Alcohol use and related problems

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.

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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.

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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.

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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

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