The alcohol dependence syndrome is usually very much easier to identify than problem-related drinking. Figure 19.3 outlines the main characteristics of the syndrome but these do not necessarily present in any particular order. Symptoms of alcohol dependence in a typical order of occurrence are shown in Table 19.27.
Unable to keep to a drink limit
Difficulty in avoiding getting drunk
Spending a considerable time drinking
Memory lapses, blackouts
Restless without drink
Organizing day around drink
Trembling after drinking the day before
Morning retching and vomiting
Sweating excessively at night
Hallucinations, frank delirium tremens
Symptoms of alcohol dependence.
The course of the alcohol dependence syndrome comprises three linked stages. The first stage is heavy social drinking, i.e. the ingestion of three to five standard drinks (units) of alcohol a day for several years. This stage can continue asymptomatically for a lifetime or, because of a change of circumstances or peer group, it can revert to a more moderate pattern of drinking or can progress to the second stage of alcohol abuse. This stage is usually associated with frequent ingestion of more than eight drinks a day and there are associated medical, legal, social and/or occupational complications. About half of such abusers either return to asymptomatic (controlled) drinking or achieve stable abstinence. In a small number of cases, such alcohol abuse can persist intermittently for decades with minor morbidity and become milder with time. About 25% of all cases of alcohol abuse will lead to chronic alcohol dependence, withdrawal symptoms and the eventual need for detoxification. This last stage most commonly ends in social incapacity and death or abstinence.
Evidence suggests that alcohol-dependent drinkers do not develop their dependence after a few drinks but that the disorder requires up to 10 years of heavy drinking to evolve (3-4 years in women). In some individuals who use alcohol to alter consciousness, obliterate conscience and defy social canons, dependence and apparent loss of control may appear in only a few months to a few years.
Mild tremor, headache, nausea and general malaise are characteristic of the hangover. Patients who are chronically alcohol dependent often do not have these symptoms, partly because they are tolerant to alcohol and tend to continue to consume alcohol on the next day. Withdrawal from alcohol causes:
• Prominent tremor
• Delirium tremens (DTs)
Delirium tremens is the most serious withdrawal state and occurs 1-5 days after alcohol (or barbiturate) withdrawal. Patients are disorientated, agitated, and have a marked tremor and visual hallucinations (e.g. ‘pink elephants’).
Signs include sweating, tachycardia, tachypnoea and pyrexia. Additional signs include dehydration, infection, hepatic disease or the Wernicke-Korsakoff syndrome. If delirium tremens is not treated promptly, death can occur.
Sons of alcohol-dependent people who are adopted by other families are four times more likely to develop drinking problems than the adopted sons of nonalcohol abusers.
A Boston follow-up study showed that one in ten boys who grew up in a household where neither parent abused alcohol subsequently became alcohol dependent compared with one in four of those reared by alcohol-abusing fathers and one in three of those reared by alcoholabusing mothers.
Several factors have been suggested, including abnormalities in alcohol dehydrogenase, neurotransmitter substances and brain amino acids, such as GABA, but, to date, there is no conclusive evidence that these or other biochemical factors playa causal role.
Follow-up studies have failed to identify any trait or tendency that significantly distinguishes those who subsequently abuse alcohol from those who do not.
This is not a common cause of addictive drinking but it is a treatable one. Some depressed patients drink excessively in the hope of raising their mood. Patients with anxiety states or phobias are also at risk.
Excess consumption in society
The idea has grown that rates of alcohol dependence and alcohol-related problems correspond to the general level of alcohol consumption in society and, in turn, to factors that may control overall consumption, including price, licensing laws, the number and nature of sales outlets, and the customs and moral beliefs of society concerning the use and abuse of alcohol.
Successful identification at an early stage constitutes an important treatment in its own right. It should lead to:
• The provision of information concerning safe drinking levels
• A recommendation to cut down where indicated
• Simple support and advice concerning associated problems
Such an approach has been found to be as effective as more expensive and specialized forms of psychotherapy in the treatment of moderate to heavy non-addictive drinking. With addictive drinking, the most favoured psychological treatment is group therapy, which involves identification, confession, emotional arousal, the implantation of new ideas, and the long-term support by fellowmembers of the group. Family and marital therapy involving both the alcohol abuser and spouse may also be important.
Behaviour therapies involving teaching patients how to drink in a more controlled way are the subject of much study.
Addicted drinkers often experience considerable difficulty when they attempt to reduce or stop their drinking. Withdrawal symptoms are a particular problem and delirium tremens needs urgent treatment (Table 19.28). Drugs that show cross-tolerance for alcohol, such as diazepam or chlorrnethiazole, may be used in a regimen that involves a steady reduction over 5-7 days. A useful chlormethiazole regimen is 9-12 capsules for 1 day, 6-8 for day 2 and 4-6 for day 3. However, long-term treatment with drugs should not be prescribed in those patients who continue to abuse alcohol. Many alcohol abusers add dependence on diazepam or chlorrnethiazole to their problems.
Drugs such as disulfiram (Antabuse) react with alcohol to cause very unpleasant acetaldehyde intoxication and histamine release. A daily maintenance dose of such a drug means that an alcohol-dependent drinker must wait until the disulfiram is eliminated from the body before drinking safely. Such drugs, therefore, can provide a ‘chemical fence’ around the drinker for at least 24 hours. Disulfiram implants have been developed that have a treatment life of 6 months. As yet there is doubt as to whether their benefit is psychological rather than pharmacological.
Whereas in the case of non-dependent heavy drinkers the goal of normal drinking within safe limits can be a very reasonable one, the alcohol-dependent drinker must be persuaded to abstain. Abstention, particularly after many years of drinking, is a difficult goal and not surprisingly many fail in the attempt. Research suggests that between 40 and 50% of alcohol-dependent drinkers are abstinent or drinking very much less up to 2 years following intervention.
Specialized treatment units, psychiatric treatment, group therapy and attendance at meetings of Alcoholics Anonymous-the self-help organization that provides members with a social structure to fill the gap previously occupied by drinking are all potential elements in the attempt to keep the alcohol-dependent individual abstinent and healthy. To date, however, there is little convincing evidence that highly expensive, time-consuming and specialized modes of treatment are superior in their efficacy to straightforward advice, support, encouragement and monitoring.
The patient should be hospitalized
Chlormethiazole’ S-12 capsules (each capsule contains
192 mg) for 24 hours, then reduced over 5 days, or
diazepam 4-100 mg for 2 days then reduced
Any dehydration should be corrected
Any electrolyte imbalance should be corrected
Any systemic infection should be treated
B vitamins should be given parenterally
ai.v. should be avoided, if possible.
Management of delirium tremens.