TAREA 14: TREATMENT OF ALCOHOL ADDICTION

TREATMENT OF ALCOHOL ADDICTION

Following recovery from the acute medical and neurological complication of alcoholism, the underliying problem - that of alcohol dependence-remains. To treat only the medical complications and to leave the management of the drinking problem to patients themselves is indeed shortsighted. Almost always drinking is resumed, with a predictable recurrence of medical illness. For this reason, the physician must be prepared to deal with the addiction or at least to initiate treatment.

The problem of excessive drinking is formidable but not necessarily as hopeless as it is made out to be. A common misconception among physicians is that specialized training in psychiatry and an inordinately large amount of time are required to deal with the addictive drinker. Actually, a successful program of treatment can be initiated by any interested physician, using the standard techniques of history taking, establishing rapport with the patient, and seeing him or her frequently, though not necessarily far prolonged periods. A useful point at which to undertake this task is during convalescence from a serious medical or neurologic complication of alcoholism or in relation to loss of employment, arrest, or threatened divorce. Such crisis may help convince the patient, better that any argument presented by the family or physician, that the drinking problem has reached serious proportions.

The requisite far successful treatment is total abstinence from alcohol, and for all practical purposes, this represents the only permanent solution. It is generally agreed that any attempt to curb the drinking habit will fail if the patient continues to drink. There are said to be alcoholics who have been able to reduce their intake of alcohol and eventually to drink in moderation, but they must represent a tiny proportion of the addicted population. Also, it is frequently stated that patients must recognized that they are alcoholics, i.e., that their drinking is beyond their control, and they must express willingness to be helped. Undoubtedly there is truth in both these statements, but they should be not interpreted to mean that patients must gain this recognition and willingness entirely on their own initiative and that they will be helped only after they do so. Physicians can do a great deal to help patients understand the nature of their problem and to motivate them to accept treatment. The help of family, employer, courts, and clergy should be enlisted in an attempt to convince them that abstinence is preferable to chronic inebriety. Patients must be made fully aware of the medica! and social consequences of continued drinking and must also be made to understand that because of some constitutional peculiarity they are incapable of drinking in moderation. These facts should be presented in much the same ways as one would explain the essential features of any other disease. There is nothing to be gained from adopting a punitive or moralizing attitude; on the other hand, patients should not be given the idea that they are in no way blameworthy for their illness. There appears to be an advantage in making patients feel that they are responsible for doing something about their drinking.

The prevalent belief that alcoholics will not stop drinking under duress also requires qualification. In fact, one of the few careful studies of this matter disclosed that relatively few patients would have sought help unless pressure had been exerted by family or employer; furthermore, in patients who carne to the clinic under duress the incidence of sustained abstinence was much the same as in those who carne voluntarily.

If earnest and sustained efforts by the physician fail to convince the patient that alcohol is a problem, it is usually impossible to modify the alcoholic tendency. The only way to make such individuals discontinue drinking is to commit them to psychiatric hospital or special institutions for the management of alcoholism in the hope that with forced abstinence and improvement in their physical state they will gain insight and later accept psychiatric or other forms of therapy.

On the other hand, if patients come to realize that the drinking is beyond their control and that something needs to be done about it, their chances of being helped are raised considerably. Indeed, under these circumstances many persons stop drinking of their own volition far periods of several months or years. Some of these patients, despite the best of intentions, will relapse. This should not serve as an excuse to abandon treatment; many patients have attained a state of prolonged sobriety after several false starts.

A number of methods have proved valuable in the long-term management of the alcoholic patient. The most important of these are the use of disulfiram (Antabuse), psychotherapy and the participation in social organizations for combating alcoholism.
Disulfiram interferes with the metabolism of alcohol, so that the patients who take both alcohol and disulfiram accumulate on inordinate amount of acetaldehyde in the tissues, resulting in nausea, vomiting, and hypotension, sometimes pronounced in degree. It is no longer considered necessary to demonstrate these effects to patients; it is sufficient to warn them of the severe reactions that may result if they drink while they have the drug in their body. Treatment with disulfiram is instituted only after patients have been saber for several days, preferably longer. It should never be given to patients with cardiac or liver disease. The drug is taken each morning, or at another suitable time daily, in a dosage of 250 mg, preferably under supervision. This form of treatment is of particular value in the spree or periodic drinker, in whom relapse from abstinence usually represents an impulsive rather than a carefully planned or premeditated act. The patient taking disulfiram, aware of the dangers of mixing liquor and the drug, is "protected'' against the impulse to drink, and this protection may be renewed every 24 h by the simple expedient of taking a pill.