The Office Diagnosis of Alcoholism
The Office Diagnosis of Alcoholism
Author: Mark A. Hurst, MD, Clinical Assistant Professor, Department of Psychiatry, Ohio State University, Assistant Medical Director for Addiction Psychiatry, Twin Valley Psychiatric System, Ohio Department of Mental Health, Columbus Ohio.Peer Reviewer: Mickey Ask, MD, FASAM, Medical Director, Addictions Treatment Program, Veterans Hospital, Loma Linda, Calif.
Editor’s Note—Alcoholism is one of the most common medical illnesses found in U.S. society. Each year, millions of individuals with alcoholism are seen in primary care settings for a variety of complaints, some of which are related to the effects of alcohol and some of which are not. These "routine" visits provide the primary care physician (PCP) a unique opportunity to identify the patients with alcoholism and assist them in obtaining treatment. Such intervention can be effective and diminish the needless morbidity and mortality caused by this devastating disorder.
This article provides an overview of alcoholism and gives pragmatic information to help us assist our patients in recovering from this treatable illness.
Introduction
Alcoholism and other substance-use disorders have been recognized as major societal problems for millennia. There are numerous references to drunkenness and the untoward effects of alcohol in ancient writings, and historically, individuals with alcoholism were considered to be weak-willed, immoral, insane, or some combination thereof. These individuals were felt to be beyond help and often were rebuked by society.1In 1956, the American Medical Association (AMA) officially recognized alcoholism as a disease.2 Since then, evidence that alcoholism is a true biomedical illness has accumulated, and many individuals with alcoholism have been successfully treated using Alcoholics Anonymous (AA) and other treatment modalities.3
Alcohol is one of the most available substances of abuse in our society, the most commonly used substance, and the most frequent substance of dependence. More than two-thirds of men and approximately half of all women drink on a regular basis, with peak ages of alcohol consumption from the late teens to mid-twenties. The highest rates of alcohol consumption (not alcoholism) are among those with higher education and higher socioeconomic status. Up to one-third of all young men may have some temporary life problems related to the use of alcohol, but only a subset of these individuals will go on to develop alcoholism.4,5
Alcohol is also a major problem in teenagers. Alcohol is the most readily available substance to adolescents and is also the most commonly used and abused substance in this age group. Studies indicate that as many as 90% of all high school seniors have tried alcohol, 50% drink at least twice weekly, and 10% are daily drinkers. This clearly has implications for not only clinical practice, but also for public health intervention and prevention.6
With regard to alcohol dependence (the terms "alcoholism" and "alcohol dependence" will be used interchangeably in this article), most studies find that between 12% and 16% of the male population and 2-5% of the female population will have lifetime histories of alcoholism. Alcoholism is more common among those with lower education and lower socioeconomic status. It should be kept in mind, however, that alcoholism is truly a disease that affects individuals of all socioeconomic, educational, ethnic, and age groups. Unfortunately, less than one-third of those affected will seek help during their lives. Additionally, alcoholism is even more common among individuals with medical illness or psychiatric problems.7
The consequences of alcoholism are great. Hundreds of thousands of people die in this country as a consequence of alcohol, nicotine, and other drug dependence and it is estimated that the annual cost of substance abuse in the United States exceeds $250 billion. These costs are not only due to the associated costs of health care, but also law enforcement and lost work productivity.8,9 Given these factors, it is obvious that all physicians should have knowledge in the identification and treatment of alcoholism and other substance-related disorders.
At-Risk Populations
One of the first challenges that a PCP faces in dealing with alcohol-related issues is determining which specific patients are at risk, and then assisting them in changing their drinking habits. Some individuals may clearly be alcohol dependent. Others may be engaging in "high-risk" drinking behavior, yet not be able to be diagnosed as alcohol dependent, and others may be at high risk for developing alcoholism by virtue of their family history or responses to alcohol. It is important to determine whether a patient falls in one of these groups to appropriately intervene and minimize the risk of alcohol-related difficulties.Ideally, it would be possible to identify individuals at high risk for alcoholism before they begin drinking and suffer the devastating effects of this illness. Although this cannot currently be done with a high degree of diagnostic certainty, alcoholism is much more common in individuals with certain characteristics. These characteristics include a positive family history (children of alcoholics are 3-4 times more likely to develop alcoholism),10 "innate tolerance" (having a less than expected behavioral response to alcohol when first exposed to alcohol, e.g., more than 3-4 drinks),11 and beginning to drink alcohol at an earlier age (i.e., age 10-12).12 If such factors are known, the patient should be counseled about this and be informed that alcohol use may carry a higher risk in them than in other individuals.
It has also been discovered that individuals at high risk for alcoholism have an enhanced response to pituitary b-endorphin when exposed to alcohol compared to low-risk individuals.13 Although this currently is not of clinical relevance for diagnostic or predictive purposes, it has reinforced the biological nature of alcoholism and has been of great importance in the development of effective pharmacological treatments.
Screening for Alcoholism
When assessing a person’s current drinking behavior, the PCP should first ascertain if the patient consumes any alcohol at all. If the patient is, and always has been a total abstainer ("teetotaler"), then a need for a family history of alcoholism is needed. If the patient does drink, then the physician should try to determine the frequency of drinking ("How many days in a week do you drink?"), the quantity ("How many drinks on those days?"), and the presence or absence of binge drinking ("What is the most you’ve drunk on any day over the past month?").14 Patients who exceed "low-risk drinking" guidelines may be at risk for developing alcohol-related problems (see Table 1). Such patients should be more thoroughly assessed for possible presence of alcoholism. If they do not meet criteria for alcoholism, they should be advised to adhere to the recommendations for "low-risk drinking."15,16 The physician should be certain to follow-up on this at subsequent appointments, giving positive feedback for successful reduction in alcohol use, and being attentive to the possibility that some of these individuals may develop alcoholism and/or revert to "high-risk" drinking.
| Table 1. Recommendations for Low-Risk Drinking15 | |
| Men: | 4 or fewer drinks per week Never more than 4 drinks per occasion |
| Women: | 7 or fewer drinks per week Never more than 3 drinks per occasion |
| For individuals older than age 65, the above quantities should be halved. |
|
| Pregnant Women: | NO ALCOHOL |
| Alcoholics: | NO ALCOHOL |
When evaluating a patient’s alcohol use, quantities consumed should be standardized. A "standard drink" contains 12 g of absolute alcohol. This is equivalent to the amount found in a 12 oz beer, a 5 oz glass of wine, or 1.5 oz (a "shot") of 80-proof liquor. If a patient drinks "tall boy" beers or "double" mixed drinks, this should be adjusted accordingly.
Screening Instruments
After evaluating a person’s current use of alcohol, it is then appropriate to proceed with a screening tool.
It would be cumbersome for a PCP to do an intensive diagnostic interview for alcoholism on all patients seen, but given the high prevalence of alcoholism, it is critical that all patients be screened. There are a number of screening tools that can be used, such as the "CAGE" questionnaire, the Michigan Alcohol Screening Test (MAST), and the Alcohol Use Disorders Identification Test (AUDIT). All have been validated in primary care settings, are quick and easy to administer, and have reasonably high sensitivity and specificity.17 It is generally advisable to complete an alcohol screening as part of routine health assessments, when prescribing medication that could interact with alcohol (i.e., opiates, benzodiazepines, barbiturates, antidepressants), or when dealing with problems that could be caused or exacerbated by alcohol15 (such as gout, peptic ulcer disease, depression, hypertension or insomnia).
Many clinicians favor the use of the CAGE questionnaire as a screening tool (see Table 2).18 It is widely used in clinical practice, takes less than a minute to administer, and can be used unobtrusively during routine history taking. An affirmative response to two or more questions is highly suggestive of an alcohol problem, and even one positive response should alert the physician to potential problem drinking and need for further assessment and continued follow-up. It should be noted that neither the CAGE nor any other screening test diagnoses alcoholism. This can only be done with a complete diagnostic assessment using standard diagnostic criteria.
| Table 2. The CAGE Questions18 | |
| • Have you ever felt that you should cut down on your drinking? | |
| • Have people annoyed you by criticizing your drinking? | |
| • Have you ever felt bad or guilty about your drinking? | |
| • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)? |
|
| Two or more positive responses are considered a positive screen. |
|
| Even one positive response warrants further evaluation. | |
The Michigan Alcohol Screening Test (MAST) is also widely used and provides reliable results.19 This is generally administered as a paper-and-pencil test and consists of 25 yes-or-no questions, which examine the patient’s pattern of alcohol use and any associated life problems. The questions are given weighted scores based upon their importance. A score of 4 or less is not associated with problem drinking. Scores of 7 or more indicate a high likelihood of alcoholism, and scores of 5 or 6 are "borderline" and indicate a need for further assessment.
In recent years, the Alcohol Use Disorders Identification Test (AUDIT) has gained increasing favor as a screening tool for alcoholism.20 It was developed by the World Health Organization specifically for use in primary care and has a high sensitivity and specificity. It may be superior to the CAGE and MAST in identifying alcohol problems in the early stages. If the physician prefers a "paper-and-pencil" screen, the AUDIT is probably superior to the MAST.
Diagnosing Alcoholism
Alcoholism has been defined in many ways. The terms "alcoholism," "alcohol dependence," and "alcohol abuse" are all used when describing alcohol-related problems. In 1990, the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence defined alcoholism as follows:
"Alcoholism is a primary chronic incurable disease with genetic, psychological, and social factors influencing its development and manifestations. It is often progressive and fatal. It is characterized by periodic or continuous:
• impaired control over drinking;
• preoccupation with alcohol;
• use of alcohol despite adverse consequences;
• distortions in thinking, most notably denial."21
Although this is a very accurate and comprehensive definition of alcoholism, it is difficult to apply this to individual patients. Currently, the most commonly used diagnostic criteria are those found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).22 They can be applied objectively to a variety of individuals in different settings, enhancing diagnostic reliability. In order to be considered alcohol dependent by DSM-IV, an individual must have a maladaptive pattern of alcohol use characterized by three of the following occurring at any time in the same 12 consecutive month period:
• Tolerance. Either needing increased amounts of alcohol to attain the desired effect or having a significantly decreased effect when using the same amount.
• Withdrawal. Developing alcohol withdrawal symptoms (see Table 3) after stopping or reducing alcohol consumption or taking alcohol or another sedative with cross-tolerance to alcohol (e.g., benzodiazepines) to treat or avoid withdrawal symptoms. An example of this would be someone who always drinks (or takes 5 mg of diazepam) at lunch to relieve a withdrawal tremor.
| Table 3. Common Symptoms of Alcohol Withdrawal*22 | |
| • Tachycardia | |
| • Hypertension | |
| • Diaphoresis | |
| • Tremor | |
| • Insomnia | |
| • Nausea or vomiting | |
| • Anxiety/agitation | |
| • Transient hallucinations (usually visual) | |
| • Withdrawal seizures | |
| * Developing within 24 hours of stopping or reducing use | |
• An Inability to Control the Use of Alcohol. Social drinkers can stop using at anytime of their choosing. Individuals with alcoholism often have times when they attempt to control the amount of alcohol they consume but are unsuccessful in doing so (consistently or predictably).
• Unsuccessful Attempts to Cut Down or Stop the Use of Alcohol. Alcoholics will often have periods of self-imposed abstinence, only to return to alcohol use again.
• Spending Long Periods of Time Procuring, Taking, or Recovering from the Effects of the Substance. The alcoholic may become preoccupied with alcohol, always be sure he or she has a supply available, and spend large amounts of time in alcohol-related activities.
• Reducing Important Activities Due to Alcohol Use. The alcoholic begins to give up time with family, hobbies, and vocational activities in favor of alcohol use.
• Continuing the Use of Alcohol Despite Adverse Consequences Relating to Its Use. A person with alcoholism may be arrested for drunken driving, yet continue to drink and drive, or may be advised to quit drinking by his physician due to elevated liver enzymes, yet continue to do so.
Alcohol dependence is a heterogeneous disorder, and not all of these criteria will apply to all individuals with alcoholism. Additionally, tolerance and withdrawal are not required for someone to be considered alcohol dependent. Individuals with no tolerance or withdrawal, but other symptoms such as an inability to control use of alcohol, unsuccessful attempts at abstinence, and multiple psychosocial consequences would be considered alcoholic as much as the individual who consumes prodigious amounts of alcohol and can attain high blood alcohol levels without evidence of intoxication. In fact, tolerance alone is inadequate to diagnose alcohol dependence—other diagnostic criteria must also be met.
Individuals who exhibit a pattern of pathological alcohol use but have never met diagnostic criteria for alcohol dependence are considered to have alcohol abuse. An individual with alcohol abuse must have one of the following within any 12-month period:
• repeated inability to fulfill major role obligations due to alcohol use (such as missing work due to substance use)
• repeated substance use in situations where it is physically hazardous (such as drinking and driving, or drinking and rock climbing)
• recurrent legal problems relating to substance use (such as multiple drunk driving charges)
• continued substance use despite interpersonal problems or social problems related to use (marital problems secondary to substance use for example).
Many individuals who are diagnosed with alcohol abuse will subsequently develop alcohol dependence, though a subset will continue to abuse without becoming dependent and others will spontaneously revert to "low-risk" drinking.
Assessment
All individuals with positive screens and those individuals who exceed "low-risk drinking" limits should be thoroughly assessed for the presence of an alcohol use disorder. Although some physicians prefer to obtain "expert" consultation from an alcohol counselor or mental health professional, physicians are uniquely qualified to diagnose alcoholism due to the nature of their relationship with patients and ability to obtain and interpret information that is not available to nonmedical professionals, such as physical and laboratory information. Additionally, patients usually feel more comfortable interacting with their PCP, which may permit them to be more forthcoming with information about alcohol use and its consequences. Finally, there is less stigma associated with a primary care visit than a trip to an alcohol treatment or mental health facility. Accordingly, involvement of the PCP is important for accurate diagnosis and successful outcome.
History
Gathering historical information and clinical interviews are the most important procedures in assessing for alcoholism.14 The physician should approach the patient in a caring and professional manner, taking care not to raise the defensiveness of the patient.23 Although information is being obtained for assessment purposes, this is also an important therapeutic contact. Every attempt should be made for this to be a positive experience for the patient in order for him to develop trust and have a willingness to accept the physician’s conclusions and recommendations. A highly confrontational approach will almost always compromise the interview and the therapeutic relationship, serving the patient poorly. If we genuinely believe that alcoholism is a potentially fatal, but treatable, illness, we should approach individuals afflicted with it with the same dignity and respect with which we approach all other patients.
For the PCP, assessment for alcoholism is rarely a single event. Alcoholism is a chronic illness, and as a result, a patient may present with different symptoms and signs of alcoholism at different times during the treatment relationship. A single appointment often provides incomplete cross-sectional information and could lead to erroneous conclusions. Conversely, a longitudinal perspective gives more complete information. If a physician has a high index of suspicion and reflects on previous treatment contacts, the diagnostic picture may become clearer, especially when both medical and non-medical information is considered and correlated.
All aspects of the history are important, including chief complaint, present illness, medical history, psychiatric history, medications, allergies, family history, social history, and systems review. Patients with alcoholism rarely complain of problems with alcohol use, but more commonly present with problems such as abdominal pain, gout, or as victims of trauma. It is only after pursuing an alcohol history that the physician becomes aware that the presenting complaint is a consequence of alcohol use. This includes not only medical problems, but also psychiatric problems such as depression, insomnia, or anxiety, as well as social problems such as marital discord, legal problems, or employment concerns.24
Medication history and allergies are often overlooked as potential sources of diagnostic information. If an individual has a history of extensive exposure to controlled drugs, the physician should ascertain the reason for this and attempt to determine their pattern of use. Specific concerns should be raised if the person has taken controlled drugs in high doses and/or for long periods for relatively minor complaints, if they run out of medication prematurely, or if they drink when taking drugs, which may adversely interact with alcohol. A complaint of "allergies" to multiple controlled drugs should raise similar suspicions. Although certainly there are individuals who are particularly sensitive to a particular class of controlled drugs, one should also consider the possibility that such an individual is seeking a "drug of choice" in that particular class.
Physical and Laboratory Findings
Physical examination, laboratory testing, and mental status assessment are also helpful in detecting possible complications of alcohol use.24 A brief summary of some common physical and laboratory findings associated with alcoholism may be found in Table 4.
| Table 4. Common Physical and Laboratory Findings in Alcoholism |
|
| Physical Findings | |
| • Unexplained bruises and abrasions | |
| • Frequent trauma | |
| • Acne rosacea | |
| • Hepatomegaly | |
| • Tremor | |
| • Alcohol on breath | |
| • Cigarette burns on chest or between fingers | |
| • Peripheral neuropathy | |
| • Memory deficits | |
| Laboratory Findings | |
| • Increased mean corpuscular volume (MCV) | |
| • Increased hepatic enzymes (GGT, SGOT, SGPT) | |
| • Elevated triglycerides, high-density lipoprotein (HDL)-cholesterol |
|
| • Elevated uric acid | |
| • Incidental rib fracture on chest x-ray | |
A number of physical illnesses are highly correlated with alcoholism, and alcohol affects virtually every organ system in the human body.25 Individuals with medical problems that may be alcohol induced should be closely questioned about their use. Early intervention on drinking habits in affected individuals can frequently stop the progression of almost all alcohol-related medical illnesses and often reverse it, further emphasizing the importance of effective alcohol screening and early diagnosis.
Physical Complications of Alcoholism
Alcohol dependence is associated with a significantly reduced life expectancy, with the average age of death of alcoholics being between ages 55 and 60 (20 years younger than the general population). The leading causes of death among alcoholics are cardiovascular and neoplastic diseases with certain cancers (head and neck, esophageal, and gastric) being over-represented. Accidental deaths and suicide are also greatly increased in alcoholics, with the rate of suicide being as high in alcoholics as it is in individuals suffering from major depression.26
Gastrointestinal System. Alcohol also may cause esophagitis, gastritis, duodenitis, and gastric and duodenal ulcers. Additionally, one-half of all cases of pancreatitis are related to alcohol use. Alcohol also has a significant effect on the liver including fatty liver, alcoholic hepatitis, and cirrhosis. Patients with hepatitis C should not use alcohol. Women are significantly more sensitive to the hepatic effects of alcohol than are men, with decreased quantities and lower durations of consumption leading to development of cirrhosis of the liver.25
Cardiovascular System. Alcohol is also one of the leading causes of cardiomyopathy.25 In the past, alcoholics were not considered to be candidates for cardiac or hepatic transplantation; however, with further recognition of the disease nature of alcohol dependence, individuals who are in remission from alcohol dependence and meet certain criteria may be appropriate transplant candidates.
Recent research has indicated that moderate alcohol consumption decreases the risk of cardiovascular disease,27 and some patients will use this as a rationale to continue drinking. While it is true that moderate use decreases cardiovascular risk, excessive use increases risk, with higher rates of cardiac arrythmias, hypertension, and stroke.25 There are many other things that patients can do to decrease the risk of cardiovascular disease, such as following a prudent diet, stopping smoking, and exercising. No one needs to drink solely for its cardioprotective effect.
Reproductive System. Alcohol also has a significant effect on the reproductive system. Impotence is common among male alcoholics, as is infertility in both male and female alcoholics. Spontaneous abortions are increased among women who are actively drinking. Low birthweight offspring are seen in pregnant women who are actively drinking, as well as in abstinent nonalcoholic women who are married to alcoholic husbands. This may be due to both the stress of living with an actively drinking alcoholic, as well as possible effects on sperm motility and sperm morphology.25,28
Fetal alcohol syndrome is a common birth defect, which is due to the effect of alcohol on the developing fetus. Other factors may also be involved such as nutritional deficits, lack of prenatal care and vitamin deficiencies, but it is clear that alcohol is a major teratogen. There is a dose-response relationship, with higher amounts of alcohol being associated with more severe pathology in the affected children. Typical features include growth retardation, microcephaly, microphthalmia, absent philtrum, a broad bridge to the nose, and learning disabilities. No amount of alcohol is proven safe in pregnancy and pregnant women should consume no alcohol at all. Additionally, women who are breastfeeding should also avoid the consumption of alcohol to avoid potential effects in the newborn.28,29
Central Nervous System. Neurological sequelae of alcoholism are not uncommon, including alcoholic cerebellar degeneration and the Wernicke-Korsakoff syndrome. Individuals affected by Wernicke’s syndrome have a broad-based gait, ataxia, abnormalities of eye movements (particularly of the sixth cranial nerve), and some memory deficits caused by thiamine deficiency. All alcoholics should be given oral thiamine as part of their treatment regimen, and those individuals experiencing symptoms of Wernicke’s syndrome should be given intravenous thiamine.
Following Wernicke’s syndrome, a Korsakoff’s syndrome may develop. This is associated with all of the signs of Wernicke’s syndrome and marked memory impairment, most notably in recent memory (although memory is globally affected). Patients often will confabulate to fill in memory gaps. This disorder may also be treated with intravenous thiamine, although less successfully than Wernicke’s syndrome. Alcoholic cerebellar degeneration causes a broad-based gait, nystagmus, and intention tremor. This condition is irreversible and its neuropathology differs from Wernicke-Korsakoff syndrome.5
There are a variety of psychiatric complications of alcohol dependence as well. Individuals who are alcohol dependent may suffer from anxiety, hallucinosis, comorbid drug addiction, comorbid personality disorders (with a clear over-representation of antisocial personality disorder), and depression. These symptoms may occur in the course of the alcohol dependence and be clearly secondary to it, or may be true comorbid psychiatric conditions that are in need of separate treatment. Substance-dependent individuals who are suffering from significant psychiatric symptomatology should have a thorough assessment for associated psychiatric illness and receive appropriate treatment when indicated. Individuals with alcoholism and associated psychiatric illness have a significantly higher relapse rate and should have this addressed in the course of their treatment.30
For a further review of the physical and laboratory findings in individuals with alcohol dependence, the reader is referred to comprehensive textbooks of internal medicine such as Harrison’s Textbook of Internal Medicine.
Initiating Treatment
After all historical and physical information is obtained, it should be summarized in a cohesive manner and presented to the patient in a kind and empathetic manner. It often is helpful to use the patient’s chief complaint and any physical data to impress upon them the seriousness of the problem. Options for treatment can then be outlined.
It would be ideal if the patient then accepted the diagnosis, entered treatment, and had life-long sobriety. Unfortunately, this rarely occurs. Individuals often have significant denial and initially may have little insight or motivation to pursue treatment. Although this is frustrating to the physician, it should be seen as another facet of the illness to be dealt with, not as a character flaw of the patient or a personal affront to the treatment provider.
If the patient is not receptive to the diagnosis or treatment recommendations, the physician might consider either a second opinion with another physician with expertise in substance dependence or suggest an "abstinence contract." With an abstinence contract, the treatment provider would ask the patient to be abstinent from alcohol and all drugs of abuse for a fixed period of time (60 or 90 days). The patient has regular appointments with the physician during this period and the course of his or her recovery is followed. Should the patient use alcohol or other drugs during this period, this gives further diagnostic information. Should the patient be successful in abstaining from alcohol and other drugs, often he or she will note positive changes and be willing to continue to abstain.
If the patient continues to drink, regular follow-up appointments should still be made, as would be done with any chronic and progressive disease. At these appointments, the physician should continue to address the alcohol issue, focusing on the development of insight and motivation to change behavior. Eliciting the patient’s reasons for changing their drinking behavior is often helpful in this respect.
Active Alcohol Treatment
There are a variety of intensities of treatment varying from medically monitored inpatient treatment in a general medical hospital, to outpatient treatment with little counseling and an agreement to abstain totally from all substances of abuse (see Table 5). The preferred level of care is the least restrictive setting in which the patient can successfully maintain abstinence and maintain medical stability. There is some evidence that many people with alcohol problems can stop alcohol use on their own,31 although many others will require a formal rehabilitation program.
| Table 5. Levels of Treatment Intensity for Alcoholism |
|
| • Medically-monitored inpatient (most intensive) | |
| • Medically-supervised inpatient | |
| • Residential treatment | |
| • Partial hospital treatment | |
| • Intensive outpatient (3 h, 3 times weekly) | |
| • Counseling (group, family, individual) | |
| • Support groups alone (least intensive) | |
Most alcoholism treatment providers in the United States use the same basic principles. These include a disease model of addiction (treating a true biomedical illness), absolute abstinence from all drugs of abuse (unless absolutely medically necessary), education, and 12-step programs such as AA. The patient may be involved with a variety of other therapeutic modalities depending upon his or her individual needs including individual counseling, group counseling, family and marital counseling, medical management, and psychiatric treatment. The focus of this phase of treatment is to help individuals achieve substance-free lives and to rebuild those areas that have been adversely affected by their illness. Virtually all life areas are affected by alcoholism and each of these areas should be addressed in each patient.32,33
One of the most important interventions that a physician can make in this stage of treatment is to stress the importance of absolute abstinence. Outcome research is very clear. In a 50-year prospective study of individuals with alcoholism, Dr. George Vaillant found that only 11% were successful in returning to sustained "controlled drinking." The remainder were either still abusing, fully abstinent, or dead. In short, it is exceedingly unlikely that an alcoholic will be successful in attempting to return to "controlled" (or social) drinking.34
Physicians should also avoid prescribing benzodiazepines, opioids, or other controlled drugs to known alcoholics or addicts, unless absolutely necessary (such as when using benzodiazepines for treatment of alcohol withdrawal).
Relapse Prevention
Most research finds that between 40% and 50% of substance-dependent individuals will have a relapse within the first three months of leaving active treatment. Therefore, it becomes important to assist individuals in minimizing both the likelihood of relapse and the duration of relapse should it occur. Preventing relapse on substances should begin with the initiation of treatment. The individual should be assisted in identifying situations and stressors that may lead to relapse and developing coping strategies to help deal with these situations. A variety of modalities may be used including counseling, self-help groups, written homework assignments, behavioral and cognitive therapies, and pharmacotherapy.35
Pharmacological treatments to reduce the likelihood of alcohol relapse may be helpful but are only a small part of a recovery program. Disulfiram (Antabuse) previously was one of the few available options. It is an irreversible inhibitor of aldehyde dehydrogenase and when individuals consume alcohol when taking this medication, they experience an unpleasant reaction due to acetaldehyde accumulation. A large multicenter Veterans Administration study, which was done in the 1980s, revealed little difference in treatment outcome between individuals taking Antabuse and control groups. Nonetheless, certain individuals may respond well to disulfiram and it may be a valuable tool in this treatment process.36
An important advance in treatment of alcohol dependence has been the development of naltrexone for use in alcohol dependence. Naltrexone is an opioid antagonist and has been used due to observable differences in endogenous opioid activity in individuals at high risk and low risk for alcohol dependence. In replicated studies, alcohol-dependent individuals taking naltrexone at a dose of 50 mg per day had a 50% lower relapse rate than individuals taking placebo and receiving the same psychosocial treatments. Furthermore, the group treated with naltrexone had decreased craving for alcohol and if they did consume alcohol, were less likely to proceed to a major relapse of uncontrolled drinking than those taking the placebo.37,38 Although no pharmacological "magic bullet" exists for the treatment of alcohol dependence (or any other substance-dependence disorder) at this point, naltrexone is an important addition to the therapeutic armamentarium. All pharmacological treatments should be combined with a comprehensive biopsychosocial treatment process to fully address the needs of the individual with alcohol dependence. Even more importantly than medication, encouragement from the physician to attend AA, contact with an AA sponsor, and maintain a commitment to sobriety can be of great value.
Summary
Substance-related disorders are extremely common in our society. All physicians will come in contact with individuals who are suffering from alcoholism and should have some knowledge of its identification and treatment. In the future, there will be better methods of prevention, intervention, and treatment in order to decrease the associated morbidity and mortality in our society. Individuals who suffer from these disorders are certainly not "hopeless" and many individuals do lead happy and productive lives after receiving appropriate intervention and treatment.
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