Alcohol use and related problems

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 Civilization. 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.

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Alcohol related psychiatric disorders

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.
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.
Toxic or nutritional disorders
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.
Auditory hallucinations – Usually voices uttering insults or threats occurring in clear consciousness. This symptom has good prognosis if abstinence can be maintained.
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:

GGT-level is raised in 70% of alcoholics, heavier the drinking the greater is the rise in GGT
MCV- is raised above normal in about 60% of alcoholics
Carbohydrate deficient transferring – Levels are increased in response to heavy drinking
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