Alcoholism

.. times increased consumption of alcohol are cited in evidence. But these data invariably fail to take account of changes in availability or use of facilities, changes in admission or diagnostic policies, or changes in the source of beverages–for example, from unrecorded to recorded supplies. In the Soviet Union a change in the internal political situation with the death of Stalin resulted in a shift from official denial that any significant problem of alcoholism existed to an outcry that its prevalence was widespread and serious, though no statistics were provided. Treatment of alcoholism The various treatments of alcoholism may be classified as physiological, psychological, and social. Many physiological treatments are given as adjuncts to psychological methods, but sometimes they are applied in pure form, without conscious psychotherapeutic intent or even with an effort to avoid it.

Physiological therapies Chemical fences One of the popular modern drug treatments of alcoholism, initiated in 1948 by Eric Jacobsen of Denmark, uses disulfiram (tetraethylthiuram disulfide). The usual technique is to administer half a gram in tablet form daily for a few days; then, under carefully controlled conditions and with medical supervision, the patient is given a small test drink of an alcoholic beverage. The presence of disulfiram in the drinker’s body causes a reaction of hot flushing, nausea, vomiting, a sudden sharp drop of blood pressure, pounding of the heart, and even a feeling of impending death. These symptoms result from an accumulation of the highly toxic first product of alcohol metabolism–acetaldehyde. Normally, as alcohol is converted to acetaldehyde, the latter is rapidly converted, in turn, to other harmless metabolites, but in the presence of disulfiram–itself harmless–the metabolism of acetaldehyde is blocked, with the resulting toxic symptoms. The patient is thus dramatically shown the danger of attempting to drink while under disulfiram medication.

A smaller daily dose of disulfiram is then prescribed, and the dread of the consequences of drinking acts as a chemical fence to prevent the patient from drinking as long as he continues taking the drug. Most therapists use the period of enforced abstinence to apply psychological and rehabilitative measures that should enable the patient ultimately to refrain from drinking without the chemical crutch. Variations of the technique include group-reaction tests and the substitution of motion pictures or verbal descriptions for the reaction test. Citrated calcium cyanamide is another drug used with similar effect, preferred by some therapists because the reaction with alcohol is milder, though its protective potency is briefer. In Japan some therapists have reported giving very small doses of the cyanamide compound, thereby allowing the patient to drink very moderately without suffering a severe reaction but provoking the reaction if the patient attempts to drink immoderately. Other substances that can produce disagreeable reactions with alcohol include animal charcoal, the mushroom Coprinus atramentarius, numerous antidiabetic drugs, and the ground pine Lycopodium selago; however, except for the latter, which has had some trial in Russia, they have attracted very little clinical interest. Aversion The U.S. /bcom/eb/article/idxref/3/0,5716,466975,00.htmlpsy chiatrist W.L.

Voegtlin developed a method of creating a conditioned reflex of aversion to alcohol by repeatedly giving the patient a precisely timed injection of an emetic drug just before a drink of his favorite beverage, resulting in nausea and vomiting before the alcohol could be absorbed. The consequent association of vomiting with drinking, causing aversion to the taste, smell, and sometimes even sight of alcoholic beverages, does not last indefinitely but may be reinforced periodically. Similar techniques have been tried in several European countries. Other methods of conditioning applied by behaviour therapists and learning psychologists include associating drinking with mild to painful electrical shocks or with temporary interruption of breathing by injection of a paralyzing drug. Nutrition, hormones, drugs A genetotrophic theory of disease holds that alcoholism is caused by a genetically determined need for extraordinary amounts of one or more vitamins. Accordingly, alcoholics have been treated with massive doses of multivitamins.

Another theory holds that alcoholism is caused by some defect of the endocrine system, the adrenal-hypophyseal axis being most commonly implicated, and, accordingly, alcoholics have been treated by injections of adrenal steroids and adrenocorticotropic hormones. Other physical and drug therapies that have been tried in alcoholics include intravenous injections of alcohol, apomorphine, injections of autoserum and alcoholized serum, brain surgery, carbon-dioxide inhalation, oxygen by injection, nicotinic acid, nicotinamide-adenine dinucleotide, lysergide (LSD, lysergic acid diethylamide), strychnine, antihistaminic agents, and many tranquillizing and energizing drugs. None of these treatments has been shown in controlled studies to be more effective than others. With some treatments, controlled studies are extremely difficult to carry out. In many cases, moreover, the treatments are accompanied by simultaneous measures having potentially psychotherapeutic and socially rehabilitative effects, especially membership in such groups as Alcoholics Anonymous (see below). It is possible that the treatment that works best is the one that is most suitable for the particular patient.

But it is also possible that the most effective therapy is the one the therapist believes in, and this factor of subjectivity may account for the inferior results achieved in controlled experiments. In the use of psychoactive drugs such as LSD, the aim often is not directly to affect the alcoholism but to produce changes in the patient’s emotional state that will help him respond to other psychosocial measures. Psychological therapies Psychotherapy in alcoholism encompasses the entire range of modalities applied in treating the psychoneuroses and character disorders, including individual and group techniques. The aim varies from eliminating some underlying cause to effecting just enough shift in the patient’s emotional state so that he can function at least temporarily without drinking. Psychoanalysis is rarely tried, having shown little success in alcoholism; analytically oriented therapies are more usual, chiefly with supportive aims.

The only psychological technique developed specifically for alcoholism consists of gaining the patient’s recognition and acceptance of his actual condition, which alcoholics often resist. Such acceptance may then be followed by a therapeutic-rehabilitative regimen. Group therapies are regarded as more effective than individual modalities with alcoholics. These range from instructional lectures and superficial discussions to deep analytic explorations, psychodrama, hypnosis, psychodynamic confrontation, and marathon sessions. Mechanical aids include didactic motion pictures, movies of the patients while intoxicated, and taped records of previous sessions.

Some therapists have experimented, as yet without definitive results, with milieus that reward and reinforce socializing behaviour, hoping thereby to extinguish the desocializing drinking behaviour. Many institutional programs rely on total push, subjecting the patient to a bombardment of methods, including drugs, hypnosis, physiotherapies, group sessions, lectures, Alcoholics Anonymous meetings, and individual psychological and religious counseling, with the hope that each patient will be affected favourably by whatever is most suitable for him. Other institutional programs rely on mere removal from the stressful outside environment, with a period of enforced abstinence. The therapists themselves may be psychoanalysts, psychiatrists, clinical psychologists, pastoral counsellors, social workers, nurses, police or parole officers, or lay counsellors–the latter often former alcoholics with special training. The places of treatment are as varied as the modalities, ranging from general hospitals to mental hospitals to mental-health outpatient clinics to specialized inpatient sanitariums and specialized alcoholism clinics to jails and penitentiaries to medical and psychiatric private offices, with patients often moving, randomly or systematically, from one milieu to another.

Awareness of the social and environmental elements in alcoholism has led to the development of treatment for spouses and occasionally for whole families, either separately or jointly, in the recognition that the patient is not just the alcoholic but the family unit. A new trend in the United States, partly stimulated by court decisions prohibiting the jailing of alcoholics for public intoxication, is the establishment of detoxication centres that provide first aid along with guidance toward more fundamental treatment. But even if adequate programs and facilities for treating alcoholism were available, it is unlikely that they would solve the problem, given the large number of new cases each year. Only preventive public-health programs can eliminate alcoholism and thus far no likely methods of prevention have been devised. Alcoholics Anonymous The patient-centred self-help fellowship of men and women called Alcoholics Anonymous enables its members to share their common experience and thus to help each other. AA was founded in 1935 by two alcoholics, Robert Holbrook Smith and William Griffith Wilson; the latter had been strongly influenced by the Oxford Group.

The members strive to follow Twelve Steps, a nonsectarian spiritual program the central points of which are reliance on God or a higher power as each individual understands that concept and the value of help to other alcoholics. Now a worldwide community of hundreds of thousands, the fellowship is organized in local groups of indeterminate size, has no dues, and accepts contributions for its expenses only from those attending meetings–where members narrate the stories of their alcoholic careers and their recovery in AA. Affiliation of the society or its groups with churches, politics, organizations, or institutions is barred by the AA Twelve Traditions. AA apparently meets deep-seated needs among its members by enabling them to associate with kindred sufferers who understand them, to accept the disease concept of alcoholism, to admit their powerlessness over alcohol and their need for help, to depend without shame or stigma on others, and to involve themselves in activities within the group and in helping other alcoholics. These goals seem to provide adequate substitutes for the alcohol-dependent way of life. AA is thought by many to be the single most successful method yet devised for coping with alcoholism.

It has spawned some allied but independent organizations: Al-Anon, for spouses and other close relatives and friends of alcoholics, and Alateen, for their adolescent children. The aim of such related groups is to help the members learn how to help an alcoholic or, at any event, how to live with one. Professionals in the field tend to think of AA as an inexpensive form of group therapy and a useful ally but recognize, as do the more sophisticated members, that it is not a panacea nor is it suitable for all types of alcoholics. Most experienced therapists agree that any form of treatment is likely to show a higher rate of success if the patient can be persuaded simultaneously to join Alcoholics Anonymous. AA groups around the world resemble each other and generally use the ideological literature (including translations) published by the central office in New York, although there are some variations in style and conduct.

In some countries the AA groups are sponsored by or affiliated with national temperance societies or accept financial support from government health agencies. There are also clubs for former alcoholics, usually sponsored by a particular institution for its former patients. One Scandinavian group seeks to achieve a stable degree of moderate drinking, rather than total abstinence. Results of treatment The success of treatment in behavioral or personality disorders is always difficult to appraise, and this is the case in alcoholism. The effects of new treatments tend to be reported enthusiastically, but critical examination of the results tends to reduce or cast doubt on the rate of apparent success.

Controlled studies, when carried out, usually undercut the claims. Follow-up studies of persons treated have usually been too brief to determine whether permanent results had been achieved, and in most cases the investigators failed to locate a substantial proportion of the former patients. Moreover, the measures of success are inconsistent. Some investigators regard only total abstinence as a successful outcome; others are satisfied if drinking bouts are curtailed and the patient’s life adjustment is improved. Perhaps between 25 and 50 percent of alcoholics who receive some form of treatment either become abstinent or achieve some abatement of the severity of their illness. Alcoholism treatment programs connected with businesses and industries, in which the alcoholic must participate if he wants to keep his job, have reported even higher success rates. Forms of frankly compulsory treatment, even if grudgingly endured by alcoholics, seem to have a high rate of effectiveness.

Some investigators have suggested that the older the patient and the longer the duration of his alcoholism, the more frequent is the occurrence of spontaneous recovery. Medicine Essays.