own needs. It is one of the more socially acceptable and justifiable addictions and the ‘workaholic’ tend to deny the problem. Such people are perfectionists.

Adonis complex: The main symptom of this disorder is an obsession to achieve an athletic, muscular body shape without an ounce of fat. The person’s self-image is distorted and the use of anabolic steroids and food supplements is common. The sufferers are mainly men between 18 and 35, with obsessive tendencies and a low to medium economic level.

Emotional dependence: A pattern of excessive emotional needs directed towards a person in their circle which can persist for a great length of time and can lead to the sufferer into situations of submission. Most people who suffer emotional dependency are women who present certain characteristics such as an excessive need for approval by others, a tendency towards exclusivity in relationships, the need to have constant access to the person they depend on, etc.

Dependence on groups who use psychological manipulation (GPM): Manipulative groups systematically use members of an association through subjective practices which have the following steps: recruitment, indoctrination and retention. These practices are based, above all, in the veiled satisfaction (not necessarily conscious) of the emotional needs of the followers and the leaders. The result is the establishment of reciprocal dependency links, a common adherence to the association which tends to be exclusive or pre-eminent (sole or virtually sole dependence to the exclusion of other links: family, friendship, etc.) and leads to a reduction in the person’s capacity to manage their own destiny (critical capacity and free choice). These sole (or almost sole) reciprocal dependency links are established through a process of institutionalization which tends to be perpetuated. There is no one single profile of a person predisposed to recruitment by a sect: any person in a vulnerable moment can be susceptible to being drawn in by a group using psychological manipulation such as a coercive sect. Any person can be susceptible to suffering a behavioural addiction, but there must be a series of factors which, between them, contribute to the development of addictive behavior. For example:

• Frequency or intensity of the behavior.
• Personality type:
  • Impulsive,
  • Low self-esteem,
  • Poor communication within the family,
  • Emotional instability,
  • Lack of social skills,
  • Introversion.
• The influence of external variables:
  • Crisis moments or situations,
  • Dissatisfaction or failure to adapt socially or to the family,
  • Role models, and
  • Education.
• The influence of social variables:
  • Publicity,
  • Social pressure, and
  • Isolation.

Treatment

Beginning from an interruption, lessening or control over the cause of the addiction, the symptoms can be normalized and the person’s vulnerability diminishes.

Experience shows that most cases which are treated have a favorable outcome. This is normally a long process where, often, commitment by the sufferer’s family is an essential tool for the success of the treatment. A good program would include the involvement in probably one-on-one work for the addict, as well as perhaps even one-on-one work with the wife. And then some family work, where the extended family, and perhaps even the children, are involved, as well as the grandparents, where everybody is sort of on the same track. Part of the problem with recovery is, somebody goes into a treatment center or whatever, and they return to the same dynamic, the same set of forces that set the stage in the first place. They relapse, not because they can’t recover, but because the family is not on the same wavelength or on the same track, and they undermine what changes really need to really occur in the family as a whole.

Currently, treatment in most cases of this disorder is based on cognitive-behavioural therapy and does not involve the use of drugs. It is based on the assumption that thinking leads to feelings that leads to behavior. It’s sort of like a triangle. And that if you change one’s thinking about something, you can change the way they feel about it. If you can change the way feel about it, you can change the way they act upon it. An addiction is just a thinking method or a belief method. Certain beliefs lead to feelings that lead to behaviors, and they are often irrational, illogical, excessive, exaggerated beliefs. A cognitive behavioral therapist will focus primarily on the thinking component, will intervene first, talk about the thinking that leads to these feelings or behaviors.

Preventative measures

There are some preventative measures which can be taken as part of normal daily life, for example:

• Teaching tolerance to frustration and responsible consumption;
• Fostering independence and personal confidence;
• Promoting and strengthening communication within the family;
• Taking part in satisfying leisure activities;
• Establishing rules, limits and time restrictions for the use of the computer, mobile phone, etc.;
• The use of parent control filters in the computer;
• Placing the computer in shared space in the house.

In the case of videogames it is important to refer to the PEGI code, available online and which provides information about such games, recommended age limits, type of game, etc.

SHERIN JINSON

It is really disheartening to see the number of youngsters getting admitted at Cadabam’S for de-addiction. And most of them between the age groups of 18 – 30 yrs. These are the years in life when the parents expect the most from their children, period when they complete their studies and try to stand on their own feet. It’s the time most of the parents eagerly wait for, after doing their duty of providing their child the best they can. It’s the child’s turn to fulfill his/ her parents dream. Who is the most unlucky person in this? Is it the parents who are not lucky enough to see their dream come true or is it the child who is not lucky to fulfill their parents?

Family usually takes time to accept the fact that their dream has been shattered. Once they accept it they may go through turmoil of emotion like guilt, regret, sadness etc. They may also start playing the blame game. After all this they come to a point where they accept that they cannot do anything to change the fact and start looking for help to save there dear ones from this. One of the most touching lines I got to hear from a mother who had come for enquiry at Cadabam’S is, “all my friends are searching the right medical college or a proper engineering college for their kids while me and my husband are in search of right rehabilitation center for my son”.

Alcoholism or addiction is considered as a curse to the society. But as a society what are we doing to help a person who really wants to come out of this and start a new life? Speaking decisively, one needs a lot of will power, ascertaining as to how far we go to achieve this goal. The numerous bars found in every nook and corner, both licensed and unlicensed leave very little room to accommodate a changing swerve in society.

It is true to alcoholism is a curse to society; fortunately it is a curse with a cure.

D. Muralidhar *, E. Sinu**

Introduction

Families of alcohol dependent persons face a number of problems including violence, disruption of family rituals, separation, divorce, inappropriate role models and economic difficulties. Alcohol dependence does not burst into the family the way a heart attack would; instead it creeps in slowly and silently, until it is finally detected and it is perhaps only then faced by the family. However, by that time it has already left its mark on each family member. Alcohol dependence is not a condition which once treated can be completely cured. It is a chronic and relapsing condition and always likely to topple the individual back to the same situation of dependence if the individual and his/ her family does not take adequate precautions. Treating alcohol dependence syndrome (ADS) therefore involves more than just getting the alcohol user to stop using alcohol, it also involves counselling the family with regard to their involvement in the recovery, readapting and rehabilitation of persons with dependence.

Role of family members in the recovery of persons with ADS:

The interaction and consequent social reinforcement from within the family environment may often influence alcohol related behaviors. Hence involvement of the significant others is an important component in altering an alcoholic’s drinking habit pattern. It was found that during the non-verbal interactions, the wives of alcoholics attend more to behaviors associated with alcoholism rather than to non-alcohol related behaviors; this has significant impact on the individual’s drinking. Research also indicates that involvement of family members by changing the contingencies within the environment can alter an alcoholic’s drinking behavior.

*Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore-560 029
**Asst. Professor of Psychiatric Social Work, Dept. of Psychiatry, Kasturba Medical College, Manipal University, Manipal-576 104

Differential social reinforcement strategies used by spouses and significant persons in the family help in the successful abstinence from alcohol consumption in individuals with alcohol dependence. It was also found that in intervention programs where spouses were actively involved, the alcoholics tend to have better adherence to treatment and abstinence (Prasadarao, 1990).

Certain family reinforcing consequences of excessive drinking help in maintaining the drinking behaviour among individuals with ADS. One of the social aspects related to drinking – attention from significant others such as family members, friends, etc., influences the alcoholic’s problem drinking. Hence it is essential to schedule the social and environmental consequences in an individual and his family, so that the alcoholic client receives maximum rewards for abstinence and withdrawal of rewards for drinking and drink related behaviors. To this effect the spouse of an alcohol dependent individual plays a significant role in reinforcing the adaptive behaviours.  Such changes in the family environment help the abstinence behavior and develop adaptive alternative, incompatible behaviors in his natural environment.

The spouse of an alcohol dependent individual can play a significant role in the treatment and in maintaining the abstinence behaviour by a) removing the reinforces for drinking; b) reinforcing the behaviours incompatible with drinking and c) rearranging the environmental cues which set the occasion for drinking in the alcohol dependent individual (Miller, 1976).

In order to influence the abstinence behaviour in the client the family needs to adhere to the following 14 steps. These steps when practiced by the family members can lead to effective abstinence behaviours in the clients with alcohol related problems by achieving the above mentioned goals.

1. Not to suspect the individual:The family members develop a habit of suspecting the client whether he had a drink or not especially when he comes home after the day’s work; some spouses smell the person/dress of the client to check if he has had a drink; though the client comes home dry they tend not to trust him; such behavior of spouse may lead the client to go back for drinks due to mistrust; do not suspect the client especially with regard to his abstinence; stop smelling his clothes, checking his belongings, etc., especially when the client comes home late.

2. Develop trust in the individual:Usually due to the chronic alcoholism, the family members tend to lose trust on the client’s role in the familial and occupational issues and his financial accountability. When once the client attains abstinence following intervention it is essential to trust him especially when he says that he abstained from drinks. Support him in a planned and graded fashion in clearance of his debts

3. Do not discuss the individual’s previous drinking problems and consequences with others: The family members frequently tend to discuss the client’s habit of excessive drinking, consequences experienced by the client and family members due to alcohol, with the visitors, friends and relatives at home. They tend to criticize the client and ridicule him in front of others. Following abstinence, do not discuss any of the previous drinking related behaviours pertaining to the client with visitors, relatives and friends at home.

4. Eliminate the alcohol related cues from the home environment:Generally, the client with chronic alcoholism tends to keep the glasses and alcohol bottles at home. He stores drinks at home, at specific places such as refrigerator, shelves, corners, under the cot etc. Following abstinence if the client is frequently exposed to drinks and the alcohol related stimuli especially during the initial phase of abstinence following treatment, it may trigger craving for drinks. Hence it is essential to remove these drinking related cues such as alcohol glasses, and alcohol bottles. Storing alcohol at home and serving guests with alcohol are not advisable.

5. Reinforce the Individual’s sobriety: The spouse, family members, friends and well wishers must appreciate and reward the client’s abstinence behaviour. Consistent reinforcement from all the significant persons of an individual with alcohol dependence always helps in maintaining the abstinence.

6. Express Happiness of Abstinence: The spouse and other family members must express their happiness over client’s sobriety and changes in his activities following his abstinence. The spouse and family must provide the client with feedback indicating the changes occurred in the family following the client’s abstinence. The spouse must indicate to him that there is a change in the client’s behaviour, and the children’s behaviour too; e.g., now the children feel happy; there is a change in the emotional atmosphere at home; interaction among family members has improved, the client takes care of children and other family members, the client attends to his work regularly, etc.

8. Encourage alternative pleasurable activities: Encourage the client to involve in various alternative activities such as developing certain hobbies at home, going for marketing, teaching children, etc., especially during the time when previously the client used to spend in drinking. The spouse can also encourage the client to resume previous interests in various activities which he used to involve before the onset of alcohol abuse.

9. Deal with interpersonal problems in the family: During the drinking period, the alcoholic client tends to develop interpersonal difficulties with family members and other relatives. These individuals with whom the client has had interpersonal difficulties and conflicts should be advised not to probe into those aspects again. These individuals must also be requested to co-operate with the client, so as to reinforce his abstinence and change in his behaviour.

10. Improve communication at home and avoid criticism: Most often the individuals with alcohol dependence tend to develop disturbed communication patterns with family members during their excessive alcohol intake. Since most part of the day they are preoccupied with alcohol and are in an intoxicated state, they stop communicating in an adaptive manner with the family members. Moreover, the family members develop a specific pattern of communication with an alcoholic client and they interact with him only by criticizing and ridiculing. Hence the family members must once again initiate adaptive communication with the client without criticizing and ridiculing him and interact with him in a positive manner, to facilitate developing normal patterns of communication in the client. Family members need to communicate uniformly with the alcohol dependent individual. Avoid addressing the client in disrespectful manner.

11. Inform his friends, other family members and relatives about his abstinence: Relapse of drinking may be triggered by the pressure from peer group and significant persons in the environment of the recovering individual. The spouse must urge/ warn these individuals (e.g., friends, colleagues and relatives) in the client’s immediate environment with drinking habit and with potential to pressurize the client for taking drinks. The spouse and other family members must firmly indicate to these individuals not to discuss about alcohol related issues with the client; not to offer him drinks; and not to invite him to situations where drinking is involved.

12. Identify risk factors for relapse: Certain potential risk factors such as meeting with specific situations, stressors at home or at work situation, crisis and conflicts, and certain emotional states may trigger a relapse in an abstaining individual. The spouse must identify these situations, especially the factors which previously used to trigger alcohol intake in the client and take necessary steps so that the client would not go for a drink. Whenever the client experiences such potential risk situations, the significant others must bring the client to the therapist, if necessary, so that a potential relapse can be prevented by handling such triggering factors.

13. Identify the behaviour that may indicate a potential relapse: The spouse must identify any change in the individual’s behaviour that may indicate a potential relapse. These factors include restlessness, boredom, frequent spells of anger, frequent returning home late, spending large sums of money, etc. During these situations the spouse must be vigilant and bring the client to the therapist in order to prevent/handle the lapse/relapse in the individual by positively responding to the situation.

14. Ensure periodic follow-up:To continue longer periods of abstinence it is essential to maintain a consistent follow-up with the treating professionals. Frequently, the individuals with alcohol dependence and their family members tend to discontinue meeting the treating professionals once the individual achieves a short period of abstinence. Maintaining follow-up with the treating professionals can identify and evaluate any possible risk factors for relapse and help the client accordingly in order to prevent such potential laps and relapsing situations. Hence, the spouse and family must encourage and bring the client consistently for periodic follow up with the professionals.

Conclusion: Usually, families bring the person with ADS to a treatment centre with a proposition of “He is drinking, we brought him and you cure him”. When a client in a treatment centre  moves from ahealthy, protecting, supporting environment to a the  same old vulnerable, unsupportive, risky  terrains, family involvement as depicted in the fourteen steps not only beneficial for the individual with the alcohol dependence syndrome in terms of recovery but also through social work intervention; the impact of alcohol dependence on family can be reduced by involving them in the treatment, recovery, family readapting, social rehabilitation and community reintegration  process by strengthening family interaction pattern and thereby improving the quality of marital and family life of the persons with alcohol dependence.

Checklist for Family Involvement in Recovery & Rehabilitation Process of Persons with Alcohol Dependence

Scoring: Yes=1, No=0 (Higher scores indicates high level of family involvement in recovery process)

*References:

• Edwards M. E. &Steinglass P. Family therapy treatment outcomes for alcoholism. Journal of Marital and Family Therapy, 1995; 21(4), 475-509.
• Lakshmi Sankaran, Muralidhar D, Benegal V (2008). Strengthening Resilience within Families in Addiction Treatment. Indian Journal of Social Work; 69, 1:45-53.
• Mahima Nayar,  Muralidhar D, Vranda MN, Pratima Murthy, Gangadhar BN, Jagadish A. Narratives of wives living with persons with alcohol dependence- why do they stay in violent marital relationships?  Indian Journal of Clinical Psychology 2010, 37(1); 37-45.
• Miller PM. A comprehensive behavioral approach to the treatment of alcoholism. In: R.E. Tarter and A.A. Sugarman (Eds.), Alcoholism: Interdisciplinary approaches to an enduring problem. Massachusetts: Addison- Wesley 1976.
• Prasadarao PSDV. Role of spouse in the treatment of persons with alcohol dependence. De-addiction  Quarterly, 1998; Vol.  3(1): 6-8.
• Pratima Murthy, Maria Christine Nirmala. Working with families of alcohol dependents.  Developing Community Alcohol Rehabilitation and Workplace Prevention Programme.  UNODC, Regional Office for South Asia. 2005.
• Radhamani BS,Muralidhar D. A study on long term abstinent alcoholics in an industrial setting. De-addiction Quarterly, 1996; Vol. 2(1): 40-41.
• Thirumoorthy A,Muralidhar.D. The experiences of wives of alcoholic abstinent and relapsed employees – A follow up study. M.Phil Dissertation. NIMHANS (Deemed) University, Bangalore. 1995.

Dr. C. Ramasubramanian MD. (Psy) DPM.,
Consultant Psychiatrist,
Madurai

Introduction

The burden of mental, behavioral and substance abuse disorders are both due to the increasing numbers and significant disability resulting from disorders. Alcohol abuse is a common public health problem with substantial impact on family and society. The lifetime prevalence of alcohol use (not abuse/ dependence) ranges from 34 % to 42 % and of other drugs (excluding tobacco) 7-12 %, the current (1 month) prevalence of opiate use: 0.7-1.6 %, cannabis: 0.4-1.7 % and minor tranquilizer: 0.1-0.2 % (Country Profile – India, 1998). 

Definition:
Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain — they change its structure and how it works. These brain changes can be long lasting and can lead to the harmful behaviors seen in people who abuse drugs.

The following statements can be used to identify addiction.
Answer yes or no to the following seven questions. Most questions have more than one part, because everyone behaves slightly differently in addiction. You only need to answer yes to one part for that question to count as a positive response.

1. Tolerance. Has your use of drugs or alcohol increased over time?
2. Withdrawal. When you stop using, have you ever experienced physical or emotional withdrawal? Have you had any of the following symptoms: irritability, anxiety, shakes, sweats, nausea, or vomiting?
3. Difficulty controlling your use. Do you sometimes use more or for a longer time than you would like? Do you sometimes drink to get drunk? Do you stop after a few drink usually, or does one drink lead to more drinks?
4. Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?

Neglecting or postponing activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
Spending significant time or emotional energy. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spend a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?

1. Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?

If you answered yes to at least 3 questions, then you meet the medical definition of addiction. This definition is based on the American Psychiatric Association (DSM-IV) and the World Health Organization (ICD-10) criteria.

Different Types of Substance Addictions

Substance addictions are those addictions where a person tends to ingest or administer himself with a certain substance. These substances may include drugs, alcohol, LSD, etc. Most of the time these substances are used for recreational or medicinal purposes. The psychological feelings and euphoria they seem to impart tends to make a person get addicted to these substances.

Caffeine Addiction:
One of the commonly observed addictions today is caffeine addiction. People tend to drink coffee and tea as a socially accepted beverage. However, caffeine tends to have stimulant effects and helps a person stay awake. It gives mental alertness and imparts calming effects on the mind. But, when one tends to drink more than 4-5 cups of coffee or tea in a day he/she may be addicted to caffeine. These people cannot work till they do not have a cup of their favorite caffeine beverage, they become restless to have it, they can’t concentrate without it, they seek relief only in downing their favorite drink.

Alcohol Addiction:
Alcohol addiction is one of the most common addictions plaguing society. People from all walks of life tend to suffer from alcohol addictions. Most of the alcoholics tend to drink to overcome their feelings of anxiety, depression and low self confidence. A person tends to develop tolerance to alcohol and begins to drink more to achieve the same stimulation feelings. They spend more time drinking alcohol and are unsuccessful trying to give up drinking.

Nicotine Addiction:
Smokers are addicted to nicotine, an alkaloid found in tobacco. The nicotine addiction is the second leading cause of death around the world. Nicotine is drugs that causes euphoria and makes the person get used to the feeling. It also helps reduce anxiety and has sedative effects on the mind.
Cocaine Addiction:
One of the most expensive drugs in the market is cocaine. It is one of the most widely abused substances in the United States as well as other parts of the world. This drug causes euphoria and increases sexual desire. It leaves the user filled with energy and gives them a feeling that they can achieve anything in the world. It tends to make a shy person more outgoing. Addicts find all their five senses heightened. It also suppresses appetite that makes users who want to lose weight more attracted to it. Soon, a person loses control over his/her life and tends to rob his own family. These addicts may take up other criminal jobs just to earn money. As I have mentioned, cocaine is a very expensive drug and highly addictive. The obsession to the drug makes the user dependent on it and even brings them to the brink of suicide.
Opiate Addiction:
One of the most common addictions in the United States is abuse of prescription drugs. Patients are given painkillers that contain opiates, a type of narcotic drug. It is usually given to people who are in great pain due to serious injuries and have undergone some major surgery. These opiates give the patient a feeling of well being, happiness, in other words, make the patient ‘feel good’. The patient begins to develop a strong desire or compulsion to take the drug. He/ she feels that without the drug the pain will intensify. Their body begins to grow tolerant to the drug and the patient begins to take high doses to achieve the effect. This drug abuse leads to liver damage, change in mood and impairment of cognitive function.

Heroin Addiction:
Heroin is one of the most addictive drugs that give an instant high to the user. It gives a certain ‘rush’ to the brain that gets people hooked to it after single use. It can either be injected, snorted or smoked. It tends to affect the central nervous system and slows down respiration. Over a period of time, regular use of heroin addiction lowers the respiratory rate so much, that it leads to instant death. The body tends to adapt very quickly to the drug and an addict needs to regularly ‘up’ the doses to achieve the effect. However, one will never experience the same effects they had the first time, how much ever they try increasing the dose.

Methamphetamine Addiction:
Methamphetamine addiction or meth addiction is a very dangerous addiction. It is a street drug that is called ‘speed’ or ‘chalk’. This drug is also available in crystallized form and looks like ice. It can be inhaled by smoking and therefore called as ‘crystal’, ‘ice’, ‘glass’, etc. It induces euphoria and helps people lose weight. However, it soon becomes addictive and regular use damages the central nervous system. Crystal meth effects include sleep disorders, physical exhaustion, failure to regulate body temperature, etc. The drug induces a feeling of superiority in the user and its effect can last for 3 to 18 hours.

Marijuana Addiction:
You may recognize marijuana by names such as ‘pot’, ‘weed’, ‘herb’, ‘chronic’, etc. It is the most widely used illegal drug in America. Marijuana causes problems with concentration, inflammation of the whites of the eyes, paranoia, stupor, etc. It has a major impact on one’s life as well as health.

Principles of Effective Treatment

Scientific research since the mid – 1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:

• Addiction is a complex but treatable disease that affects brain function and behavior.
• No single treatment is appropriate for everyone.
• Treatment needs to be readily available.
• Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
• Remaining in treatment for an adequate period of time is critical.
• Counseling — individual and/ or group — and other behavioral therapies are the most commonly used forms of drug abuse treatment.
• Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
• An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
• Many drug–addicted individuals also have other mental disorders.
• Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse.
• Treatment does not need to be voluntary to be effective.
• Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
• Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases as well as provide targeted risk–reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

Effective Treatment Approaches

Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components. A continuum of care that includes a customized treatment regimen — addressing all aspects of an individual’s life, including medical and mental health services — and follow–up options (e.g., community – or family-based recovery support systems) can be crucial to a person’s success in achieving and maintaining a drug–free lifestyle.

Medications

Medications can be used to help with different aspects of the treatment process.

Withdrawal: Medications offer help in suppressing withdrawal symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment” — it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

Treatment: Medications can be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, we have medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse.

• Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as the other medications. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments.
• Tobacco: A variety of formulations of nicotine replacement therapies now exist —including the patch, spray, gum, and lozenges — that are available over the counter. In addition, two prescription medications have been FDA–approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.
• Alcohol: Three medications have been FDA–approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients — this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.

Behavioral Treatments

Behavioral treatments help patients engage in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches.

Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling. Some programs also offer other forms of behavioral treatment such as —

• Cognitive–behavioral therapy, which seeks to help patients recognize, avoid and cope with the situations in which they are most likely to abuse drugs.
• Multidimensional family therapy, which was developed for adolescents with drug abuse problems — as well as their families — addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
• Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.
• Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

Residential treatment programs can also be very effective, especially for those with more severe problems. For example, therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community — treatment staff and those in recovery — as a key agent of change to influence patient attitudes, perceptions and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the re-socialization of the patient to a drug-free, crime–free lifestyle.

Dr. Srinivas Reddy

MRC Psych (UK)

Consultant Psychiatrist

Cadabam’S Group

Alcohol has been one of the most commonly used chemical substances for intoxication by man since time immemorial. Alcohol use has been increasing year on year and also the problems associated with its use. While no one knows exactly when alcohol was first used, it was presumably the result of a fortuitous accident that occurred at least tens of thousands of years ago. The discovery of late Stone Age beer jugs has established the fact that intentionally fermented beverages existed at least as early as 10000 BC. In India alcoholic beverages appeared during Indus valley Civilisation. Distilled spirits originated in India around 800 BC.

The expression alcohol problems encompass a wide range of untoward occurrences, from maladaptive, impaired or harmful social behaviors, to health complications and the condition of alcohol dependence. Alcohol problems are not incurred just by chronic excessive drinkers, but also by persons who drink heavily on isolated occasions (e.g., accidents, violence, poisoning, etc)

The disease concept of alcoholism embodies  three basic ideas 1) some people have a specific vulnerability to alcohol misuse, 2) excessive drinking progresses through well defined stages, at one which the person can no longer control his drinking 3) excessive drinking may lead to physical and mental disease of several kinds.

Social causes for excessive alcohol use is more common among males of lower education, lower income, manual labourers or people on daily wages, unemployment and any other social stresses. Among genetic causes men and women belonging to families with alcoholic parents or siblings are twice as likely to develop alcohol dependence as those without such family history. The risk is threefold when the disorder is present also in second or third-degree relatives. One of the most significant psychological risk factors for alcoholism is depression in India. The risk is also high in people with schizophrenia, bipolar disorder, social phobia and people with antisocial and borderline personality disorders. Alcohol abusers overemphasise the pleasant aspects of drinking and to exclude the negative ones.

Alcohol Related Disorders

Excessive consumption of alcohol-refers to a daily or weekly intake of alcohol exceeding a specified amount. Alcohol misuse refers to drinking that causes mental, physical, or social harm to an individual.

Alcohol dependence – diagnosis of dependence is made if three or more of the following have been experienced at some time during the last year. A strong desire to take the substance, difficulty in controlling the substance taking behaviour in terms of onset, termination or levels of use, physiological withdrawal state, evidence of tolerance such that increased doses of alcohol are required to achieve effects originally produced by lower quantity of alcohol, progressive neglect of alternative pleasures or interests and increased amount of time necessary to obtain or take the alcohol or to recover from its effects, persisting with substance use despite clear evidence of overtly harmful consequences.

Alcohol causes physical, psychological and social damage. Excessive consumption of alcohol may lead to physical damage in several ways. First it can have direct toxic effect on brain and liver. Second, it is often accompanied by poor diet which may lead to deficiency of protein and B vitamins. Third, it increases the risk of accidents, particularly head injury. Fourth, it is accompanied by general neglect which can lead to increased susceptibility to infection. Gastrointestinal disorders are common, notably liver damage, gastritis, peptic ulcer, oesophageal varices, acute and chronic pancreatitis. Alcohol use is associated with hypertension and increased risk of stroke.

Alcohol related psychiatric disorders

1. Intoxication phenomena – High intake of alcohol can lead to falls, respiratory depression and inhalation of vomit. Memory blackouts and short term amnesia are frequently reported after heavy drinking.
2. Withdrawal phenomena – Occurs across a spectrum of severity, from mild anxiety and sleep disturbance to the life threatening state known as delirium tremens. The symptoms generally occur in people who have been drinking heavily for years and who maintain a high intake of alcohol for weeks at a time. The symptoms follow a drop in blood concentration. They characteristically appear on waking, after the fall in concentration during sleep. Dependent drinkers often take a drink on waking to stave of withdrawal symptoms. Early morning drinking is diagnostic of dependency. With increasing need to stave of withdrawal symptoms during the day, the drinker becomes secretive about the amount consumed, hides bottles, or carries them in a pocket. Cheap alcohol may be drunk regularly to obtain the most alcohol for the least money. The earliest and commonest feature of alcohol withdrawal is acute tremulousness affecting the hands, legs and trunk. The sufferer may be unable to sit still, hold a cup steady. He is restless and easily startled. Nausea vomiting and sweating are frequent. Insomnia is also common. If alcohol is taken, these symptoms may be relieved quickly, if not, they may last for several days. As withdrawal progresses, misperceptions and hallucinations may occur. Later there may be epileptic seizure and finally after 48 hours delirium tremens may develop.
3. Toxic or nutritional disorders
4. Associated Psychiatric disorders – As patient becomes more and more concerned with the need to obtain alcohol, interpersonal skills and attendance to usual interests and responsibilities may deteriorate. Suicidal rates among alcoholic are much higher than people who do not drink. Alcoholics have impaired psychosexual function. They may develop a belief that their partner is unfaithful.
5. Auditory hallucinations – Usually voices uttering insults or threats occurring in clear consciousness. This symptom has good prognosis if abstinence can be maintained.
6. Social damage – Marital and family tension is virtually inevitable.

The divorce rate among heavy drinkers is high, and the wives of such men are likely to

become anxious, depressed and socially isolated. The home atmosphere is detrimental to the children because of quarrelling and violence. Children of heavy drinkers are at risk of developing emotional or behavioural disorders, and of performing badly at school. At work the heavy drinker often progresses through declining efficiency, lower grade jobs and repeated dismissals to lasting unemployment. There is also strong association between road accidents and alcohol misuse. Excessive drinking is also associated with petty offences, sexual offences, fraud and crimes of violence including murder.

Detection

Brief screening questionnaires can be helpful, for example the CAGE questionnaire which consists of the following four questions:

1-      Have you ever felt you ought to Cut down on your drinking?

2-      Have people Annoyed you by criticising your drinking?

3-      Have you ever felt Guilty about your drinking?

4-      Have you ever had a drink first thing in the morning (an Eye opener) to steady your nerves or get rid of a hangover?

Laboratory Tests for Alcohol Dependence – The most useful tests are:

1)      GGT-level is raised in 70% of alcoholics, heavier the drinking the greater is the rise in GGT

2)      MCV- is raised above normal in about 60% of alcoholics

3)      Carbohydrate deficient transferring – Levels are increased in response to heavy drinking

4)      Blood Alcohol Concentration – Alcohol can be detected in the blood in appreciable amount for 24 hours after an episode of heavy drinking.

Approach to treatment of alcohol misuse

• Raise awareness of problem
• Increase motivation to change
• Support and advice
• Withdraw alcohol (controlled drinking)
• Cognitive Behavior Therapy
• Couple therapy
• Alcoholics Anonymous
• Medication (disulfiram, acamprosate)
• Motivational Interviewing
• Express empathy
• Avoid arguing – don’t be judgemental
• Detect and roll with resistance
• Point out discrepancies in history
• Raise awareness about contrast between alcohol user’s aims and behaviour.
• Treatment of Dependence is usually treated by medication (benzodiazepines) commonly in the first week, followed by psychological treatments like group therapy, cognitive behavioural therapy and couple therapy.
• Medications to help maintenance are Disulfiram, which acts by blocking the oxidation of alcohol so that acetaldehyde accumulates and causes unpleasant reaction when alcohol is taken.
• Acamprosate – This drug suppresses the urge to drink. It acts by stimulating the GABA inhibitory neurotransmission and decreasing the excitatory effects of glutamate.
• Antidepressant drugs in some individuals
• Follow up at AA

Prevention in the community-

Increasing the taxes on Alcohol

Ban Advertisements

Education

Increasing quality of Life

Effective population controls

Dr. Vijaylakshmi

Consultant Psychiatrist

Cadabam’S Group

Well, all of us have our own views and experiences about people who struggle with their addictions – simply called – habits. Other words in use are alcoholic, drug addict etc. It is good to name them as a person with problems to each substance rather than using words which make a negative connotation. This group of people may exhibit a range of behaviors related to lack of control in use of a variety of chemicals or substances like tobacco, cannabis, alcohol, or activities like gambling, playing internet games, watching porn films, being involved in sexual relationships.  In brief, people affected by this illness tend to use excessively a substance or any activity that imbalances other parts of the individual’s life and affects him and those surrounding him in different subtle ways and interferes with normal life.

Some of these disorders have been clearly identified and researched while  few have got a negative connotation and such people are looked at differently in the society in general and family in particular. Some of these groups of disorders are still not discussed openly or awareness regarding them is still low.

Many of us are unaware that inability to use time fruitfully – to be productive and satisfactory to self and others is an indicator towards lack of mental well-being. For some people this may not manifest as symptoms.  According to WHO, Health is defined as well being in physical, psychological, social and spiritual areas and not mere absence of disease or illness. Hence it is essential to look into this aspect during active treatment interventions and follow up recovery period of individuals with chemical dependence.

Life for all is a series of adjustments between individual needs and collective appropriateness and feasibility. Some of us are able to gear up and take stressors as challenges and prove ourselves while others want to take the easy path by trying to find joy however short lasting and repeating such acts in futility even after gaining information and experience which are contrary.

The other day a young boy of 17 years was brought to me for his habit of taking marijuana since last four years.  It is indeed sad to see how very young people are getting into these chemicals. It is not only the people with money, even rag pickers as young as 10 years have been known to be dependent on variety of chemicals.

There has been an ongoing debate about the nature-nurture controversy regarding this difficulty. Many will argue that ethical, moral weaknesses should not be covered by labeling as sickness and expect the society to be kind, compassionate and tolerant of such people. Like all other illnesses there is a contributing role of genetics and social environment.

Whatever the arguments or counter arguments – the fact remains that there are people who are unable to lead normal lives and their choices, preferences and their overall behavior in society creates difficulties for themselves and their significant others or even strangers as for example when an intoxicated person drives on the roads. Hence more often such people will be brought for medical attention by their family or by police.

Like with many other health problems, we as a society need to be aware and take steps for its prevention. Early detection and adequate and continuous treatment are very essential so as to ensure full recovery. Denying, minimizing, wishing it away, trying to solve it within the family are all inadequate methods to handle such an issue. The best way to care for such people is to get professional help. Most often it becomes difficult as the individual does not cooperate.

In most cases bringing the affected person for the necessary treatment is an uphill task. It may be several years before the person reaches a state to agree for seeking help. Even when some families forcibly try to get help – the client very often feels cheated, violated and holds resentment against them.
This subject matter is vast and I plan to pen my thoughts about a few issues that I feel are important in treatment of people with these disorders.

1. Awareness: Awareness regarding signs and symptoms of chemical dependence. There is a great need to enhance Public awareness regarding the indicators of this problem. The affected person almost always feels he is in control but his actions and behavior clearly indicate the opposite. There is a long list, to mention a few
   1. Increase in the amount and frequency of drug or alcohol use
   2. Denial of problem
   3. Excuses for use
   4. Hang over, bad trips
   5. Health problems
   6. Interpersonal difficulties
   7. Problems at school, college, work place and family
   8. Dramatic change in mood when drinking or using chemical
   9. Stealing money
   10. Memory loss
2. Concept of enablers: For each person that has got into alcohol or any other drug or anything else that comes under dependence disorders, there will be one or more people around who could be identified as enablers. There is a need to involve the enablers in the treatment of affected people so that recovery is complete and long lasting.
3. Concept of Dual diagnosis: Many people who need help for their addictions or dependence problems may also have other emotional disorders, which complicates the treatment process and both may interact in variable ways so as to delay recovery.
4. The twelve step programme: The twelve steps are the historical and practical foundation of Alcoholics Anonymous and have since been modified for use in different self-help group settings. Members find their sobriety in the steps and they need to continue to work on themselves. The first three steps are about surrendering. Simply put – admit the presence of a problem – see that help is available and ask for that help. Step four to six encourages self assessment. People working at these steps need to look back at a long list of strained relationships, avoidable losses, personal guilt and shame. They need the courage to admit that their lives have been a mess and it is time they make a list, come clean and share their secrets to someone they trust and then be willing to leave all the heartache behind and start anew. Step seven to nine focuses on such peoples need to learn to live in the community and be willing to reach out and ask for help. Make amends for those whom they have hurt. The last three steps involve action. They continue to correct any mistakes they make, take help and guidance to keep their sobriety and help others struggling with similar problems. They find sobriety by reminding themselves that “we keep what we have by giving it away”.
5. Sobriety slogans: The idea is to choose one or more of these, which they like or feel they need to put to practice in their lives.
   • Keep it simple
   • First things first
   • One day at a time
   • One is too many, and a thousand never enough
   • Hugs not drugs
   • Let go and let God
   • Live and let live
   • HALT (Hungry, angry, lonely  or tired – take care of yourself before attempting anything challenging
   • Each day a new beginning
   • Expect a miracle
6. Importance of a sponsor: This person is a member of a twelve-step meeting who can serve as a counselor, big brother or sister, and a friend all rolled into one. The sponsor needs to be sober for at least two years, someone you like or admire, of the same sex as you. The other qualities needed are trustworthiness, honesty and reliability. The person needs to be available when help is needed.
7. Learning: Learning new coping skills, how to say no, identifying danger zones, making choices, having good times without chemicals, structured activity schedule so as to ensure minimal boredom.
8. Medication: Adequate use of appropriate medication for necessary periods of time can be very supportive and help in keeping the abstinence which is necessary for all the unlearning of patterns of behavior and new learning to take place in a supportive, encouraging therapeutic relationships.

The main goal of all intervention – is to help to maintain abstinence and give them tools to build a healthy and long lasting program of recovery. Treatment plan needs to be tailor-made for individual needs though broad principles remain common. An interactive team approach with good support, cooperation and understanding from the close family and friends goes a long way in ensuring recovery.