100 Questions and Answers About Alcoholism

100 Questions & AnswersAbout Alcoholism

Charles Herrick, MDNew York Medical College

Charlotte A. Herrick, PhD, RNProfessor EmeritasSchool of Nursing

University of North CarolinaGreensboro, North Carolina

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Herrick, Charles.100 questions and answers about alcoholism / Charles Herrick and Charlotte A. Herrick.

p. cm.ISBN-13: 978-0-7637-3918-8ISBN-10: 0-7637-3918-91. Alcoholism—Miscellanea. 2. Alcoholism—Popular works. I. Herrick, Charlotte A. (Charlotte Anne),1933- II. Title. III. Title: One hundred questions and answers about alcoholism. RC565.H3735 2007616.86’1—dc22

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Contents

Introduction v

Acknowledgments ix

Part 1: The Basics 1

Questions 1–12 discuss fundamental questions about alcohol, including:• What is alcohol? • Is alcohol a drug?• When and how was alcohol discovered?

Part 2: Diagnosis 41

Questions 13–19 discuss the recognition and diagnosis of alcoholism, including:• What is the DSM-IV?• What is alcohol dependency? • What is alcohol abuse?

Part 3: Risk, Prevention, and Epidemiology 63

Questions 20-33 discuss factors contributing to alcoholism, such as:• What is the prevalence of alcohol use and alcoholism?• What other risk factors are associated with alcoholism?• How can I prevent my kids from drug and alcohol abuse?

Part 4: Treatment 93

Questions 34-60 detail treatment options, including:• Who is qualified to diagnose and treat alcoholism?• What is AA, and how does it work?• What is ASAM, and what are the criteria for placement in a particular program?

Part 5: Associated Conditions 157

Questions 61-74 address concerns about other medical conditions associated withalcoholism, for example:

• What are the medical consequences of alcoholism?• Can alcoholism cause dementia?• Are there other neurological effects of alcoholism?

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1 0 0 Q U E S T I O N S & A N S W E R S A B O U T A L C O H O L I S M

Part 6: Special Populations 187

Questions 75-89 explain the effect alcohol has on different populations, such as:• My baby was born with fetal alcohol syndrome. What is that, and what does it

mean for my baby?• How do I know whether my child is just experimenting with alcohol and drugs

or has a real problem with them?• How are men and women different in their response to alcohol?

Part 7: Surviving Alcoholism 231

Questions 90-100 focus on survival, personal rights, and resources, including:• Will I ever be able to drink again?• I was arrested for a DUI. What should I do? • What are my rights to privacy?

Appendix 257

Glossary 261

Index 281

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Introduction

Perhaps no medical topic arouses more confusion, dismay, and pas-sion in both the public and the medical profession than alcoholism.Although alcohol is often associated with joy and celebration, rit-ual, and reverence, alcoholism is associated with sorrow and moralfailing, disease, and death. No other disease entity can be conceivedas having such extreme attributes. This is particularly evident in ourcountry since its inception, where attitudes toward alcohol con-sumption have swung back and forth from liberal use to strict pro-hibition. The debates that stirred the American Revolutionoccurred more often in taverns than churches. Witness the mostrecent popular movie Sideways, in which wine brought out the bestand worst of two friends, arousing aesthetic appreciation, love, pas-sion, anger, and betrayal, but ultimately humor. Wine was neverblamed, and sales of pinot noir increased dramatically. Contrastthat movie with an earlier one, Leaving Las Vegas, that also gar-nered critical acclaim but with less popular appeal. It portrayed aman who was inevitably successful in drinking himself to death. Atone extreme, alcohol represented bacchanalian reverence, and at theother, it represented a living hell.

We currently live in a culture that has little tolerance for risk;thus, drugs such as Vioxx and Ephedra are banned from the marketbecause of their perceived dangers. This perception of risk is basedon emotion, however, not on fact. Society’s decision to ban certainsubstances while allowing others to be freely available has little todo with the dangers inherent in any particular substance, and it hasmore to do with the emotional outcry that a particular substanceengenders. For example, consider the seemingly benign over-the-counter medication acetaminophen, or Tylenol. Tylenol was firstintroduced in 1956. About 150 acetaminophen-related deaths are

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reported every year in the United States alone. Add tothat the associated morbidity and mortality from thoserequiring liver transplants from Tylenol overdoses, andthe numbers become even greater. Contrast that withEphedra, a once hugely popular drug for weight lossand bodybuilding that has been linked to a grand totalof 155 deaths. The deaths from Vioxx are more diffi-cult to calculate because these deaths are primarilyfrom patients already suffering from cardiovasculardisease and not from the direct effects of the drugitself. The estimates suggest up to 27,000 deaths sinceits introduction in 1999. The outrage leading to itsremoval had more to do with the company’s refusal toacknowledge the risks than the risks themselves. Alco-hol, however, is responsible for approximately 85,000deaths annually from injuries or diseases directlyrelated to the use or abuse of alcohol. Thus, peopleoften judge the risks and benefits of a particular sub-stance based more on cultural, religious, and moralbeliefs than on scientific fact. Alcohol is a prime exam-ple (see Part 3 for more information about risk).

Alcohol is the single most unique intoxicantbecause it is a legal, nonprescription, and culturallysanctioned substance that causes more devastatingeffects to human lives than any other known drug,whether available by prescription or over the counteror on the street. Prohibition, the one attempt in Amer-ican history to prohibit alcohol use, was a miserablefailure, with the cure being worse than the illness.Although it successfully cut the deaths from cirrhosisin half, it came at the cost of increased crime and socialunrest.

Ingesting anything—medicine, an illegal drug, oreven food—is an act that entails a degree of risk.

Alcohol is thesingle mostunique intoxi-cant because itis a legal, non-prescription,and culturallysanctionedsubstance thatcauses moredevastatingeffects tohuman livesthan any otherknown drug,whetheravailable byprescription orover thecounter or onthe street.

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1 0 0 Q U E S T I O N S & A N S W E R S A B O U T A L C O H O L I S M Introduction

Therefore, people should understand the risks and thealternatives before ingesting anything. Informed con-sent is both a legal and an ethical responsibility ofhealthcare providers to ensure that their patients areknowledgeable about the drugs they are ingesting,including over-the-counter medications, herbal reme-dies, street drugs, food, and alcohol (see Question 99for a more detailed discussion of informed consent).

This book on alcohol and alcoholism provides nec-essary information for readers to make informed deci-sions. Examining the topic of alcohol and addictionwill also provide readers with information about theinfluence of alcohol on their own personal well-being.Although the focus of this book is on alcohol and alco-holism, many of the questions and answers pertain toother addictive substances and behaviors as well, andthus, this book may offer some useful insight into thenature of addiction on a more general level.

We live in a time when there is a belief that scien-tific facts will ultimately help in legislating morality.The culture wars, whether they are fighting overhealth care, the environment, or other social issues,muster their troops of “scientific experts” when callingon the “facts” to forge political, legal, and moral policy.This is no more evident than the “war on drugs,” inwhich both sides argue persuasively for the need tocontinue or abandon current policies.

Although the institution of medicine has acceptedthe concept of alcoholism as a disease, the larger cul-ture with its personal values and beliefs, whichincludes healthcare providers themselves, continues todebate the issue, with many still viewing alcoholism asa moral failing. This book examines the facts of alco-holism. The following controversial perspective about

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alcoholism is discussed: Is it a disease or a moral fail-ing? Hopefully a path may be developed in order tofind the way out of this no-man’s land, where emo-tions, rather than reason, have left a field littered withthe broken lives of those who this horrible afflictionhas devastated. Because of the controversy of alco-holism as a disease or a moral failing, this bookexplores the controversy at length so that the readercan be properly informed about the issues and thus bebetter prepared to understand them in a way that isempowering rather than confusing.

Susan’s comment:

We celebrated when Ben recently had his 30th birthday.Nearly 6 years ago, while driving, he lost control of the car.The person behind him was very alert, stopped quickly,and found him slumped over the wheel and foaming at themouth. When the ambulance arrived, Ben was awake butdidn’t remember what had happened. After many hoursand a battery of tests in the emergency room, a place thatwould become very familiar in the coming years, the doctorexplained the diagnosis of an alcohol withdrawal seizure.My reply, as well as his sister’s, was “thank you, but I wasinterested in a medical report, not social work.” Accordingto Dr. Herrick, his psychiatrist and co-author of this book,Ben is a “malignant alcoholic” who is still alive—30 hospi-tal trips and 7 rehabs later.

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This book is dedicated to my family, particularly my wife, whoallowed me the time and provided me with invaluable assistance incompleting this book.

I would also like to thank my children, who had to put up withmy preoccupation with this book for so many weekends.

It is also dedicated to the many patients that I have had theprivilege to treat. I am constantly surprised and impressed by theirpersistence in the face of adversity.

Finally, my hope is that this book may prove useful to not onlypatients and their families, but to physicians and other healthcareproviders who continue to struggle with understanding thisunusual disease.

Charles Herrick, MD

I want to express the honor and pleasure that I have experienced byco-editing a book with my son, Charles Herrick. I am a proudmother!

I want to thank my husband, Bob Herrick, and Chuck’s fatherfor his support and patience in helping us to see this project tofruition.

Most of all I would like to thank Ana Cristina Herrick,Chuck’s wife, for being the liaison between the co-authors. Shecoordinated our efforts, provided editorial comments and con-tributed creative ideas to explore the issues. She was the “lynch pin”who made it come together!

Charlotte A. Herrick, PhD, RN

Acknowledgments

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The BasicsWhat is alcohol?

Is alcohol a drug?

When and how was alcohol discovered?

More . . .

PART I

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2


Alcohol

an organic chemicalthat consists of car-bon, oxygen, andhydrogen.

1. What is alcohol?Alcohol is a simple organic chemical that consists ofcarbon, oxygen, and hydrogen. Organic chemicals allcontain carbon, hydrogen, and oxygen as their essen-tial makeup and typically come from organisms, butthere are many synthetic products that make our livesmore convenient. Plastic, oil, and the general makeupof the human body are all organic chemicals. Alcohol,which yeast (a type of fungus) produces, is essentiallya waste product from its consumption of sugar. Allalcoholic beverages contain predominantly water, sec-ondarily alcohol, and finally, depending on the initialsubstance used in the fermentation process, a varietyof other organic chemicals that give each particularbeverage its unique color and flavor. Fermentation canlead to only an alcohol content of 10% to 15% becauseany concentration over that will kill the yeast. Toincrease the alcohol concentration beyond 15%, oneneeds to boil it off from the water—hence the devel-opment of distilled spirits.

2. Is alcohol a drug?When considering whether alcohol is a food or a drugone must ask what is the meaning of the term “drug?”Most people view a drug as a mind-altering chemical,illegally obtained and consumed and potentially dan-gerous (e.g., heroin, cocaine, methamphetamine, mari-juana, and LSD). Drugs have a pejorative connotation.Alternatively, any particular pill that a physician mightprescribe is viewed as a medication. The connotationof medication is “health giving” or “healing.” Thus,antibiotics, antidepressants, antihypertensives, anal-gesics, and chemotherapeutic agents are thought of as

All alcoholicbeverages con-tain predomi-nantly water,secondarilyalcohol, andfinally,depending onthe initialsubstance usedin the fermen-tation process,a variety ofother organicchemicals thatgive each par-ticular bever-age its uniquecolor and fla-vor.


3


The Basics

Historically,Americanshave not con-sidered alco-hol, caffeine,and tobacco tobe drugs ormedications.Consequently,they areviewedsocially andlegally differ-ently fromdrugs or med-ications.

medications and not drugs. Cancer chemotherapeuticagents are prescribed to kill cancer cells. These agents,however, do not know the difference between a cancercell and a normal cell. Fortunately, cancer cells growfaster than most normal cells, and these agents kill thefaster growing cells more than the slower growingcells. Otherwise, they are rather indiscriminate killers,which is why they have terrible side effects and arequite dangerous. They are some of the most toxic sub-stances known to humans; however, they are notthought of as drugs or poisons. Instead, they are con-sidered to be medications that have the power to heal.

Historically, Americans have not considered alcohol,caffeine, and tobacco to be drugs or medications.Consequently, they are viewed socially and legallydifferently from drugs or medications. In fact, suchcategorical distinctions between a drug, a medica-tion, and a socially acceptable substance are purely aproduct of culture and have nothing to do with theproperties inherent in any of these particular sub-stances. All of the categories that these substancesfall under have the potential for mind-alteringeffects. The clinical term for mind altering is literallypsychotropic. Even antibiotics have been known tocause mind-altering effects; however, some sub-stances have known predictable, psychotropic effectsand are sought specifically for that purpose.

The cultural construction of substances provides the linkbetween the pejorative term “drug” and its psychotropiceffects, which is the reason for the public’s misunder-standing about psychiatric medications. The assump-tions are as follows: All drugs are psychotropic. All drugs

Psychotropic

a drug that has aneffect on the psychicfunctions of thebrain, behavior, orexperience.


4


are addictive. All psychiatric medications are psy-chotropic; therefore, all psychotropic medications usedin psychiatry to treat mental illness are addictive. Thisstatement is false (see Question 14 for another descrip-tion with respect to the definition of dependence).

If you were to examine the etymological root of med-ications or drugs (as they should be synonymouslyregarded), you would be rather shocked. The term“pharmakos,” from which the words pharmacy andpharmaceutical are derived, was originally used toidentify the human sacrifice that was offered to “cure”societal ills. With time, the word pharmakos increas-ingly became associated with the various poisons thatwere ingested by the pharmakos as part of the sacrificeand eventual “cure.” These poisons, when ingested,then had a dual role—to kill (the pharmakos) and tocure (society). Now that modern medicine has theability to understand disease processes and the mecha-nisms of drug actions, “pharmakos” has unwittinglybeen liberated from the pejorative term “poison.” Pre-scription medications kill more individuals in Americaevery year than poisons and street drugs combined.Thus, in the end, alcohol is like any of the pharmakosused past and present. It is a medicine, a drug, and afood. Which particular category alcohol falls into is asmuch a matter of the person using it as it is society’sperception of that person and the substance of alcohol.

3. When and how was alcohol discovered?Alcohol was likely first discovered in early human his-tory during the hunter/gatherer days. It was first foundin fruit and honey that had been left standing too long.Mead, made from honey, was most likely the first alco-holic drink. Beer did not develop until there was suffi-


5


The Basics

cient grain that could be harvested with the rise ofagriculture. Wine came about around 6,000 BC. Moreconcentrated alcohol did not develop until the adventof distillation. Beer and mead remained the drink ofpeasants, as their primary nutritional and economicresource was grain, whereas wine required cultivationof grapes, a much more expensive and intensiveprocess, taken over primarily by the Catholic Church,which had the money and resources to cultivate it.Thus, wine was the drink of the religious and the elite.

Fermented sources of alcohol remained the onlysources of alcohol for 9,000 years, until the develop-ment of distillation by Arab alchemists (alcohol comesfrom the Arabic “al kohl,” meaning any material’s“basic essence”). Distillation works because alcohol hasa lower boiling point than water and can be boiled offbefore water boils. It is recaptured in another con-tainer, providing a more concentrated mix of the sub-stance. Distillation did not reach the West until theMiddle Ages. Around this time, Europe was facedwith the Black Death, and Europeans’ survival led to acontinent-wide problem, with alcohol as both anescape from misery and a celebration for those whosurvived. Consequently, there was a dramatic increasein alcohol use and a parallel increase in problems asso-ciated with its use. It was not until the 17th centurywith the advent of other beverages such as tea, coffee,and cocoa that led to a reduction in alcohol consump-tion. Even as late as the latter part of the 19th century,however, a safe supply of water was nonexistent, andthus, alcohol remained a safe form of fluid intake rela-tive to water. It was the confluence of the germ theoryleading to safe water production, religious revivalism,and the application of medical concepts to chronicalcohol dependence that ultimately led to the view of


6


One of themost intrigu-ing phenom-ena is thealmost uni-versal produc-tion andconsumptionof alcohol.What possibleadvantagewould there beto humans toconsume alco-hol overhumans whodo not?

alcohol as being evil. The following question addressesthese issues at greater length.

4. Why do humans use alcohol?For anyone who has had a drink and enjoyed the expe-rience, the question seems ridiculous. For anyone whohas suffered the ill effects of alcohol either directlyor through the sufferings of a loved one, the answerseems beyond comprehension. To bridge the extremesof use and abuse, there are three reasons why humansuse alcohol. First, there may be an evolutionary reasonthat humans use alcohol. Second, there were healthreasons for alcohol consumption, particularly in West-ern Europe. Finally, many people use alcohol to expe-rience its psychotropic effects.

EvolutionEvolution attempts to explain how and why certaintraits in human nature exist. One of the most intrigu-ing phenomena is the almost universal production andconsumption of alcohol. What possible advantagewould there be to humans to consume alcohol overhumans who do not? This question has resulted in thedevelopment of a hypothesis known as the “drunkenmonkey hypothesis” (Stephens & Dudley, 2004). It isbased on a number of facts that when linked togethersuggest a possible explanation to support a survivaladvantage for the consumption of alcohol. Thehypothesis begins with our ancestors, the primates. Alarge portion of a primate’s diet consists of fruit.Where competition for fruit is great, the ability tolocate ripe fruit quickly has a selective advantage. Asfruit ripens, the yeasts on it convert the sugars to alco-hol. The amount of alcohol on the fruit is related tohow ripe the fruit is. Locating fruit by the smell of

Drunken monkey hypothesis

an evolutionary the-ory as to why havinga taste for alcoholmay convey somesurvival advantageby allowing animalsto choose fruit that isthe ripest.


7


The Basics

Drosophila

a type of fruit fly thatis commonly used totest genetic influ-ences to variousphysical and behav-ioral traits.

Alcohol dehydrogenase

an enzyme that is abiological catalystthat accelerates thebreakdown of alcoholinto aldehyde,responsible for manyof the negativeeffects of alcohol.

Aldehyde dehydrogenase

an enzyme thataccelerates thebreakdown of alde-hyde into acetic acid,a nontoxic chemicalthat is easily elimi-nated from the body.

alcohol is the quickest method for locating ripe fruit.Therefore, having a keen sense of smell and taste foralcohol would aid in the acquisition of the fruit. Mon-keys, as well as other fruit-eating animals, have the abil-ity to identify ripe fruits based on the smell of alcoholdispersed by the fruit downwind. Although humankindgave up fruit as a major source of nutrition eons ago,humans share a substantial portion of their geneticancestry with primates. The current problems with alco-hol may be a modern fallout of an initially importantsurvival advantage to having a taste for alcohol.

Although this remains a controversial hypothesis, ithas its appeal. First, alcohol content has been measuredin some fruits, and scientists have found that unripefruit contains no alcohol, whereas overripe fruit con-tains about 4% alcohol. A monkey preferentially selectsfruit with an alcohol content of about 1% at its peak ofripeness. Other species also seem to locate fruit basedon alcohol content, including the fruit fly Drosophila,and a variety of birds, butterflies, and fruit bats.

Health BenefitsAdditional evidence includes the fact that apparentlyalcohol, in moderation, conveys some health benefits toour species as well as others (see Question 28). Fruitflies, for example, live longer and have more offspringwhen exposed to intermediate amounts of alcohol com-pared with no alcohol or high amounts of alcohol. Ifalcohol had only negative health benefits, the selectiveadvantage for its taste and smell may not have devel-oped. Other evidence includes that the genes for alcoholmetabolism, notably alcohol dehydrogenase and alde-hyde dehydrogenase, vary widely within the humanspecies, being less prevalent in East Asians. Withoutthese enzymes, the consumption of alcohol is an

Enzyme

a biological moleculethat catalyzes oraccelerates a chemi-cal reaction. Mostenzymes are pro-teins.


8


Aqua vitae

latin for “the water oflife.”

Potable

drinkable water.

intensely unpleasant experience, and thus, those indi-viduals avoid it. This genetic variation in taste for alco-hol suggests that such genes are selective depending onthe environment. Where these genes are more preva-lent, the rates of alcoholism increase (see Question 20).

Alcohol is unique among intoxicants in that throughoutits early history it was viewed as lifesaving. For most ofthe past 10 millennia, alcohol was probably the mostcommon daily beverage and was a necessary source offluids and calories. In a world of contaminated and dan-gerous water supplies, alcohol earned the title granted itin the Middle Ages: “aqua vitae,” or the water of life.Alcohol was primarily consumed in the West as analternative to water because potable water was scarce.Alternatively, in the East, the practice of tea drinkingallowed for potable water, and the fact that 50% ofAsians lack the enzyme to metabolize alcohol properlycontributed to the more limited use of alcohol in theirculture (see also Question 22, Table 6). Additionally, theanalgesic and euphoric aspects of alcohol were wellknown. Proverbs mentions alcohol as a means of reliev-ing pain and suffering. Finally, alcohol provided a bufferagainst fatigue so that one could avoid the boredom anddrudgery of long marches or backbreaking labor in thefields.

Psychotropic EffectsIntoxicant use has a long history. The attempt to alterone’s conscious state is universal and appears almostinstinctual, seen first in small children taking pleasurein spinning around or hyperventilating. It is seen inevery society and in every epoch. The move from a“natural high” associated with various physical activi-

The attemptto alter one’sconscious stateis universaland appearsalmostinstinctual,seen first insmall childrentaking pleas-ure in spin-ning aroundor hyperventi-lating.


9


The BasicsMitigate

to soften or becomeless harsh.

Metaphysical

relating to a realitynot investigated bythe natural sciencesor perceptible to thenormal senses.

ties, especially sex, to a chemical substance causingsuch a state is a short distance. Drug use has a place inall cultures and has been and continues to be associ-ated with religious rituals and spiritual awakening.This has most likely occurred for a couple of reasons.First, it allows for a particular culture to control theuse and thus mitigate any harmful effects that mayoccur from misuse or overuse. Second, altered states ofconsciousness are sought in order to obtain knowledgeof the divine or the deeper, hidden truths about lifeand the world. Certain drugs are purported to offer ametaphysical and epistemological window into themeaning of life. Alcohol is frequently associated withdivine heavenly rest. The Eucharist confers immortal-ity, and the Koran depicts a paradise flowing withwine. They all demonstrate a desire to penetrate theineffable and to comprehend the universe. The OldTestament and the Talmud make ample references tothe virtues of alcohol and that intoxication is a way ofrelieving oneself from the struggles of life. Today, alco-hol plays a much different role in our lives. Although itcontinues to remain part of ritual and religion, its useis more commonly viewed as a form of relaxation andentertainment. Alcohol is increasingly the social lubri-cant that allows people to be less anxious at socialgatherings and enhances the enjoyment of oneanother’s company. It also stimulates the appetite andenhances the taste of food.

5. How do chemicals work in the brain?We begin with a short introduction to how the brainworks in general and how chemicals interact with neu-rons to alter communication between nerve cells. This

Epistemological

the study of thenature and groundsof knowledge espe-cially with referenceto its limits and valid-ity.


10


Motor cortex Somatosensory cortex

Sensory associativecortex

Visual associativecortex

Visualcortex

Wernicke’sarea

PrimaryAuditory cortex

Broca’sarea

Parsopercularis

Figure 1 Brain and general divisions. From brainconnection.com. Used with permission.Copyright © 1999 Scientific Learning Corporation. All rights reserved.

Gray matter

the part of the brainthat contains thenerve cell bodies,including the cellnucleus and its meta-bolic machinery.

White matter

tracts in the brainthat consist ofsheaths (calledmyelin) coveringlong nerve fibers.

Neuron

a nerve cell made upof a cell body withextensions calleddendrites and theaxon.

will help you to understand how the brain responds tothe ingestion of alcohol. The brain is a complex organthat is comprised of gray matter and white matter. Graymatter consists of the cell bodies of neurons and othersupport cells. White matter consists of long tracts ofaxons, like telephone lines, that run between the neu-rons. Figure 1 shows the brain and its general divisions,and Figure 2 shows a single neuron. Different areas ofthe brain have somewhat different functions. For exam-ple, the motor cortex controls voluntary movements ofthe body, and the sensory cortex processes informationto the senses. Different areas of the brain communicatewith other areas nearby as well as more distantly. Infor-mation starts in the gray matter and travels via the axonsof the neurons, making up the white matter in the brain.


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The Basics

Dendrites Nucleus Synapses

CELL BODY

AXONMyelin sheath

Schwann cell

Synaptic terminals

Node of Ranvier

Figure 2 Single neuron. From brainconnection.com. Used with permission. Copyright ©1999 Scientific Learning Corporation. All rights reserved.

Motor cortex

an area on the outerpart of the brain thatis responsible for vol-untary motor control.

Sensory cortex

an area on the outerpart of the brain thatis responsible fororganizing sensoryinput into a coherentperception at thelevel of conscious-ness.

Neurons and NeurotransmittersThe brain contains billions of neurons that interactwith each other electrochemically. This means thatwhen a nerve is stimulated, a series of chemical eventsoccurs that in turn creates an electrical impulse. Theresulting impulse propagates down the nerve lengthknown as the axon and causes a release of chemicalscalled neurotransmitters into a space between thestimulated nerve and the nerve that it wishes to com-municate with, known as the synaptic cleft (see Fig-ure 3). The neurotransmitters interact with receptorson the second nerve, either stimulating or inhibitingthem. The interaction between the neurotransmittersand receptors can be likened to a key interacting with alock, where the neurotransmitter or “key” engages thereceptor or “lock,” causing it to “open.” This “opening”is really a series of chemical changes within the secondnerve that ultimately either causes that nerve to “fire”

Axon

that part of the neu-ron or nerve cell thatis a long tube con-ducting signals awayfrom the cell body.


12


or not to “fire.” Brain activity is the result of an orches-trated series of nerves firing or not firing in binaryfashion. It is much like a computer where very compli-cated processes begin as a series of 1’s or 0’s (on or off,fire or do not fire).

After the nerve fires, releasing neurotransmitters intothe synaptic cleft, the neurotransmitters must beremoved from the area in order to turn the signal off.There are two ways that these chemicals can beremoved in order to turn the signal off. The first is bydestroying the chemical through the use of anotherchemical known as an enzyme with that specific pur-pose in mind. The second is by pumping the chemicalback up into the nerve that released it by using anotherspecial chemical known as a transporter or transportpump. The process of pumping chemicals back intothe nerve is known as reuptake (see Figure 3). It isimportant to understand these basic principals ofneurophysiology because all psychoactive compounds,whether neurotransmitters, hormones, medications,addictive drugs, or alcohol, involve one or more of thesemechanisms. The differences between their effectsstem from the particular receptor and neurotransmitterwith which it interacts. Alcohol works in the brain in amanner similar to other chemicals, as a “key” that fitsinto a specific “lock” that opens a door for further com-munication. Alcohol, unlike many other drugs of abuse,however, is not a magic bullet targeting a specific areaof the brain and a specific neurotransmitter or receptorsystem. Alcohol works on both the motor and sensorycomponents of the brain and has multiple neurotrans-mitter effects, although it does have a receptor thatappears to be specifically designed for it. These effects

Electrochemical

the means by whicha nerve conducts sig-nals through thebody and axon. Thiscauses a release ofchemicals.

Neurotransmitters

chemical released bynerves that commu-nicate with othernerves causing elec-trochemical changesin those nerves tocontinue to propa-gate a signal.

Synaptic cleft

the gap betweennerves where neuro-transmitters arereleased that allownerves to communi-cate with oneanother.

Receptors

specific areas of pro-tein on a neuron thatare configured torespond only to spe-cific neurotransmit-ters.

Transporter

also known as atransport pump.Transporters aremade up of proteinsthat act as “vacuumcleaners,” taking upleftover neurotrans-mitters from thesynaptic cleft andtransporting themback into the nervecell that originallyreleased them.


13


The Basics

Synaptic vescicle

Post-synaptic densityNeurotransmitterreceptors

Neurotransmitterre-uptake pump

Neurotransmitters

Voltage-gatedCa++ channels

AxonTerminal

Presynaptic

SynapticCleft

Postsynaptic

Figure 3 Synaptic Cleft. www.wikipedia.com.

are not unique to alcohol. Opiates have opiate recep-tors, and marijuana has marijuana receptors, whichmeans that the body produces chemicals with similaractivity as their ingested cousin, alcohol.

6. How does alcohol affect the brain?The exact cause of intoxication at the cellular level isnot clearly known. It appears that although alcohol hasa wide-ranging effect on the brain, certain brainregions are preferentially more sensitive to alcohol, andcertain neurotransmitter systems are involved. Theneurotransmitters affected by alcohol include gamma-aminobutyric acid (also known as GABA), glutamate,serotonin, dopamine, and the endogenous opiates.These neurotransmitters are involved in variousaspects of alcohol’s short- and long-term effects on thebrain that include both intoxication but also with-drawal and possibly addiction. Some neurotransmittersare excitatory—that is, they increase the firing rate ofnerve cells that would normally fire at a lower rate

Transport pump

see transporter.

Reuptake

the process by whichneurotransmittersreturn to the presy-naptic cells afterbeing released intothe synaptic cleft andattaching receptorson the postsynapticcells.

GABA

gamma-aminobu-tyric acid, the brainsmajor inhibitory neu-rotransmitter. Thisneurotransmitterdampens all brainactivity.


14


with a given environmental input—whereas some areinhibitory, or decrease the firing rate of nerve cells inresponse to a given environmental input.

GABA is the brain’s major inhibitory neurotransmit-ter. The function of GABA is to inhibit or dampenoverall brain activity. Thus, general arousal is damp-ened, leading to decreased motor tension and anxietyand increased sedation and sleep. GABA also hasanticonvulsant activity, which prevents seizures. Alco-hol causes GABA to be more potent in the cerebralcortex by altering the GABA receptor in such a way asto make it more attractive to GABA. Most currentprescription sedatives (antianxiety inducing) and hyp-notics (sleep inducing), such as diazepam and loraz-epam, or zolpidem, are medications that act on thisneurotransmitter system in a similar manner as alco-hol. Barbiturates such as phenobarbital also act onGABA receptors. Additionally, anticonvulsant med-ications such as valproic acid, gabapentin, and lamot-rigine increase GABA activity, though by a differentmechanism than the sedative hypnotics. Experimentaldrugs have been used on laboratory rats that actuallyblock the behavioral manifestations of alcohol intoxi-cation, including sedation and loss of coordination.The lack of signs and symptoms of alcohol use proba-bly occurs because these experimental drugs bind tothe GABA receptor blocking alcohol’s ability to alsobind at the same site.

Glutamate is the brain’s primary activating neurotrans-mitter and is another neurotransmitter system that alco-hol affects, but it is opposite from GABA. Glutamatehas a primary role in learning and memory functions

Glutamate

the brain’s majorexcitatory neuro-transmitter. Thisneurotransmitteractivates all brainactivity.

Serotonin

one of the brainsmajor neurotransmit-ters.

Dopamine

one of the brain’smajor neurotrans-mitters.

Endogenous opiates

opioids that developor originate withinthe body.

Anticonvulsant

a drug that preventsseizures from occur-ring.

Barbiturates

a class of drugs thateffect GABA to pre-vent seizures fromoccurring. They areused for anxietydisorder until thediscovery of benzo-diazepines, whichwere found to bemuch safer in.

Phenobarbital

a barbiturate cur-rently used as ananticonvulsant.


15


The Basics

through the alteration of neuronal growth. It can alsoplay a role in nerve cell death when its levels are too highthrough a process known as excitotoxicity. It alsoappears to have a role in the development of psychosisand seizures. Glutamate’s effectiveness is reduced byalcohol’s damping effect on its major receptor known asthe NMDA receptor (for N-methyl-D-aspartate, thechemical that specifically attaches to that particular glu-tamate receptor). Acute alcohol use also inhibits therelease of glutamate, which in turn impacts on the releaseof several other neurotransmitters downstream, includ-ing dopamine, norepinephrine, and acetylcholine.Chronic alcohol use, on the other hand, potentiates orincreases the brain’s sensitivity to glutamate. This occursthrough a process known as upregulation, where thebrain is like a thermostat producing more NMDAreceptors in order to compensate for alcohol’s dampeningeffects. Upregulation may relate to the effects of toler-ance, which means that increasing amounts of alcoholare needed in order to increase GABA further anddampen glutamate. This may also explain withdrawalsymptoms, where sudden increases in glutamate activitymay account for nerve toxicity leading to hyperactivity,psychosis, and seizures.

Serotonin, a third neurotransmitter, is implicated in alco-hol’s intoxicating effects. Serotonin plays a role in anxiety,mood, sleep, appetite, and sexual function. Drugs thatacutely boost serotonin can cause an alcohol-like high.The hallucinogens, such as LSD, mescaline, and psilo-cybin, impact the serotonin neurotransmitter system,thus inducing hallucinations and euphoria and alsoimpairing other cognitive functions. Evidence demon-strates that acute alcohol administration increases sero-tonin activity in the brain as well as impacts various

Valproic acid

an anticonvulsantmedication that actson GABA and is FDAapproved for use inbipolar disorder(manic depression).

Gabapentin (Neurontin)

an anticonvulsantmedication that maybe used as an adjuncttreatment with otherdrugs for seizures foradults and childrenover 12 years old.

Lamotrigine

generic name forLamictal–an anti-convulsant.

Excitotoxicity

the pathologicalprocess by whichneurons are dam-aged and killed bythe overactivation ofreceptors for theexcitatory neuro-transmitter gluta-mate.

NMDA (N-methyl-D-aspartic acid)

an amino acid deriva-tive acting as a spe-cific agonist at theNMDA receptor.

Norepinephrine

a neurotransmitter in the brain as well as a stress hormonereleased by the adre-nal glands.


16


serotonin receptors, increasing the activity of some recep-tors while decreasing the activity of others. On the otherhand, chronic administration of alcohol leads to adecrease in serotonin activity in the brain and causesupregulation of some serotonin receptors that may con-tribute to the development of some of the symptoms oftolerance and withdrawal when alcohol is abruptlystopped. Particularly symptoms of anxiety, dysphoria, andinsomnia often increase. Serotonin may also be responsi-ble for the nausea that people experience from alcohol.Ondansetron, a serotonin receptor blocker, is used as anantiemetic in cancer chemotherapy and may have similarbeneficial affects in alcoholism. It appears that the anti-depressant medications known as selective serotoninreuptake inhibitors (e.g., fluoxetine) increase serotoninin the brain and decrease drinking behavior in rats whohave been selectively bred for alcohol preference andfound to have low serotonin. This effect has also beenfound in humans, although its effects are so modest thatthey are not clinically useful. Serotonin can also affectother neurotransmitter systems. Serotonin can increaseGABA activity, which may contribute to memory lossand cognitive impairment. Serotonin also stimulates therelease of dopamine, which also effects attention, concen-tration, memory, mood, and psychosis.

Opiates, also known as narcotic analgesics, are mostcommonly thought of as pain medications that are asso-ciated with addiction. In the 1970s, it was discoveredthat opiates attach to very specific opiate receptors in thebody and brain that cause analgesia or pain relief. Whywould the body have such receptors if it did not alsomake its own chemicals that fit those receptors? Fromthe findings of this research came the discovery ofendogenous opiates known as enkephalins and endor-phins. These chemicals cause similar effects on the

Acetylcholine

the first neurotrans-mitter discovered.

Potentiates

to make more activeor effective, to aug-ment, and to makemore potent.

Sensitivity

probability of a posi-tive test amongpatients with a par-ticular disease.

Hallucinogen

a classification ofdrugs that produceshallucinations,euphoria, an alteredbody image, dis-torted or sharpenedvisual and auditoryperceptions, confu-sion, loss of motorcoordination, andimpaired judgmentand memory.

Ondansetron

generic name forZofran, an antiemeticdrug that acts onspecific serotoninreceptors.

Antiemetic

a drug known for itsantinausea andantivomiting qualities.


17


The Basics

body as the opiates that are ingested. Alcohol appearsto increase an endogenous opiate known as beta-endorphin. Research has demonstrated that mice specifi-cally bred for the lack of a particular opiate receptor haveno interest in alcohol. When chemicals are administeredthat block the beta-endorphin receptor, rendering it dys-functional, mice decrease their alcohol consumption sim-ilarly to those who do not have the receptor to beginwith. This research has led to the development of spe-cific treatments (see Questions 49 and 50). It is now rec-ognized that opiate receptors are found on knowndopamine pathways in the brain, which suggests thatenkephalins and endorphins, when attached to thesereceptors, also play a role in the release of dopamine.

Dopamine is a major neurotransmitter associated withthe brain’s reward system (Figure 4), but it also plays a

Cingulate gyrus Anterior nucleus ofthalamus

Thalamus

Fornix

Mamillary bodies ofhypothalamus

Hippocampus

Para-hippocampalgyrus

AmygdalaUncus

Hypothalamus

Para-olfactoryarea

Figure 4 Limbic areas involved with mood and reward. From brainconnection.com. Usedwith permission. Copyright © 1999 Scientific Learning Corporation. All rights reserved.

Selective serotonin reuptake inhibitors (SSRI)

a class of antidepressant/antianxiety medica-tion that works byblocking the serotonintransporter.

Fluoxetine

the generic name forProzac, which is aselective serotonin

reuptake inhibitor(SSRI).

Opiate

a type of opioid.


18


role in attention and concentration, involuntary move-ments, and hallucinations. Alcohol boosts dopamine inthe brain, leading to euphoria and possibly contributingto addiction. Increasing scientific evidence suggests thatall drugs of abuse, including nicotine, boost dopamine toone degree or another; however, in experimental studieswith laboratory animals, selectively knocking out thesespecific dopamine pathways affects the quality of alcoholadministration but not the various reinforcers thatprompt the animal to continue to self-administrator.Table 1 lists the various neurotransmitters and alcohol’seffect on the various neurotransmitter systems.

The intoxicating effect of alcohol generally correlateswith the amount of alcohol in the blood. In personswho are not alcoholic, blood alcohol concentrations of25 mg per deciliter indicate mild intoxication mani-fested by alterations in mood, thought, and motor con-trol. At levels above 100 mg per deciliter, signs ofvertigo, double vision, slurred speech, and unsteadygait increase. The legal limit was 100 mg per deciliter,but most states have adopted the more conservativelimit of 80 mg per deciliter to meet the guidelines forfederal highway funding; however, studies demonstratethat levels even as low as 47 mg per deciliter are asso-ciated with an increased risk of involvement in motorvehicle accidents. Blood alcohol levels of 500 mg perdeciliter or greater may lead to respiratory arrest anddeath. Several modifying variables can influence theoutcomes. At the same concentration, a rising bloodlevel of alcohol causes greater intoxication than afalling blood level. This is known as the Mellanbyeffect. Chronic alcohol use can lead to tolerance sothat intoxication occurs at much higher levels than

Narcotic analgesic

an opioid used tocontrol pain.

Enkephalins

an endogenous opi-oid made up ofamino acids. They areproduced in the brainand have an affinityfor opiate receptorsites, acting similarlyto analgesics andopiates.

Endorphins

short for endogenousmorphine. Seeenkephalin orendogenous opiate.

Vertigo

dizziness, as in theroom is spinningaround. This is abrain effect asopposed to light-headedness or feel-ing faint, which isdue to low bloodpressure.

Mellanby effect

impairment fromalcohol is greater at agiven blood alcohollevel when theamount of alcohol inthe blood is increas-ing as opposed todecreasing. This alsoexplains the differ-ences in feeling“hung over” asopposed to “buzzed”at the same alcohollevel depending on afalling or rising level.


19


The Basics

mentioned previously here, and patients with bloodalcohol levels of 500 mg per deciliter are commonlyseen in emergency rooms without clinically significantrespiratory distress.

Table 1 Alcohol’s Effects on Neurotransmitter Systems

• Effects on the dopamine system–Increase dopamine in mesocorticolimbic system–Reinforcing, rewarding effects

• Effects on the opioid peptide system–Activation of opioid peptide system–Reinforcing and rewarding effects (Mu)–Aversion (Kappa)–Craving

• Effects on NMDA glutamate system–Blockage of NMDA receptor (allosteric effect)–Sedative/hypnotic effects–Neuroadaptation–Withdrawal

• Effects on the serotonin system–Neuroadaptation aversion–Depression, anxiety

• Effects on stress hormones–Stress response (fight or flight)–Increased epinephrine and norepinephrine

Experience Transmitter/Receptor

Euphoria/pleasure Dopamine, OpioidsAnxiolysis/ataxia ↑GABASedation/amnesia ↑GABA + ↓NMDANausea 5HT3

Neuroadaptation NMDA, 5HTStress CRFWithdrawal GABA, NMDA (↑Ca, ↓Mg)


20


7. What is addiction?The American Society of Addiction Medicine(ASAM) defines addiction in the following manner:“Addiction is a disease characterized by continuous orperiodic impaired control over the use of drugs or alco-hol, preoccupation with drugs or alcohol, continueduse of these substances despite adverse consequencesrelated to their use, and distortions in thinking, mostnotably denial.” Addicts typically begin by experimen-tation, evolve into regular but controlled use, and ulti-mately find themselves in periodic episodes of loss ofcontrol over the use of alcohol that causes impairmentin various areas of their lives, either physically orsocially. Despite these negative consequences, theycontinue to use. The issue of loss of control is a con-troversial one, as addicts to one degree or another areable to exhibit control over their use with a variety ofreinforcers; however, the reinforcers, whether they arenegative or positive, have much less impact than alco-hol itself in modifying the behavior of an addict. Forexample, for most people, one physical accident fromalcohol use requiring an emergency room visit wouldbe negatively reinforcing—that is, it is enough to mod-ify their drinking behavior to avoid future accidents.For an alcoholic, the visit to the emergency room ismerely a pattern of frequent visits.

Preoccupation with obtaining and using alcohol refersto the fact that the addictive substance plays a centralpart in their inner lives, whether or not they areactively using it. Thus, maintaining abstinence is onlyone element in one’s treatment, as the major strugglecontinues internally. This internal struggle includes,but is not limited to, denial. Also included are thelitany of excuses for continued use, the blaming of oth-

American Society of Addiction Medicine (ASAM)

established in 1989,was the first Ameri-can medical societyto focus on drugs andalcohol.

Reinforcers

the stimuli that arecoupled with abehavior in operantconditioning that areeither applied orremoved to elicit thedesired response.


21


The Basics

ers, particularly family members and caregivers, fortheir failure to maintain abstinence, and the frequentlycited identification with some other emotional prob-lem that really needs to be addressed rather than thealcoholism itself. The negative consequences play littleif any role in modifying the continued use, which isthe final aspect of addiction. From ASAM’s perspec-tive, addiction and dependence can be used inter-changeably. The varying concepts of physiologicaldependence, psychological dependence, and addictionare more thoroughly explored in Question 14.

Addictive behaviors may include gambling, sex, drugs,and all of the variations on those themes, whichrecently include the use of the Internet and involve-ment with pornography. From that simple definition, itappears that no biological or pathophysiological processmust be invoked. The addiction may result from theinvolvement or the pursuit of an activity, rather than onwhat direct effect the pursuit of the activity may haveon the brain. How can gambling or the Internet havethe same effects on the brain as opiates or alcohol?There is no receptor specific for gambling or the Inter-net like there is for opiates or alcohol. Somehow thebehavior and the pursuit of an activity take on a life oftheir own, to the exclusion of all other responsibleactivities. If that is the case, then how can addiction bea disease? This is the subject of our next question.

Susan’s comment:

Unfortunately, Ben’s blood alcohol levels have been morethan 400 or 500 several times. He always amazes thosewho treat him because he is so lucid. Although he exhibitsintoxicated behavior, he is not “falling down drunk” anddoes not exhibit any signs of respiratory distress. One time,


22


however, he was in the high 500s and was comatose afterarrival at the emergency room. Thankfully, he began toimprove immediately with treatment.

Although I understand that he needs to be sober beforetreatment, I always worry that one day we won’t be “cry-ing wolf ” and that something important might be missedwith the overall diagnosis of “severe ETOH intoxication.”Thus, I still continue to bring him to the emergency room.Sometimes I get tired of apologizing; however, many tripshave been made to the same place for the opposite condi-tion: complications from alcohol withdrawal. There is cer-tainly a marked difference in the attitude of medicalpersonnel at the times when he is clearly sick rather thandrunk. Although I sometimes sense that caregivers believethat Ben “deserves” the punishing symptoms of with-drawal, for the most part, they are sympathetic to his plightand mine. Needless to say, I have become acquainted withpeople on the ER staff, who often say to me when I eitherbring him myself or follow the ambulance, “I don’t knowhow you do it.” Most of the time my response consists oftwo questions. First, I ask, “Do you have children?” Whenthey nod their head, which most do, I simply ask, “Wouldn’tyou?” The look of disapproval that is in their eyes seems togive way to a bit more understanding after that.

After Ben is stable and while we are awaiting the results ofthe blood tests, I sometimes go back to my nearby office to fillin my co-workers who have watched this process so manytimes. Someone says, “Doesn’t he realize what he’s doingto you?” I reply, “First, he’s got to realize what he’s doing tohimself.”

8. How is alcoholism a disease?Alcoholism clearly represents problematic behavior;however, before alcoholism can be defined as a dis-


23


The Basics

ease, the concept of disease needs to be understoodmore completely.

The concept fundamentally presumes a causal naturethat results in a pathological state. The most commonexample that everyone can agree on is an infectiousdisease, where a foreign organism invades the bodyand causes a specific set of pathological processes tooccur in the body that ultimately express themselvesas various signs and symptoms. Signs are objectiveevidence that an outside observer can elicit through aphysical examination and/or a set of tests such asblood or urine tests and/or imaging tests. Symptomsare the subjective manifestations of the disease thatthe individual feels. These include the aches, pains,and various discomforts that the person sufferingfrom the disease feels. The discovery of specific treat-ments that killed the underlying organisms strength-ens the disease concept, thus restoring the individualback to their normal state, free of signs and symp-toms of that disease.

With technological advances, however, the concept ofdisease has changed. For example, why do some indi-viduals develop a disease when exposed to a germ,whereas others do not? Genetics, local environmentalconditions, and immune systems all became sources ofstudy in understanding why some individuals carryinga particular organism are more prone to develop thedisease. Disease is no longer a simple matter of findinga germ and killing it. Cause now entails not just theexistence of the germ, but also multiple other factorsthat interact together with the germ to increase one’schances of developing a particular disease.


24


In that respect, alcohol can be viewed in the samemanner as the germ theory of disease. It is the foreignsubstance that is the necessary but not the only factorin the development of alcoholism. Genetic and envi-ronmental factors also play a role in making alcoholmore or less lethal to any one particular individual.Statistical chances for the development of the diseaseare well calculated in terms of amount and exposure toalcohol over time. A natural course develops in thedevelopment of the disease with repeated exposure overtime. There is a consistent set of signs and symptomsthat develop in the course of the disease. Physical examfindings and laboratory tests can support the diagnosis.Abstinence is the key to treatment, albeit the biggestobstacle because of the easy availability of the offend-ing substance.

If you still believe that this analogy is wrong, consider acounterfactual example of a real disease. Tertiary syphiliscauses behavior problems. It took years before the under-lying cause was discovered, but it was well understoodthat it was transmitted through sexual contact. It was theresult of “immoral behavior,” and thus, a great deal ofstigma was attached to it (as there still is). Before the dis-covery of penicillin, the psychiatric wards were populatedwith these patients. Nevertheless, only one third of indi-viduals exposed to syphilis that are untreated develop ter-tiary syphilis. Thus, two thirds of individuals who wereexposed to syphilis escaped both the fatal stages as well asthe stigma attached to the infection. Why do some peo-ple develop tertiary syphilis while others do not? Whatfactors, either inherent in the individual, the environ-ment, or the organism, cause only a third to develop thefatal form? Certainly it is not a matter of choice, of rightliving, or of free will. It is, in the end, a matter of luck.

Genetic andenvironmen-tal factors alsoplay a role inmaking alco-hol more orless lethal toany one par-ticular indi-vidual.


25


The Basics

This example raises the unspoken fact that inherentprejudice exists in ascribing responsibility to individu-als for their disease no matter what the disease is. Thisis especially true today with heart disease and cancerthat unhealthy lifestyles and the increase in obesitycause, but even the seemingly most upright andhealthy individuals can get sick. It is not unheard of tohear comments about someone who gets sick fre-quently as weak or “thin skinned,” whereas others whoamazingly avoid all illnesses are upright, moral, or pos-itive thinkers. Our culture is rampant in applyingmoral values to disease and illness. In that regard, alco-holism is merely on a continuum in terms of people’sattitudes and perceptions.

Susan’s comment:

When my kids were little, I was amazed at how cruel theother kids could be. As Ben and his friends grew, they usu-ally settled things around a keg of beer. Benny enjoyed thatintangible thing that we all secretly wanted for our kids—popularity—so there were many parties and a lot of drink-ing. If the “guys” didn’t get “wasted,” they weren’t cool. Inthe adult world, however, when it comes to alcoholism, cru-elty is universal. People who never turn down a drinkthemselves can certainly be judgmental. These same peoplecan’t wait to scour the DWIs printed in the paper each dayhoping to find someone they know. I wish I thought theywere doing so to thank God that they haven’t gotten“pinched.” Instead, they get some sick kind of pleasure out ofit and can’t wait to get to work to see whether others haveseen it. If it weren’t so true, it would be funny. Also, I oftenhear discussions regarding the disease versus moral failingconcept: “Well, insurance pays for it, so it must be a disease.”


26


Proximate cause

in evolutionary the-ory, the initial causethat changes thebehavior of a biologi-cal system. Pullingone’s hand from afire is caused by areflex arc in the nerv-ous system andwould be an exampleof a proximate cause.

Our health care system has redefined itself as dictated bythe insurance companies, whose own newly created lan-guage refers to the patient as the “subscriber” and the doctoras the “provider.” The decision of what they cover and denybecomes the final arbiter of a “real” medical condition inmany people’s eyes. Insurance coverage provides for this“disease,” so it must be one!

9. What makes alcohol addictive?Several theories exist about why alcohol is addictive.These can be divided into three broad categories: biolog-ical, psychological, and social. The biological categoryconsists of both proximate and ultimate causes. Proxi-mate cause refers to the immediate physiologicalprocesses involved in how particular substances are moreaddictive than others. Less proximate causes include thegenetic susceptibility toward being more prone to devel-oping addiction. The ultimate cause refers to evolution-ary explanations as to why humans developed anattraction to alcohol and why addiction became part ofour genetic makeup. The evolutionary explanation onwhy humans drink alcohol was addressed in Question 4,which entailed the drunken monkey hypothesis. Theproximate cause of alcohol’s affect on the brain regardingthe various neurotransmitter systems that alcoholimpacts was addressed in Question 6. The various neu-rotransmitter systems seem to converge on dopamine.Like the expression “there are many roads to Rome,”there are many neurotransmitter pathways to dopamine.Dopamine is the neurotransmitter in the brain that ismost associated with reward. Alcohol increasesdopamine both indirectly through other neurotransmit-

Dopamine isthe neuro-transmitter inthe brain thatis most associ-ated withreward. Alco-hol increasesdopamine bothindirectlythrough otherneurotrans-mitters as wellas directly ondopamineitself.

Ultimate cause

in evolutionary the-ory, the untimatecause for why a par-ticular behaviorevolves to serve anevolutionary purposethat has survivalvalue.


27


The Basics

Bupropion

generic for Well-butrin, marketed asan antidepressant,and Zyban, marketedas a smoking cessa-tion medication.

Zyban

see bupropion.

Psychosocial theory

a theory developed inthe early 1900s thatthe cause of mentalillness pertains toenvironmental cir-cumstances.

ters as well as directly on dopamine itself. Research hasdemonstrated that dopamine is the neurotransmitter sys-tem affected by all drugs of abuse and probably influ-ences all addictive behaviors. One of the most successfulmedications prescribed for smoking cessation is bupro-pion, known as Zyban, which increases dopamine in thebrain. The genetics of alcohol addiction are covered inQuestion 21.

Learning TheoryPsychological and social theories also explain howalcohol is addictive. These theories can be thought oftogether under one broad category known as psy-chosocial theory. The most well-known and promi-nent theory is learning theory. Learning theoryincludes classical conditioning, operant condition-ing, and modeling.

Classical ConditioningClassical conditioning is a form of learning that occurswhen a stimulus is paired in time with a reward thatcauses an automatic response. Pavlov, a Russian physiol-ogist, used dogs as his subjects to demonstrate this basicphenomenon. In Pavlov’s now classic experiment, a bell(stimulus) was paired with food (reward), causing a dogto salivate. After repeated pairings, the food could beremoved, and the bell alone would cause a dog to sali-vate. This automatic response required no consciouslearning on the dog’s part.

Learning theories

pertain to the acqui-sition of knowledgeand skills and modi-fying behavior tolearn new behaviorsthrough behaviormodification inter-ventions (positiveand negative rein-forcement, extinc-tion) and cognitivebehavior interven-tions.

Classical conditioning

a type of learningthat results when aconditioned andunconditioned stimu-lus are pairedtogether, resulting ina similar response toboth stimuli.


28


Operant conditioning

a type of learningthat is concernedwith the relationshipbetween voluntarybehavior and theenvironment.

Modeling

learning through per-vasive imitation.

Operant ConditioningThe psychologist B.F. Skinner developed the theory ofoperant conditioning in the 1950s with the inventionof the Skinner box. In operant conditioning, a rewardis paired with a specific behavior, such as a rat pressinga lever in order to obtain food or water. The rate andintensity of the lever pressing can be measured againstthe type of reward offered. The number of lever press-ings required can be varied in order to obtain a reward.Varying the numbers of pressings before a reward isgiven is known as intermittent reinforcement and is themost powerful way to sustain a behavior and hamperthe extinction of that particular behavior. The mostwell-known example of that in everyday life is the slotmachine. The length of time extinction occurs afterthe reward ceases can be measured in order to deter-mine the power of a particular reward and the behaviorused in achieving that reward. Offering punishmentwhen a particular behavior is elicited can also modifybehavior in order to eliminate it. This model offers oneof the most useful ways of testing the power of specifi-cally addictive substances.

ModelingThe last psychosocial theory is modeling, which refersto learning by witnessing other’s behaviors. Role mod-els are powerful learning tools. We generally want tocopy the behaviors of those we admire. In our society,for better or worse, our role models are celebrities andthat is why companies use them to sell their products.If celebrities were not successful at selling various con-sumer products companies would not hire them andpay them such handsome fees. Advertisers use celebri-

Intermittent reinforcement

the reinforcement ofa behavior (thereward) that occurssome of the time asopposed to continu-ous reinforcementthat occurs everytime after the behav-ior occurs.

Extinction

elimination of a clas-sically conditionedresponse by therepeated presenta-tion of the condi-tioned stimuluswithout the uncondi-tioned stimulus.


29


The Basics

ties as role models to enhance the image of the product.If we find a celebrity we admire using a particular prod-uct, that product will become much more attractive tous. If that product is alcohol we will want to use it too.All three of these theories offer insight into behaviorsin general and more specifically alcohol addiction.

Putting biology and learning theory together, one canbegin to see how they conspire to cause addiction.Alcohol is a substance that alters perception, self-regard, and mood, generally in positive ways. Theseeffects are highly reliable in that they always occurwith alcohol use and are a function of alcohol’s directphysiological affects. Using alcohol is generally associ-ated with environments and people that are social,engaging, and if not festive, then at least pleasant.Also, when the environment is anxiety provoking,alcohol has the ability to reward the user by reducinghis or her anxiety. Consequently, with continued use in aspecific environment of choice, the positive effects ofalcohol become paired with the environment, makingthe environment immediately attractive and associatedwith drinking alcohol. Over time, the number ofalternative reinforcers or rewards that can substitutefor alcohol decreases, as the immediate reward ofingesting alcohol is more reliably available and repro-duced.

This pattern of use that is associated with specificenvironments that support and reinforce such use leadsto a “crowding out” of alternative positive rewards thatpreviously competed with alcohol but now require toomuch effort and planning when compared with drink-ing. It is well known that individuals in general gravi-tate toward smaller but sooner rewards over larger but


30


later rewards. This is true across all ages and all typesof rewards. For example, a well-known study has con-sistently demonstrated that most young children willchoose the immediate reward of a few M&Ms ratherthan wait a prescribed amount of time for a bag ofM&Ms. Likewise, the immediacy of the reward fromthe use of alcohol overwhelms any delayed gratifica-tion that abstinence may bring. Over time, with thedevelopment of tolerance, an ever-increasing amountof alcohol must be consumed in order to obtain thedesired effect, and the immediate discomfort of with-drawal from alcohol further reinforces its use as a wayof avoiding the punishing feelings from nonuse. Thestrength or weakness of these effects obviously dependson the personality (and/or the genetic makeup) of theindividual. It is clear that some individuals are more sus-ceptible to the addictive effects of alcohol than others.

10. What aspects of alcoholism arevoluntary or involuntary?The assessment of whether any human behavior is volun-tary or involuntary has both ethical and scientific im-plications. Historically, the study of psychology wasoriginally regarded as a moral science, whereas the behav-ior of all other nonhuman organisms and inanimateobjects was regarded as part of the natural sciences. Thisdivision seemed logical because humans act based onconscious voluntary deliberation, whereas all other thingsappear to act in a more mechanical involuntary manner.To some degree, that general belief and separation remaintrue today, illustrating science and society’s continuingstruggle to separate human behaviors that are a result ofnatural causes (involuntary) from those that are a result of


31


The Basics

choice (voluntary). As science continues to advance, theline separating these two alternatives is becoming increas-ingly blurry; however, every society’s ability to functioneffectively and with a sense of fairness requires such dis-tinctions be made. This is important because if a sociallyundesirable behavior is regarded as voluntary, then theperson behaving in that manner should be held responsi-ble for his or her actions and punished appropriately. If,however, his or her undesirable behavior is involuntary, itshould be excused and prompt society to treat the personhumanely in a manner that provides care and relief.

The distinction is easy to make when behavior occursas a result of a specific pathological process, such as abrain tumor or a seizure, or when someone commitsfraud, as the recent Enron trial demonstrated. What ifthe behavior, such as alcoholism, blurs the boundaries,however? Convincing someone that alcoholism is adisease appears to be, on the surface, a bit of rhetoricalspin, especially when voluntary abstinence is the treat-ment of choice for a problem that argues that thechoice to drink is not voluntary in the first place. Thetransition of an individual from a social drinker to analcoholic, when there is no overt pathophysiologicalevidence of a disease, continues to invite a great deal ofsocietal anger. This transition can be complicated anddifficult to define because it is based on a pattern ofbehavior that many people can identify with becausethey too have had a drink in their lives, and it appearedto be a matter of choice when to stop, hence thenotion of moral failing.

The courts generally rely on psychological theories ofbehavior to help them distinguish between behaviors

Convincingsomeone thatalcoholism isa diseaseappears to be,on the surface,a bit of rhetor-ical spin, espe-cially whenvoluntaryabstinence isthe treatmentof choice for aproblem thatargues that thechoice to drinkis not volun-tary in thefirst place.


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Eliciting stimuli

plural for eliciting astimulus. It is a trig-ger that elicits aninvoluntary or auto-matic response.

that are voluntary from those that are involuntary. Asnoted in Question 9, psychological theories of behav-ior rely on learning theory. The courts define volun-tary behavior as behavior that responds to rewards andpunishments, whereas involuntary behavior is definedas the result of a response to eliciting stimuli. Thismakes sense for the simple fact that the courts enforcethe law by prescribing punishments to those whobreak it and thereby (hopefully) providing an incen-tive to not break the law in the future. This is essen-tially the difference between operant and classicalconditioning in that operant conditioning is thoughtto be voluntary and classical conditioning involuntary.

Alcohol dependence is highly rewarding as well as act-ing strongly in a manner that generates various elicitingstimuli ultimately prompting automatic responses. Bothoperant and classical conditioning effects act in concertso that the degree of influence on the behavior as volun-tary verses automatic is difficult to determine. Studiesrepeatedly demonstrate that people with severe addic-tion problems do respond to rewards and punishmentsjust as people without addiction problems do, but toa significantly lesser degree, especially when thoserewards/punishments are competing with the highlyrewarding addictive substance. Alcoholics also havevery strong reactions to eliciting stimuli, such as evok-ing overwhelming cravings when passing a favorite bar,meeting up with a drinking buddy, or having the smelland taste of a particular drink. In fact, eliciting stimulican even provoke such negative reactions as withdrawalsymptoms even after someone has been successfullydetoxed on an inpatient setting and they enter a placewhere those withdrawal symptoms began. For example,

Alcoholics alsohave verystrong reac-tions to elicit-ing stimuli,such as evok-ing over-whelmingcravings whenpassing afavorite bar,meeting upwith a drink-ing buddy, orhaving thesmell and tasteof a particulardrink.


33


The Basics

to understand these feelings better, imagine going with-out water for a day or food for a week. The thirst andappetite centers would become so strong as to focuscentrally and to prompt you to act in any way that cansatisfy your thirst or hunger. This has great survivalvalue, but alcohol has essentially highjacked that part ofthe brain so that it responds more intensely to alcoholthan any other reward or punishment.

If we are to answer the question more thoroughly,other factors need to be considered when determiningwhether any particular alcoholic’s drinking is volun-tary. These include a number of issues: (1) The moreimpaired someone is intellectually, the less voluntaryhis or her behavior can be. This is why society and thecourts generally do not regard the mentally retarded orminors as responsible as normal adults. (2) The morereactive someone’s emotions are to trivial incidents, theless voluntary their actions can be in response to theiremotional states. (3) The more the need to relieve paindrives the craving for alcohol, the less voluntary thebehavior can be. (4) The more restricted the choicesone feels that he or she has, the less freedom he or shehas to act otherwise. (5) The more universal the pat-terns of responses are, the more apt they are part of aprocess that transcends individual choice. (6) Themore detrimental the behavior is to one’s health andsurvival, the less voluntary it is. (7) Finally, howingrained and unchanging the behavior is despiteattempts to modify the behavior with various conse-quences, the less voluntary it is. All of these factorsplay a role in how voluntary one’s alcoholic behavior is.People undoubtedly choose to drink, but no onechooses to be an alcoholic.


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Delirium tremens (DTs)

an acute withdrawalsyndrome from alco-hol that frequentlyoccurs in alcoholicswho have a 10-year(or more) history ofheavy drinking.

Susan’s comment:

The notion of “eliciting stimuli” is hard to imagine, but Ihave watched it happen. For example, being in a hospitalsetting seems to exacerbate Ben’s withdrawal symptoms.After pouring a toxic substance into his body with little toeat for days and subsequently stopping, Ben’s body is com-pletely depleted—like a car running out of gas. Interest-ingly enough, Ben’s surroundings directly impact theseverity of his symptoms. The progressive nature of the dis-ease, along with “kindling” (Question 66), has resulted inhis suffering from serious delirium tremens (DTs) (seeQuestions 63 and 64). This condition, however, has onlymanifested itself in the hospital setting. During the timesthat he takes Ativan and withdraws at home, I watch verycarefully for signs that he may be headed “off the reserva-tion,” but it doesn’t seem to happen. There may be a lot ofreasons for that, but I believe that the hospital setting elic-its his anxiety much worse than the home environment.

11. Is alcoholism a disease or just a badhabit?Alcoholism has actually had a long history of debateover its exact nature. Although alcoholism was alwaysconsidered a scourge, Thomas Trotter, a doctor at theturn of the 19th century, was one of the first to relatealcoholism to the increasing numbers of patients inasylums. Doctors working in the asylums were seeingincreasing numbers of patients suffering from mentalillnesses as a result of alcoholism. Trotter consideredthe heavy drinker to be ill. Brühl-Cramer, a Germandoctor, also considered heavy drinking to be a diseaseand used the term dipsomania to describe the disor-der. He went on further to state that the loss of moral

Dipsomania

an uncontrollableurge or craving foralcohol. This is an oldexpression for analcoholic.


35


The Basics

judgment was a consequence and not the cause of thedisease. Lippich (1799–1845), an Austrian doctor whofollowed 200 drinkers for 4 years, produced the firststatistical evidence of the effects of alcohol and estab-lished that alcoholics were more prone to illness andhad fewer children and shorter lives than the generalpopulation. Benjamin Rush, the revolutionary hero,considered the father of American psychiatry, pub-lished An Inquiry into the Effects of Ardent Spirits on theHuman Mind and Body in 1784. He wrote that alco-holism was due to a loss of the will and that althoughit may have begun as a matter of choice it eventuallybecame a necessity.

E.M. Jellinek, a New England physician, was the firstto attempt a classification of alcoholism. He foundedthe Research Council on Problems of Alcohol in 1937and undertook the first serious statistical study of theproblem in the United States, eventually published in1942. His study demonstrated the failure of prohibi-tion and showed the complexity and variability ofdrinking habits within populations across the UnitedStates. He was instrumental in getting the WorldHealth Organization (WHO) to accept his definitionof alcoholism and to define it as a disease. Jellinek wasthe first to describe alcoholism as a dependence thatinterferes with all aspects of one’s life, including a per-son’s mental health, bodily health, personal relation-ships, and occupational functioning. Because of that,he felt medical care was necessary. Alcoholism becameknown as Jellinek’s disease.

There has been a long-standing historical tradition thatalcoholism is not simply a matter of choice because the


36


consequences of the behavior are so self-destructive thatno one in his or her right mind would ever choose sucha course of action. The emphasis has been consistentlyplaced on the loss of control that the alcoholic experi-ences in his or her attempts to stop despite such obvi-ously destructive consequences. This criterion definesthe boundary between the normal and the pathologicaland not the amount or frequency of one’s alcohol con-sumption. Mounting biological and psychological evi-dence continues to show that people struggling withalcoholism are different from the normal population.

There are many ways to try to understand and dissectthe behavior of an alcoholic, and no one doubts that thebehavior is abnormal; however, calling alcoholism a dis-ease suggests that it is the result of a specific patho-physiological process, which it clearly is not.Alcoholism is more likely the final end product ofvarying conditions, but so are obesity, heart disease,and cancer. Many people are quick to criticize the dis-ease concept because the social consequences suggestthat if we do not hold alcoholics responsible for theirbehavior then the “disease” provides an excuse for thelack of control and continued drinking. In fact, no evi-dence exists showing that people with alcoholism needan excuse to drink. Quite the opposite occurs—callingalcoholism a moral failing, a disease, or a disorder doesnot change the alcoholic’s self-destructive behaviorand the problems associated with that behavior. It onlychanges the perceptions of people who have reasons totreat alcoholics as either ill or contemptible. As Shake-speare so eloquently wrote, “A rose by any other namesmells just as sweet.”

There has been a long-standing historical tradition thatalcoholism isnot simply amatter ofchoice becausethe conse-quences ofthe behaviorare so self-destructivethat no one inhis or her rightmind wouldever choosesuch a course ofaction.


37


The Basics

Susan’s comment:

People often deem alcoholism as a lack of self-control, eventhose who display the same characteristics in other areas.For example, Ben’s older sister has always struggled withher weight, but her brother’s illness/behavior has still beenvery difficult for her; she is unable to hide her disappoint-ment and anger. This, of course, hurts him, which elicitsanger in me. Several months ago, after another of Ben’srelapses on an important occasion, she was very frustrated,leading her to be unkind, pompous, and judgmental. As shewas berating her brother, I could feel the anger building inme. I asked her whether she thought that Ben had a lack ofself-control. She exclaimed, “Yes, I certainly do.” I thenasked her to explain the difference between his lack of self-control with alcohol and her struggle with weight. Ofcourse, she was furious because I had struck her where ithurt. This is only one example of how alcoholism has thepotential to gut family relationships.

12. What causes the disease of alcoholism?The facile answer would be drinking alcohol in excesscauses alcoholism, but that begs this question: Why dosome people drink to excess, whereas others do not?Why can some people drink larger quantities thanothers and suffer no ill effects? If alcoholism is a dis-ease (see Question 11), then it should be considered adisease of lifestyle—that is, alcoholism is the conse-quence of particular cultural and environmental forcesplaying on one’s biological predisposition. Conse-quently, multiple causes, rather than one simple cause,must exist. This is true for most medical conditions.The three leading causes of death—heart disease,stroke, and cancer—are all diseases of lifestyle. For


38


example, consider the link between smoking and lungcancer. Smoking did not exist in Western culture untilthe discovery of the New World in the late 15th cen-tury. For centuries later it gradually took root as anacceptable and perhaps even healthy habit. It was onlyin the last 50 to 60 years that doctors began to suspectthat it was responsible for the rise in lung cancer. Still,it took many years of statistical analysis before scien-tists could demonstrate a clear causal link between cig-arette smoking and lung cancer. Even this statisticalanalysis required a cultural shift to accept that fact.Even today, people argue, “My grandmother smokedher entire life and died at the ripe old age of 90 fromnatural causes. How can cigarettes possibly cause can-cer?” The reality is that cigarette smoking is only onepiece, albeit a big one, of the causal puzzle that leads tolung cancer. Instead, when physicians talk about cause,they are really talking about various risk factors thatinfluence the odds of developing a particular illness.This is discussed at greater length in Questions 21 and22. Alcohol use is a necessary but not sufficient causein the development of alcoholism.

A variety of sources inside and outside of a personimpact the odds of becoming alcoholic. The biopsy-chosocial model provides a framework for understand-ing the multifactorial causes of alcoholism. In thismodel, considerations are given to biological, psycho-logical, and social factors that influence the odds ofdeveloping any particular disease. This model providesa greater understanding of “diseases of lifestyle.” Forexample, applying the biopsychosocial model to lungcancer demonstrates the biological risk factors of fam-ily history, the presence of particular genetic markers,and the direct effects of particular carcinogens acting


39


The Basics

People whoare antisocialor prone torisk taking aremore likely toabuse drugsand alcohol.Also, peoplewho are anx-ious, particu-larly in socialsituations, aresusceptible toalcohol abuseand depend-ence.

on the tissues; psychological risk factors of addictive per-sonality, and/or certain mental illnesses such as schizo-phrenia, that make an individual more prone to smoking;and the social risk factors of exposure to peers whosmoke, the person’s diet and activity level, or exposure toother environmental toxins. All of these factors influencethe odds of having lung cancer.

Biologically, alcoholism is associated with changes invarious neurotransmitter levels and activity. Addition-ally, alcoholism frequently runs in families, suggestinga genetic, or heritable, aspect to the illness. Psychologi-cally, certain personality types are more prone to devel-oping alcoholism. People who are antisocial or proneto risk taking are more likely to abuse drugs and alco-hol. Also, people who are anxious, particularly in socialsituations, are susceptible to alcohol abuse and depen-dence. Socially, alcoholism is linked to stressful lifeevents, usually entailing an overwhelming psychologi-cal trauma. Individuals with a posttraumatic stressdisorder (PTSD) are more prone to alcoholism. Insummary, no one cause of alcoholism exists. It is amultifactorial disorder caused by a genetic predisposi-tion, personality traits, psychological trauma, and envi-ronmental factors.

Susan’s comment:

The “biopsychosocial” model can easily be applied to Ben.

Biologically, a very significant family history of alcoholabuse exists on both sides. In addition, Ben suffered a skullfracture in three places as a result of a fall when he was 2.5years old. Two CAT scans of his brain about 2 years apartin the past 5 years reveal “diffuse cerebral atrophy fairlysevere for the patient’s age.” Everyone agrees that there is a

Posttraumatic Stress Disorder (PTSD)

a mental/emotionaldisorder that is char-acterized by persist-ent distressingsymptoms lastinglonger than 1 monthafter exposure to anextremely traumaticevent.


40


relationship between that event and how severe his diseaseis. If nothing else, this serves as more evidence that it is“not his fault,” which a mother needs to believe.

Psychologically, Ben was diagnosed with moderate tosevere ADHD in the fourth grade, but at the time, I wasnot a believer in a condition that seemed like an excuse forlack of attention and laziness. He was excitable as a smallchild, and as he grew, that turned into serious anxiety.

Socially, Ben’s father lost his business in a very public andhumiliating way, a consequence of drinking, about a yearafter the first withdrawal. Along with that, Ben’s accus-tomed lifestyle was lost: his own convertible, a waterfronthouse with a boat, country club membership, etc. In addi-tion, Ben’s dad also had a much-loved girlfriend who diedsuddenly at around the same time. Currently, the worstsource of inner conflict for him is his relationship with hisfather, who still drinks actively. I have done everything tokeep them apart but have failed, and the loyalty of this sonto his father is both destructive and unshakable. Myremarriage almost 6 years ago has been a huge adjustmentfor Benny, who was used to having me all to himself.


DiagnosisWhat is the DSM-IV?

What is alcohol dependency?

What is alcohol abuse?

More . . .

PART II


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13. What is the DSM-IV?DSM-IV and DSM-IV-TR are the abbreviations forDiagnostic and Statistical Manual of Mental Disorders (IVrefers to the 4th edition, and TR stands for text revised).This is considered the standard diagnostic manual forestablishing the diagnosis of various mental disorders.In its introduction, a few caveats are outlined. First, theterm “mental disorder” implies a distinction from “phys-ical” disorders that is a relic of mind/body dualism. Sec-ond, the term “‘mental disorder’ lacks a consistentoperational definition that covers all situations.” Third,the categorical approach has limitations in that discreteentities are assumed when in fact there are no absoluteboundaries dividing one disorder from another. Fourth,the criteria for each disorder serve as guidelines onlyand should not be applied in either a “cookbook fash-ion” or in an “excessively flexible” manner. Finally, thepurpose of the manual is primarily to enhance agree-ment among clinicians and investigators, and it does notimply that any “condition meets legal or other non-medical criteria for what constitutes mental disease,mental disorder, or mental disability” (see the Introduc-tion and Cautionary Statement of DSM-IV-TR).

You should keep these caveats in mind, as it is easy toget caught up in a physician’s diagnosis, believing thatit is set in stone, which it is not. As new information isacquired about treatments, the diagnoses and treat-ment plans are very likely to change. Additionally, it isnot uncommon for clinicians to disagree on the diag-nosis because of the previously mentioned caveats.After an initial assessment, when reading the variouscriteria individually, it may be easy to assume accuracyand jump to the conclusion that criteria have identi-


43


Diagnosis

fied the condition. Only time and the guidance of askilled clinician, who is probing and comprehensive inhis or her questioning, will help to establish a diagno-sis that leads to an effective treatment plan.

Any set of psychological symptoms must either impairfunctioning or cause significant distress in order to qual-ify as a psychiatric disorder. It is easy to make assump-tions and/or come to false conclusions with this lastcriterion as a guide. What constitutes distress or disabil-ity is often a quality-of-life issue. If a Harvard-educatedMBA holds a midlevel job in a small company, does thatmean that he or she has not risen to an expected poten-tial? Consequently, he or she may be labeled as “dis-abled” or “distressed” because of the perceived lack ofsuccess. If he or she is a daily drinker, was it the drinkingthat led to his or her lack of progress? Was it simply alifestyle choice of wanting to leave the rat race? Ulti-mately, only that individual can answer such questions;however, with the guidance of a good therapist, honestanswers may be found. Unfortunately, we live in a cul-ture that increasingly stresses material wealth as the finalmeasure of success. This can and has led to a lot of “dis-tressed” individuals in our society who all too oftensearch for “therapeutic” solutions for their misguidedsense of “failure.”

14. What is alcohol dependency?According to the ASAM, addiction and dependencyare interchangeable terms (see Question 7). In themid-1980s, the WHO operationalized the concept ofdependence syndrome, adapted by both the DSM and

According tothe ASAM,addiction anddependencyare inter-changeableterms (seeQuestion 7).


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Table 2 DSM-IV-TR Criteria for Alcohol Dependence

A maladaptive pattern of alcohol use, leading to clinically significantimpairment or distress, as manifested by three or more of the followingseven criteria, occurring at any time in the same 12-month period:

1. Tolerance, as defined by either of the following:• There is a need for markedly increased amounts of alcohol to

achieve intoxication or desired effect.• There is a markedly diminished effect with continued use of the

same amount of alcohol.2. Withdrawal, as defined by either of the following:

• For the characteristic withdrawal syndrome for alcohol, refer toDSM-IV.

• Alcohol is taken to relieve or avoid withdrawal symptoms.3. Alcohol is often taken in larger amounts or over a longer period

than was intended.4. There is a persistent desire, or there are unsuccessful efforts to cut

down or control alcohol use.5. A great deal of time is spent in activities necessary to obtain alco-

hol, use alcohol, or recover from its effects.6. Important social, occupational, or recreational activities are given

up or reduced because of alcohol use.7. Alcohol use is continued despite knowledge of having a persistent

or recurrent physical or psychological problem that is likely to havebeen caused or exacerbated by the alcohol (e.g., continued drinkingdespite recognition that an ulcer was made worse by alcohol con-sumption).

Source: The American Psychiatric Association. (1994). Diagnostic and StatisticalManual of Mental Disorders (4th ed.) (DSM-IV-TR, p. 197). Washington, DC:Author.

ICD (International Classification of Diseases) com-mittees. The syndrome refers to a cluster of physiolog-ical, behavioral, and cognitive processes. TheDSM-IV-TR delineates these processes with the fol-lowing specific criteria as described in Table 2.

Because only three of seven criteria are required tomeet the diagnostic requirement for dependence,whereas tolerance and withdrawal are prominently fea-tured, they are not necessary to meet the definition of

ICD (International Classification of Diseases

this is the WorldHealth Organization’smanual for classify-ing all diseases,including mentalillness and substanceabuse.


45


Diagnosis

dependency. Therefore, there is the possibility that anindividual can be dependent without developing toler-ance or withdrawal. There is also the possibility that aperson can develop tolerance and withdrawal withoutactually being dependent. This is an important conceptthat requires further explanation.

Dependency’s distinction from tolerance and with-drawal is one of the greatest sources of confusion withrespect to drugs in general and alcohol more specifi-cally. Many prescription and nonprescription medica-tions on the market can cause tolerance and with-drawal syndromes. The most obvious drug that peoplethink about in terms of dependency includes the pre-scription pain medications called opiates. Everyonewho takes these medications on a regular basis willdevelop some level of tolerance and withdrawal, andtherefore, the medications must be tapered in order toavoid withdrawal symptoms. As the criteria demon-strate, the experience of tolerance and withdrawalalone does not mean that a person has developed anaddiction or dependency to medication.

Many medications that cause tolerance and with-drawal are never thought of as addictive, includingsome antihypertensive medications, anticonvulsantmedications, steroids, and antidepressant medications.Physicians have never regarded any of these as addic-tive. Alternatively, many street drugs do not cause anymeasurable physiological changes in the body thatcould be labeled as tolerance or withdrawal, but never-theless, these are some of the most highly addictivesubstances known to humans. This then leads to ahumorous irony. When certain medications are pre-scribed for their psychotropic effects rather than any


46


other effects they might have, such as antidepressantsand antianxiety agents for depression and anxiety asopposed to migraines or seizures, evidence of toleranceand withdrawal is immediate proof of addiction,despite the fact that no other criteria of dependenceare met while using these medications. At the sametime, many argue that because some street drugs showno evidence of tolerance or withdrawal, they areabsolutely not addictive.

Again, as the criteria explicitly state, if the drug doesnot become a central activity in people’s daily lives (theother five criteria delineated essentially fall under theconcept of “loss of control”), then they are not ad-dicted or dependent on the drug. There is, however,another source of unending confusion, which issemantic in nature. Conflating the DSM definition ofdependency with the common definition of depend-ency can only be thought of in a pejorative way. Thisonly further confuses the concept. People depend onall kinds of things that are specific to their individualneeds. A diabetic, for example, is dependent on his orher insulin, a paraplegic on his or her wheelchair, and aperson with schizophrenia on his or her antipsychoticmedication. Under these circumstances, being depend-ent on something on a daily basis to restore one’shealth and allow one to improve his or her ability tofunction in the world is a good, not bad, thing. Unfor-tunately, the pejorative term for dependency has ledmany patients to refuse or stop necessary treatmentssimply because of the belief that it is an addiction anda sign of weakness or moral failing. Again, the largerculture is at work on this issue, where any form ofreliance on anything or anyone outside of oneself is asign of weakness.


47


Diagnosis

Table 3 DSM-IV-TR Criteria for Alcohol Abuse

• A maladaptive pattern of alcohol use leading to clinically significantimpairment or distress, as manifested by one (or more) of the follow-ing, occurring within a 12-month period:1. Recurrent substance use resulting in a failure to fulfill major role

obligations at work, school, home (e.g., repeated absences or poorwork performance related to substance use; substance-relatedabsences, suspensions, or expulsions from school; neglect of chil-dren or household)

2. Recurrent substance use in situations in which it is physically haz-ardous (e.g., driving an automobile or operating a machine whenimpaired by substance use)

3. Recurrent substance-related legal problems (e.g., arrests forsubstance-related disorderly conduct)

4. Continued substance use despite having persistent or recurrentsocial or interpersonal problems caused or exacerbated by theeffects of the substance (e.g., arguments with spouse about conse-quences of intoxication, physical fights)

• The symptoms have never met the criteria for substance dependencefor this class of substances.

Source: American Psychiatric Association. (1994). DSM-IV-TR, Diagnostic andStatistical Manual of Mental Disorders (4th ed., Text Revision, p. 199). Wash-ington, DC: Author.

15. What is alcohol abuse?Abuse is the self-administration of any drug in a cul-turally disapproved manner that causes adverse conse-quences. The National Institute on Alcohol Abuse andAlcoholism defines alcohol abuse as “a maladaptivedrinking pattern that repeatedly causes life problems.”The DSM-IV-TR defines alcohol abuse in Table 3.

Abuse is often diagnosed in individuals who recentlybegan using alcohol. Over time, abuse may progress todependence; however, some alcohol users abuse alcoholfor long periods without developing dependence. Thedifference between dependence and abuse is mostobvious in terms of the issue of tolerance and with-drawal. As was earlier pointed out, however, toleranceand withdrawal are not necessary to the diagnosis ofdependence. Using ever-increasing amounts of alcohol

Abuse is the self-adminis-tration of anydrug in aculturallydisapprovedmanner thatcauses adverseconsequences.


48


and spending ever-increasing time in pursuit of alcohol(along with the negative consequences as defined inabuse) are sufficient issues to warrant the diagnosis ofdependence. Thus, someone may periodically misusealcohol in a way that gets him or her into trouble, but hisor her use never escalates to the point of dependence.

16. How do you know whether you arean alcoholic?As noted Questions 14 and 15, alcoholism refers tothe two DSM-IV-TR categories of alcohol abuse anddependence. The simple answer, therefore, is that if anindividual fits either of those categories, then he or sheis an alcoholic. The more complex answer takes intoconsideration the caveats noted in the previous answerabout the limitations of the DSM-IV-TR. Should thefollowing criteria be used to define alcoholism: “aninability to fulfill a major role” or “recurrent use despitesocial or interpersonal problems such as argumentswith one’s spouse about the consequences of intoxica-tion”? What does “often” mean? One patient reportedthat her alcohol counselor compared her high level offunctioning despite her “alcoholism” to WinstonChurchill’s alcoholism. Her response to the compari-son was curt, but to the point, “And where would Eng-land be today if he had been forced into a rehab duringthe war?”

It is important to distinguish between quantitative andqualitative differences. A quantitative differencebetween a regular drinker and an alcoholic suggests aslippery slope downward. The line must be drawnsomewhere along that slippery slope between the nor-

Using ever-increasingamounts of alcohol and spendingever-increasingtime in pur-suit of alcohol(along withthe negativeconsequencesas defined inabuse) are suf-ficient issues towarrant thediagnosis ofdependence.


49


Diagnosis

mal, regular drinker; the heavy but functional drinker;and the abnormal, pathological alcoholic. The qualita-tive difference between a drinker and an alcoholic sug-gests that these two different individuals representdistinct types or categories. Nothing in the diagnosticand medical literature actually represents such cleardistinctions. Where should the line be drawn betweennormal blood pressure and hypertension? Betweenbeing merely overweight and obese? Between precan-cerous tissue and cancer? Between heavy drinking andalcoholism? Clearly there are types, according to diag-nostic criteria, that everyone can agree on as represent-ing hypertension, obesity, cancer, and alcoholism;however, that still does not capture a large number ofpeople who fall somewhere in between. The line isdrawn depending on risk. For example, when lookingat hypertension, studies demonstrate that blood pres-sure higher than 140/90 for people over the age of 18years has a dramatically increased risk of heart attacksor strokes compared with those with blood pressuresthat are lower than those numbers. Increased risk isnot a guarantee, just a higher probability. How manydrinks you consume daily can also be measured againstrisk but offers no guarantee either. The easiest way tounderstand this is to think of buying a lotto ticket.Buying two tickets may double your chances of win-ning, but the odds still remain infinitesimal.

Consider the example of a person who drinks threedrinks five times a week and on two occasions up to sixdrinks. Clearly this person’s alcohol use is heavy, butwhat if this person has never missed work, has neverhad relationship difficulties, has never had an eyeopener, has never shown up to an important engage-ment intoxicated or endangered himself or herself


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DWI

a legal acronym fordriving while intoxi-cated.

because of intoxication, but noticed after stopping fora couple of days some mild withdrawal symptoms suchas tremors and insomnia. Out of concern, he or shesees the doctor for a physical examination, includinglaboratory studies, and everything is found to be en-tirely normal. This person clearly demonstrates toler-ance and withdrawal, but this person does not meetthe criteria for either alcohol abuse or dependence!Contrast this with a person who drinks only on week-ends but drinks to the point of passing out every timeand has no idea how much he or she consumes, hashad several DWIs, and has been told by the physicianthat he or she has alcohol-induced liver disease. Despitethese consequences, the person can neither control theamount that he or she drinks nor stop drinking. Thisperson has never experienced withdrawal symptoms.Nevertheless, this person does meet the criteria for alco-hol dependence!

To reiterate, alcoholism does not depend on theamount or frequency of alcohol used! A third scenarioincludes those people who call themselves alcoholicsbut have absolutely no objective pathological evidenceto support their belief. Their livers are fine. They havenever needed hospitalization or detoxification. Theyhave never shown up to work drunk. Nobody has everwitnessed them misusing alcohol. For them, however,they felt that alcohol was playing a role in their lifethat was leading them down a path toward eventualself-destruction. They somehow understood their vul-nerabilities and headed them off at the pass or at leastbelieved strongly enough that that is what they neededto do. Are they really alcoholics who stopped their dis-ease dead in its tracks? Many people who are alcoholicremit spontaneously. They decide one day to stop, andthat is the end of it.

To reiterate,alcoholismdoes notdepend on theamount or fre-quency of alco-hol used!


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Diagnosis

Validity

the accuracy of theoutcome of a test orinstrument (i.e., theextent to which a testor instrument meas-ures what it intendsto measure).

17. What are the screening toolsavailable for alcoholism, and are theyreliable?To understand the validity and reliability of screeningtools, you must understand that they are measured andcompared in terms of sensitivity and specificity. Sen-sitivity refers to the ability to identify correctly thoseindividuals who are true alcoholics in a population.Specificity refers to the ability to correctly identifythose individuals who are clearly not alcoholics. Teststhat have high sensitivity and specificity are valid andreliable. No test, not even specific laboratory tests, is100% sensitive and specific. False positives and nega-tives exist for every test. That does not make them use-less. Keep these concepts in mind when consideringthe use of the various screening tools used.

Several screening tools are available to identify alco-holism. In 1982, the WHO developed the AUDIT,which is an abbreviation for Alcohol Use DisordersIdentification Test. It was designed as either a briefstructured interview or self-assessment to be incorpo-rated into general health screening or during a generalmedical history. AUDIT has 92% sensitivity and 94%specificity. This means that it correctly identifies 92 of100 alcoholics and 94 of 100 nonalcoholics (see Table4 for the complete screening tool).

Because many felt that the AUDIT was too time con-suming, shorter versions were developed. These short-ened versions, known as the AUDIT-PC, AUDIT-C,and FAST, essentially contain the first three or fourquestions of the AUDIT. Needless to say, they are not

Reliability

the ability to repro-duce the same out-comes upon repeatedtesting.

Specificity

probability of a nega-tive test amongpatients without dis-ease. A very specifictest, when positive,rules in disease.

Sensitivity

probability of a posi-tive test amongpatients with a par-ticular disease.


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Table 4 The AUDIT

The Alcohol Use Disorders Identification Test is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore,it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly aseffective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

Questions 0 Points 1 Point 2 Points 3 Points 4 Points

1. How often do you have a drink containing alcohol?

2. How many drinks containing alcohol do you have on a typicalday when you are drinking?

3. How often do you have six or more drinks on one occasion?

4. How often during the past year have you found that you werenot able to stop drinking after you had started?

5. How often during the past year have you failed to do what wasnormally expected of you because of drinking?

6. How often during the past year have you needed a first drink inthe morning to get yourself going after a heavy drinking session?

7. How often during the past year have you had a feeling of guiltor remorse after drinking?

8. How often during the past year have you been unable toremember what happened the night before because you hadbeen drinking?

9. Have you or has someone else been injured as a result of yourdrinking?

10. Has a relative, friend, or a doctor or other health care workerbeen concerned about your drinking or suggested you cut down?

Never

1 or 2

Never

Never

Never

Never

Never

Never

No

No

Monthlyor less3 or 4

Less thanmonthlyLess thanmonthlyLess thanmonthlyLess thanmonthlyLess thanmonthlyLess thanmonthly

2–4 times amonth5 or 6

Monthly

Monthly

Monthly

Monthly

Monthly

Monthly

Yes, but not inthe past yearYes, but not inthe past year

2–3 timesa week7–9

Weekly

Weekly

Weekly

Weekly

Weekly

Weekly

4 or moretimes a week10 or more

Daily oralmost dailyDaily oralmost dailyDaily oralmost dailyDaily oralmost dailyDaily oralmost dailyDaily oralmost daily

Yes, duringthe past yearYes, duringthe past year

Scoring: Less than 10 does not require additional medication.


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Diagnosis

as valid, and thus, they require the person administer-ing the test to question further when a concern is iden-tified. The first question in FAST—“How often doyou have eight or more drinks on one occasion?”—cor-rectly identifies up to 70% of hazardous drinkers whoanswer either weekly or daily/almost daily. Thus, it canbe administered rapidly, and one need not ask addi-tional questions unless someone answers the first ques-tion as monthly, less than monthly, or never.

CAGE is another common screening tool. CAGE isthe mnemonic for the four questions asked: (1) Didyou ever feel the need to Cut down on your drinking?(2) Have friends or family Annoyed you by criticizingyour drinking? (3) Have you ever felt bad or Guiltyabout your drinking? (4) Have you ever had a drink inthe morning, an Eye opener, in order to get rid of ahangover? This was developed in 1974 and focuses onlifetime rather than current drinking. It is the mostwidely used in clinical practice and takes only a minuteto administer. Two positive responses are considered apositive result. Because CAGE does not focus on pat-terns and amounts of drinking, it does not identifycurrently hazardous drinking. Sensitivity ranges from60% to 90% and specificity from 40% to 95%.

In order to avoid the lengthiness of AUDIT and limita-tions of CAGE, the Five-shot screening tool was devel-oped that incorporated the first two questions of theAUDIT with three questions from the CAGE. Thisincludes two questions regarding frequency and theamount of alcohol with three basic questions from theCAGE and their various responses as noted in Table 5.At a cut off score of 2.5, the Five-shot tool was found to


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Table 5 The Five-shot Questionnaire

Question Response Points

How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are 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 hang-over?

NeverMonthly or less often2 to 4 times per month2 to 3 times per week4 or more times per week1 or 23 or 45 or 67 to 910 or moreNoYesNoYesNoYes

00.51.01.52.000.51.01.52.0010101

Other scores use a different scoring range for women when the number of drinks typically consumed is considered. Total score = SUM (points for all 5 questions).Interpretation:

minimum score: 0maximum score: 7A score of 4 or more is seen in male alcoholics.

Performance:A score of 3.0 was 77% sensitive and 83% specific for moderate or heavy drinking. The overall accuracy was 83%.A score of 4.0 was 56% sensitive and 94% specific. The overall accuracy was 90%.A score of 5.0 was 29% sensitive but 98% specific. The overall accuracy was 90%.


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Diagnosis

have a sensitivity of 96% to 100% and a specificity of76%, which provides an overall accuracy of 78%.

MAST, the Michigan Alcohol Screening Test, wasdeveloped in 1971 to detect alcohol dependency. Theoriginal tool was 25 questions in length, but this toohas been modified to provide for more rapid screening.Its major drawback is its emphasis on lifetime drinkingrather than current patterns of alcohol use; thus, it is apoor tool for early detection. Its sensitivity is 86% to98%, and its specificity 81% to 95%.

Primary care physicians have found it difficult toincorporate screening tools into their practices. Thisoccurs for a variety of reasons: Time constraints oftenpreclude their ability to screen every possible problemthat may be hidden from them adequately, fears ofoffending their patients often cause discomfort inbroaching the subject, and finally, a sense of helpless-ness in being able to refer the patient to the appropri-ate care if the problem is identified. One way aroundthis discomfort is to reframe the questions in as posi-tive and nonthreatening manner as possible. For exam-ple, instead of asking a leading question from theCAGE (“you’ve never tried to cut down on your drink-ing, have you?”), you ask the more positive question(“you’ve tried to cut down on your drinking before,right?”), as if to imply we have all tried to cut down onour drinking.

Because a large proportion of traumas are alcohol-related patients, they are first asked to answer a seriesof questions regarding any history of trauma on theirgeneral health questionnaire:


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1. Have you had any fractures or dislocations to yourbones or joints?

2. Have you been injured in a traffic accident?3. Have you ever injured your head?4. Have you ever been injured in a fight or assault?

If the patient answered yes to one or more of thesequestions, an additional question was asked:

5. Did any of these injuries occur during or afteralcohol use?

If the patient answered positively to two or more ques-tions, the physician would then ask about frequencyand quantity of alcohol use. If consumption was high,the physician then asked the CAGE questions. Thismethod reduced the number of patients asked aboutalcohol to one in seven and identified one in four oftrauma patients as having an alcohol problem. Thisscreening system correctly identified 70% of alcoholicsand was felt to be reasonably unobtrusive. Interest-ingly, in the primary care setting, the sensitivity andspecificity of the various screening tools differ than inthe research setting. For example, the CAGE has beenfound to be only 62% sensitive for males and 54% sen-sitive for females in the primary care setting. TheAUDIT was found to be more sensitive than theCAGE, though still less so than in the research set-ting. The other downside of the AUDIT is its lengthi-ness. As a result of these retests, at least in England,the Five-shot was ultimately found to be the quickestand most effective screening tool to administer, with asensitivity and specificity of 63% and 95%, respectively.What is the utility of screening tools independent of


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Diagnosis

intervention? Screening tools are found to influencepatient behavior alone, with reductions in alcohol con-sumption occurring simply by bringing it to thepatient’s awareness and attention.

Susan’s comment:

Like many of you who read this book, my struggle with myson’s addiction to alcohol didn’t start when he began to drink. Istill say that I wasn’t in denial. I really had no idea that hewas different—different from all his friends who did all of thesame things, or so I thought. Somehow I turned the other waywhen some signs were revealed. Because his father, my ex-husband, was and still is an active alcoholic, it was easy tobelieve that all of those empty vodka bottles hidden around thehouse belonged to him. It has taken me a long time to realizethat I wanted to believe the excuses Ben gave me. Actually, hewas in denial for a very long time even after I faced the horri-ble truth. It was a very slow process getting him to “get hisarms around” being an alcoholic. For me, not one day goes bythat I don’t look at other males his age and wonder why myson is totally disabled by something that all of his friends didwith no consequence, something that is part of all my extendedfamily’s “war” stories, something that society thinks I should beashamed of, and something that may cause this mother to buryher only son.

Everyone who loves an alcoholic has his or her own way ofcoping. Mine has been to do three things: (1) to see to itthat my only son gets every chance to live by any meansnecessary, (2) to be very forthcoming regarding his condi-tion so that he doesn’t ever feel that I am a part of the over-whelming shame I know he feels, and (3) to studyalcoholism extensively in an effort to understand “theenemy.” Those things have often resulted in tears, heart-break, and despair. Most of the time, however, I have felt

Screening toolsare found toinfluencepatientbehavioralone, withreductions inalcohol con-sumptionoccurring sim-ply by bring-ing it to thepatient’sawareness andattention.


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relief that my son and I were not alone in his suffering. Myhusband, not Ben’s father, wishes that I would be much lessopen about his “problem,” but I function as I must—oneday at a time. Incidentally, of the words abuse, addiction,and dependency, I find that the use of “dependency” is theleast of the “evils.”

18. What is the difference between type Iand type II alcoholics?The pursuit of categorizing subtypes of alcoholics hasbeen an ongoing one for at least the past 200 years.Jellinek was the first physician to subdivide alcoholisminto four distinct phases: the prepathogenic period con-sisting of occasional symptoms of alcohol abuse, a path-ogenic period consisting of a prodromal phase, a crucialphase, and a chronic phase. The prodromal phase wasnotable for the onset of blackouts, the crucial phase bythe onset of loss of control, and the chronic phase byprolonged intoxication. The rate at which individualspass through these phases appeared to follow two dis-tinct patterns and was associated with distinguishablepersonality characteristics that are now referred to astype I or type A alcoholics and type II or type B alco-holics.

Studies suggested the following distinguishing featuresbetween type I and type II alcoholics: Type I charac-teristics include an onset later in adulthood; drinkingto relieve anxiety; the development of psychologicalbut not physical dependence; and finally, although itmay be inherited, usually an environmental trigger.Type II characteristics include an association withcriminal behavior (sociopathy); an onset in teen orearly adult years; drinking specifically to get high; andfinally, more likely inherited. Sons of type II alcoholic


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Diagnosis

persons are seven times more likely to develop type IIalcoholism compared with the general population. Arecent Korean study published in 2005 demonstratedthat a link exists between the gene coding for theenzyme known as alcohol dehydrogenase that breaksdown alcohol into acetaldehyde and type II alcoholics.The theories from these studies remain controversial;however, recent evidence of varying responses to par-ticular psychotropic medications based on one’s partic-ular subtype adds further support. These medicationsare discussed in detail in Question 52. Data on daugh-ters of persons with alcohol problems are less clear.Daughters might be at an increased risk if the biologi-cal mother is alcoholic, but these studies do not delin-eate between subtypes. A recent twin study in womenfound higher concordance in identical twins than infraternal twins.

Susan’s comment:

Like any other theory, the distinction between type I andtype II alcoholism is not as simple as it may seem, and Benis an example. Although his history indicates type II alco-holism, he has never demonstrated violence or sociopathicbehavior; however, the notion of different “types” does pro-vide some guidelines that more people should be aware of.Too many type I alcoholics mistake type II alcoholics as theonly type. In that way, they can stay in denial regardingtheir own consumption because they can function most ofthe time.

19. Are there any biological tests that aidin the diagnosis of alcoholism?No biological test is available that alerts a patient orphysician about whether an individual is at risk ofbecoming an alcoholic if he or she drinks regularly.


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Biological testsfor alcoholismmeasure boththe direct andindirect effectsof chronicalcohol use onone’s body.

The science of alcoholism is still far away from discov-ering specific genetic markers to identify those at risk;however, some biological tests help to identify thosepatients who have developed medical consequences ofrepeated heavy drinking. These tests are not specificfor alcoholism per se. The fact that one has biologicalfindings suggestive of alcoholism, therefore, is not adefinitive test of one being an alcoholic. Nor is it thecase that the absence of such biological findings rulesout any possibility that one is an alcoholic. Many alco-holics never develop any laboratory abnormalities as aresult of their drinking. To reiterate why there is thisphenomenon, recall that the diagnostic criteria foralcohol dependence and alcohol abuse discussed earlierin Questions 13 and 14 do not require such evidenceto establish the diagnosis.

However, the biological effects of chronic heavy alco-hol use result in laboratory findings that demonstrate aconsistent and reliable pattern. For this reason, anyonepresenting to a physician’s office with this pattern willbe asked in detail about his or her pattern of drinkingand, in all likelihood, will be told to stop all drink-ing no matter how much or little alcohol is consumed.This is because—even if the laboratory abnormalitiesare not a result of alcohol—alcohol may be contribut-ing to the problem irrespective of whether someone isan alcoholic. People with hepatitis should not drink forany reason. Biological tests for alcoholism measureboth the direct and indirect effects of chronic alcoholuse on one’s body. Alcohol’s most direct impact is onthe liver, leading to hepatitis, with a characteristicincrease in various chemistries, most notably GGT(gamma-glutamyl transpeptidase), but also AST

GGT (Gamma Glutamyl Transpeptidase)

a liver enzyme thatwhen elevated isassociated with alco-holic liver disease(among other dis-eases).


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Diagnosis

AST (Aspartate Aminotransferase)

an indicator of acuteliver disease. See ALT.

ALT (Alanine Aminotransferase)

an indicator of acuteliver disease. SeeAST.

Carbohydrate-deficient transferrin

a protein found inblood involved intransferring iron tocell tissues.

Clotting factors

a group of proteinsspecifically designedto interact togetherto cause blood to clotand stop bleeding.

Thiamine

vitamin B1.

Macrocytic

from “macro” forlarge and “cytic” forcell. Primarily in ref-erence to large redblood cells from thi-amine deficiency(pernicious anemia)that is common inchronic alcoholicswhose nutrition ispoor.

(aspartate aminotransferase) and ALT (alanineaminotransferase). GGT is the most sensitive indetecting alcohol consumption and therefore monitor-ing relapse, but false negatives and false positives doexist. Carbohydrate-deficient transferrin is anotherbiomarker; though less sensitive, it is more specific foralcoholism. AST and ALT are elevated in all forms ofhepatitis and are not particularly sensitive but are morespecific in detecting the affects of alcohol consump-tion. They are also late-stage indicators that may nor-malize after maintaining about 6 weeks of sobriety.Because the liver is involved in the production of clot-ting factors, these can be affected by alcohol’s effecton the liver, leading to increased bleeding times.

Chronic alcoholism also affects the hematological sys-tem. Alcohol has both direct and indirect effects onthis system. First, most alcoholics use alcohol as theirprimary source of calories. This inevitably leads tosevere vitamin deficiencies, notably the B vitamins,thiamine, and folate. These, in turn, lead to anemiathat is known as macrocytic, meaning that the redblood cells are enlarged. This causes a low hemoglobinand hematocrit associated with an elevated mean cor-puscular volume. Direct effects of alcohol, however,can affect the entire hematological system, includingthe white blood cells, which are a part of the body’simmune system, the red blood cells, which carry oxy-gen throughout the body, and finally the platelets,which are involved in the clotting process. Alcoholsuppresses all of these, leading to anemia, immuno-suppression, and thrombocytopenia, or a lowering of

Hematocrit

measures of the pro-portion of blood vol-ume that is occupiedby red blood cells.


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Mean corpuscular volume

a measure of the sizeof the red blood cells.

Anemia

a deficiency of redblood cells.

Immuno-suppression

involves an act thatreduces the activa-tion or effectivenessof the immune sys-tem.

Thrombocytopenia

the presence of rela-tively few platelets inblood.

the platelets, which leads to prolonged bleeding andeasy bruising. Additionally, potassium, phosphate, cal-cium, and magnesium levels can be affected in chronicalcoholism. Other effects of alcoholism on the bodywill be further detailed in questions 61 and 62.

Platelets

also known as throm-bocytes. A type ofblood cell involved inthe cellular mecha-nisms of the forma-tion of blood clots.


Risk,Prevention, and

EpidemiologyWhat is the prevalence of alcohol use

and alcoholism?

What is the risk of inheriting alcoholism?

What other risk factors are associated with alcoholism?

More . . .

PART III


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20. What is the prevalence of alcohol useand alcoholism?Prevalence refers to the current number of people suf-fering from an illness in a given year. This numberincludes all of those who have been diagnosed in prioryears as well as in the current year. Per capita alcoholconsumption has declined from its peak in 1980 of 2.8gallons per year to its current level of about 2.2 gallons.Rates vary regionally and are higher in New Englandand lower in the Midwest and Southeast, with Floridaas the exception. Amounts peak in the 18- to 29-year-old group and then gradually decline.

Currently, nearly 14 million Americans, or 1 in every13 adults, abuse or are dependent on alcohol. About4.6 million of these individuals are women. Whenconsidering percentages, the following apply to theU.S. adult population:

• Current drinkers: 44%• Former drinkers: 22%• Lifetime abstainers: 34%• Abuse and dependency in the past year: 7.5% to 9.5%• Lifetime prevalence: 13.5% to 23.5%• Adult hospital inpatients: 20%• Emergency room visits that are associated with

alcohol: 10% to 46%• Patients in community-based primary care practices

who engage in at-risk drinking: 1 in 6• Traffic fatalities in 1998 that were related to the

presence of alcohol in one or more of the accidentparticipants: 38%

• The U.S. adult population who were currently abus-ing or dependent on alcohol and that had received anytreatment in the 12 months before interview: 10%

Currently,nearly 14millionAmericans, or1 in every 13adults, abuseor are depend-ent on alcohol.


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Risk,Prevention,and Epidemiology

• Individuals with a past diagnosis of alcohol depend-ence who reported ever having any kind of alcoholtreatment: 28%

• People who recovered from a previous alcohol disor-der and who did so without having received anytreatment (often termed “natural recovery”): 75%

• Costs for alcoholism each year in the UnitedStates: $185 billion

In contrast to the U.S. statistics, the WHO examinedmental disorders and found that alcohol dependenceor harmful use was present in 6% of patients evaluatedin primary care offices worldwide. In Britain, one inthree patients in community-based primary care prac-tices had at-risk drinking. Alcoholism is more com-mon in France than it is in Italy, despite virtuallyidentical per capita alcohol consumption.

21. What is the risk of inheritingalcoholism?Increasingly, all kinds of conditions or diseases areattributed to genes. What exactly does this mean?Genes are a series of molecules that are passed onfrom parents to children. They provide a code for pro-teins. Proteins are the workhorses that make peopleinto who they are physically, cognitively, and behav-iorally. The question of what genes do in coding forpeople’s personalities and behavioral propensities hasnever been completely understood. The cascade ofinteracting effects that begins with a series of genestranscribed into a protein that ultimately leads to apropensity toward alcoholism is too vast to be fullyelucidated. Consider a simple trait that is fully deter-mined, such as eye color. Even in the instance where

Gene

a specific sequence ofnucleotides in theDNA and RNA, whichis a unit of inheri-tance that controlsthe transmission andexpression of specifictraits in people andother living organ-isms. Scientists andclinicians believe thatalcohol dependenceand abuse is influ-enced by genetic fac-tors.


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Mendelian

the central tenets ofgenetics developedby Gregor Mendel.They relate to thetransmission ofhereditary character-istics from parentorganisms to theirchildren; they under-lie much of genetics.

Muscular dystrophy

a group of heritablediseases character-ized by the progres-sive wasting ofmuscles.

Cystic fibrosis

an inherited diseasefound in Caucasiansthat appears early inchildhood.

Phenylketonuria

an inherited meta-bolic disease thatcauses mental retar-dation because of theinability to oxidizethe metabolic prod-uct of phenylalanine.

the likelihood of two blue-eyed parents having a blue-eyed child is almost certain, it remains possible forthem to have a brown-eyed child possibly due to localenvironmental, albeit biological, effects. Environmentactually entails not only what people commonly thinkof including their culture, nationality, occupationalchoices, friends, family, how many bars and liquorstores are available, but also local cellular environmentsthat include other genes, proteins, and various chemi-cals interacting on a specific gene—then one begins toappreciate the complexity of the question. It is difficultenough to work out the influence that genes have onphysical structures. No scientist has yet to predict with100% accuracy how genes determine the developmen-tal biology of even simple organisms. Genes are not ablueprint in the way that blueprints are conceived. Ifbiological development is so fraught with unpre-dictability, imagine the degree of difficulty in beingable to predict behavioral problems as a result ofgenetic influences.

Genetic and Environmental FactorsThe range in which genes and the environment inter-act is vast, from clear but not 100% predictable geneticdeterminism to unclear genetic influence. The diseasesthat are clearly genetic are generally single gene errorsthat follow Mendelian patterns of inheritance. Thescientist Gregor Mendel, who was the first man todemonstrate how patterns of inheritance can be math-ematically described, explained the Mendelian orGene Theory. Such diseases include muscular dystro-phy, cystic fibrosis, and phenylketonuria. There arealso genetic diseases that are not inherited per se, butrather are due to direct damage to the genes. The mostcommon example is Down’s syndrome. Finally, there

Down’s syndrome

a person with Down’ssyndrome is mentallydelayed and hascharacteristic facialfeatures.


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are polygenic diseases, meaning that multiple genes areinvolved in influencing the development of a particulardisease. These diseases include cancer, heart disease,diabetes, and most mental illnesses.

InheritanceThe question of inheritance often implies geneticinheritance, entailing a sense of predestination ordeterminacy. The underlying theme behind the idea ofinheritance is that it is beyond one’s control, and there-fore, the individual is not held responsible for his orher actions. This concept is fraught with ethical andpolitical overtones that have been discussed at somelength previously. To say that genes determine a par-ticular outcome is to lead to misconceptions. There area myriad of influences that genes are subject to bothbefore and after they code for a particular protein thatare not immediately determined. Alternatively to saythat the environment escapes deterministic notions isequally absurd. People not only inherit their parents’genes, but also their parents’ home and culture. Theyhave no more choice about the environment they wereborn into than they have about their parents’ genes.

Nature Versus NurtureThe misconception is that if a set of behaviors is dueto a person’s genes, then it must be an illness thatrequires medical treatment, but if the behaviors are dueto a poor environment, then the illness must be due toa social, political, or moral problem (see Question 10again to review the issues surrounding voluntarybehavior). The real questions are as follows: What arethe various genetic and environmental influences?How much does each contribute to the developmentof an individual’s physical, cognitive, and behavioral

The under-lying themebehind theidea of inheri-tance is that itis beyond one’scontrol, andtherefore, theindividual isnot heldresponsible forhis or heractions. Thisconcept isfraught withethical andpoliticalovertones thathave beendiscussed atsome lengthpreviously.


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For example,by studyingthe offspringof alcoholics,we know thatof 100 peoplewith alco-holism, 18will have chil-dren who willalso becomealcoholics,whereas of100 peoplewho are notalcoholics, only5 will havechildren whowill becomealcoholics.

makeup, or what are their contributions to a disease?All that can really be done is to examine a populationof related individuals and note the variations in both aparticular behavior and a group of symptoms and theirgenetic relatedness. For example, by studying the off-spring of alcoholics, we know that of 100 people withalcoholism, 18 will have children who will also becomealcoholics, whereas of 100 people who are not alco-holics, only 5 will have children who will become alco-holics. These statistics still do not allow us tospecifically predict the 18 who will develop the condi-tion and the 82 who will not. The two biggest studieson alcohol and genes are twin studies and adoptionstudies. A third study was designed in the laboratory.

Twin and Adoption StudiesTwin studies focus on the relationship of identicaltwins to fraternal twins and their varying rates of alco-holism. If alcoholism is inherited, identical twinsought to become alcoholics at greater rates than frater-nal twins because they share 100% of their genes—incontrast, fraternal twins share only 50% of their genes.A number of studies have consistently shown higherconcordance rates for drinking behavior and possiblyalcoholism in identical twins compared with fraternaltwins. The heritability estimates for genetic influenceaccount for between 50% and 60% of the variation inthe risk for alcoholism in males. Studies of femaletwins, in contrast, however, demonstrate smaller ratesof concordance, although studies using population-based twin registries have found that genetic influ-ences on alcoholism to be of similar magnitude in bothmales and females.

What evidence is found from adoption studies? Adop-tion studies examined biological children of alcoholic

Concordance rates

the rate at whichgenetically relatedindividuals sharewith one another aparticular trait.


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parents adopted into nonalcoholic homes and biologi-cal children of nonalcoholic parents adopted into alco-holic homes. If environment plays a greater role, thenthe home a child is raised in will have the greatestinfluence in the development of alcoholism. If, on theother hand, genes play a greater role, then the child’sbiological parents will have the greatest influence inthe development of alcoholism. In all studies of maleadoptees, those whose biological parents were alcoholicwere at a significantly higher risk for alcoholism thanwere children whose biological parents were not alco-holic (i.e., 1.6 to 3.6 times greater). These data portray agenetic contribution to the risk for developing alco-holism. The studies of female adoptees demonstratedmixed results, perhaps providing some evidence of possi-ble sex differences in heritability, but the numbers ofalcoholic female adoptees in the studies were too small todraw any definitive conclusions.

In the laboratory, one is able to measure subjective andobjective responses to the consumption of alcohol andcompare those responses between sons of alcoholicsand nonalcoholics. The sons of alcoholics reportdecreased subjective ratings for feeling intoxicated, andthey objectively had evidence of intoxication given thesame amount of alcohol as sons of nonalcoholics. Thestudy population consisted of white male college stu-dents who drank alcohol but were not alcohol depend-ent. Ten-year follow-up data were recently publishedfor these young men. Of the sons of alcoholics, 26%were alcohol dependent by 30 years old, as opposed to9% of the control group whose fathers were not alco-holic. Furthermore, 56% of the sons of alcoholics whoreported fewer objective and subjective reactions toalcohol became alcohol dependent, as opposed to 14%of the sons of alcoholics who did not report decreased


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reactions. Few sons of nonalcoholic fathers becamealcoholic. There are some biological propensitiestoward alcoholism that are independent of but may beinfluenced by genes. Finally, a study examining thebrains of alcoholic versus nonalcoholic subjects foundthat the amygdala is smaller in subjects with familyhistories of alcoholism, suggesting that inherited dif-ferences in brain structure may also affect risk. Theamygdala is an area of the brain that is thought to playa role in the emotional aspects of craving, which canlead to addiction.

22. What other risk factors are associatedwith alcoholism?The concept of risk is a modern one. The word derivesfrom the Italian riscare, meaning “to dare.” Before such aconcept, the future could only be predicted by consultingthe gods, prophets, or astrologers, and when bad thingshappened, they were attributed to fate. The concept ofrisk was born out of a simple yet practical questionregarding games of chance when money was at stake.Given certain known events that just occurred in thegame, what are the odds for winning the game? Fromthere, everything about predicting the future grew, andforecasting with degrees of certainty for future events ofall kinds developed. Humans, however, are poor atassessing risk, and as a result, they are lousy predictors ofthe future. Studies have regularly demonstrated thathumans overly focus on sensational events that are highlyunpredictable to the exclusion of much more mundaneevents that pose greater risks and are more predictable.

The most common example of this is fear of flyingbecause of plane crashes and more recently terrorism,yet the person doesn’t give any thought that driving

Amygdala

attached to the tail ofthe caudate structureof the brain that isconsidered a part ofthe limbic system.


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one’s car to work daily poses a far greater risk. Thelesser fear associated with driving one’s own car comesfrom both the illusion of control and its daily occur-rence. A less common but more recently describedsensational example is the risk associated with swim-ming pools verses guns. What is more dangerous: aswimming pool or a gun? This answer, based on simplestatistics, is swimming pools. In 1997, 550 childrenwho were 10 years old and younger drowned in swim-ming pools. There are 6 million swimming pools inthe United States, which translates statistically intoone drowning annually for every 11,000 pools. In1998, 175 children 10 years old and younger died as aresult of guns. Approximately 200 million guns are inthe United States, translating into one death for everymillion guns. Thus, if you own both a gun and a swim-ming pool, your child is 100 times more likely to diefrom the swimming pool than the gun.

Knowledge of risk provides some power over predict-ing future events so as to make the odds more favorableto attaining one’s goals. For example, although wearingseat belts does not change the odds of getting into anaccident, it does change the odds of surviving one. Inmedicine, knowledge of risk helps the clinician under-stand the odds of developing certain diseases. Remem-ber, however, that odds, no matter how favorable orunfavorable, are still just odds, with the outcome forany particular event still unknown. Just because theodds of developing lung cancer are greater for one whosmokes a pack of cigarettes a day than one who doesnot does not mean that the outcomes are certain.

Some risk factors you can change, and other risk fac-tors you cannot. Individuals cannot change the genesinherited from their parents, but they can use the


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knowledge of their family history to help make choicesin life to reduce other risk factors contributing to theprobability of developing a particular disease. Modifi-able risk factors are those factors that can be changed,such as stopping smoking, changing one’s diet andexercise regimen, or abstaining from alcohol. Otheropportunities for “beating the odds” include followingthe recommendations for various diagnostic tests forbreast cancer, colon cancer, and heart disease, depend-ing on whether someone has a family history for a par-ticular condition. Now that you have been introducedto the concept of “risk,” here are some of the risk fac-tors associated with alcoholism.

Being poor and uneducated increases the risk for alco-holism. George Valliant, the doyen of alcohol research,found that innercity, non–college-educated men begandrinking approximately 10 years earlier than college-educated men. They were also more likely not to drink,but if they drank, they were more likely to die as a resultof their drinking. This fact demonstrates that it is notthe frequency of alcohol consumption as much as it isthe pattern of alcohol consumption that places a personat risk. Mortality from both groups, however, was morecommonly related to tobacco use.

Being Caucasian or Hispanic as opposed to AfricanAmerican increases the risk for alcoholism. Addition-ally, Native Americans tend to have the highest ratesof alcoholism, whereas Asian Americans have the low-est. This may be partly due to the genetic variation inalcohol-metabolizing enzymes alcohol dehydrogenase,which depends on one’s race (see Table 6).

Individualscannot changethe genesinherited fromtheir parents,but they canuse the knowl-edge of theirfamily historyto help makechoices in lifeto reduce otherrisk factorscontributingto the proba-bility of devel-oping aparticulardisease.


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Table 6 Genetic Variation in Alcohol-Metabolizing Enzymes

• Alcohol Dehydrogenase

Polymorphism occurs at ADH2 and ADH3 gene

ADH2*1 ADH2*2 ADH2*3 ADH3*1 ADH3*2

White American 95% < 5% < 5% 50% 50%African American 85% < 5% 15% 85% 15%Asian 15% 85% < 5% 95% 5%

15% of African Americans have the ADH2*3 allele, causing an increased alcoholmetabolic rate and an increased elimination of acetaldehyde.

• Aldehyde Dehydrogenase (ALDH)

85% of Asians have the ALDH2*2 allele, causing a decreased elimination ofacetaldehyde (and alcohol) and flushing response

Males are at greater risk for alcoholism than females.Lifetime prevalence was 20% in men and only 8% inwomen. When examining rates in the past year, theyare 10% and 4%, respectively. This is partly attributedto the fact that women do not metabolize alcohol asefficiently as men and thus are more prone to theimmediate negative effects of it. When women dodevelop problems with alcohol, they tend to developthem later in life, tend to combine alcohol with pre-scription drugs, and are less likely to be recognized ashaving a problem or receive treatment for their prob-lem. This may be because women are less likely towork outside of the home, and thus, they are lessexposed to the financial, occupational, and legal trou-bles that may accompany heavy drinking.

Finally, as you age, the prevalence of alcoholismdecreases. The prevalence of alcoholism in people over65 years old is around 3%; however, these numbersmay not be as reliable and are harder to recognize, and


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less alcohol is required to cause a significant problemfor the individual.

23. Are certain religious groups atgreater risk for alcoholism?Religious and cultural differences also influence therisk for developing alcoholism. By far, the groups asso-ciated with lowest risk have been Jews and Muslims,but it appears to be for very different reasons. InJudaism, wine is used primarily ritualistically from avery early age, and thus, patterns of use are establishedearly and maintained throughout one’s religious life.Judaism as a faith offers no real moral opinion on theuse of alcohol, but through practice, it offers examplesof a balanced, moderate approach to its use. Althoughoccasional drunkenness is tolerated, repeated examplescan lead to isolation from the community. Islam, onthe other hand, strictly prohibits the use of alcohol.This is interesting because the Koran is no more dis-approving of wine than the Bible and because theprophet Muhammad looked on wine as the embodi-ment of well-being, wealth, and fertility and recom-mended moderation. The early history of Islam hasmany examples of regular alcohol use among its practi-tioners; however, because of the rise of conservativesthroughout the Muslim world during the last few cen-turies, alcohol consumption has been strictly prohib-ited. This may partly have been due to an attempt todemonstrate outwardly Islam’s uniqueness from theother religions.

The Bible generally describes moderate use of winewithout condemnation; it does contrast that with


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drunkenness, which it clearly condemns. Catholicismand Protestantism, on the other hand, generally viewalcohol as a potential evil and alcoholism as a sin, but theemphasis in books, catechisms, sermons, and pastoraladdresses is typically focused on issues of sex, such asmasturbation, premarital and extramarital sex, abortion,and artificial insemination to the exclusion of drunken-ness. With an emphasis on the sinfulness of virtually allpleasurable activities, along with the general silenceregarding drunkenness, as opposed to other overindul-gences, the inability to develop an institutionalized reli-able response leads parishioners to vacillate betweenabstinence and overindulgence without any real opportu-nity to develop models for moderate ritualized use.

24. How do African Americans,Hispanics, Native Americans, andAsian Americans compare with respectto risk of developing alcoholism?African AmericansDepending on the study, young African Americanmen either drink less or have similar drinking patternsas young white men. Clearly fewer binge drinkingepisodes exist in black universities as compared withwhite universities. Black women drink less then theirwhite counterparts; however, blacks suffer more fromhealth problems related to alcoholism, such as cirrhosisof the liver, alcohol-withdrawal delirium, esophagealcancer, and so forth. Most legal problems stem fromdrug use. The prison population is made up more ofcocaine users than alcoholics.

The Biblegenerallydescribes mod-erate use ofwine withoutcondemnation;it does contrastthat withdrunkenness,which itclearly con-demns.


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HispanicsHispanics are the second largest ethnic group in theUnited States and constitute an extremely diversegroup because of their varying ethnic backgrounds andopenness to intermarriage. Thus, keep that in mindwhen examining the evidence. Among the largestgroup of Hispanics are Mexican Americans, followedby Puerto Ricans and Cubans. These three groupshave different cultural heritages and different eco-nomic and geographical distributions. Mexican Amer-icans have higher rates of alcoholism than otherHispanic groups. Puerto Ricans have higher rates ofcocaine dependence. Inhalant use is more commonamong Cubans in South Florida. When MexicanAmericans acculturate to the United States, their useof alcohol increases further.

Native AmericansThere are 400 recognized tribes in the United States,with each having different customs and rituals, values,and beliefs. These differences reflect not only culturalvariations but genetic variations as well; however, theredoes seem to be a genetic vulnerability to alcohol thatis common to all, including the Native Alaskans,whose modern history was less traumatic than theirlower continental counterparts. The predisposition hasnot yet been fully elucidated and probably has to dowith the population’s lack of exposure to alcohol untillate in its evolutionary history. Other factors also play arole that cannot be denied, such as their displacement,a lack of economic opportunities, and resulting poverty.A large percentage of Native Americans are sent toboarding schools, which only increases their risk ofdeveloping alcohol and other drug-dependent prob-


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lems on their return home. Selling alcohol to NativeAmericans was illegal until 1953 when they weregranted full citizenship. The incidence of alcoholismamong Native Americans is twice the national average.Tribal rates of adolescent suicide, auto accidents, childabuse and neglect, and spousal abuse differ and can bedirectly linked to the rates of alcoholism.

Asian AmericansAsian Americans constitute the fastest growing minor-ity in the United States. They also are an extremelydiverse group, as Asia is the largest continent in theworld but also geographically encompasses groupsfrom its far western regions such as Turks and Arabsthat are more European to its far eastern outposts inthe Pacific such as Samoa that are not part of theAsian continent. The largest groups consist of Chi-nese, followed by Filipinos, Indians, and Vietnamese.The vast majority is either on the west coast inChicago or New York City, but the southeastern statesare growing. National surveys have difficulty capturingsuch a large and diverse population, and thus, conclu-sive generalizations cannot be made. Asian Americanstend to have the lowest rates of alcoholism among allU.S. citizens. Asians are far more likely to use alcoholrather than other drugs. Teen alcohol use is growingprobably with the acculturation to the United States.Still, within-group differences do occur, with Koreanshaving higher rates then Chinese. Vietnamese teenshave the highest rates of drug and alcohol abuseamong Asian Americans. Genetic differences appearto play an important role in rates of alcoholism amongAsian Americans, as demonstrated in Question 22(Table 6).


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25. What is the morbidity and mortalityassociated with alcoholism?A curious fact about health care in the past 50 to 70years has not been the great technological develop-ments that have sprung up but the general eradicationof many of the infectious diseases that once took a dev-astating toll on the younger and older populations.Although the most dramatic improvements in morbid-ity and mortality in human history are attributed toimproved hygienic measures (potable water, plentifulnoninfected food, vaccine programs, proper waste man-agement), the last half century has improved on thosefoundations to the point where the most dangerous dis-eases are now associated with a largesse of resources.

The leading cause of death, cardiovascular disease, isclearly associated with our changing lifestyle, whichis now largely sedentary and given to overconsumption.Cancer, the second leading cause of death, is also dueto lifestyle issues, which includes not only tobacco, butalso diet and exposure to environmental carcinogens aswell. Thus, alcohol-related morbidity and mortalitymay be considered to be in good company, as there are85,000 deaths annually attributed to its overuse, atleast half from accidents directly related to it, whereasthe other half from diseases associated with it. Thisnumber may seem large, but it pales in comparison tocardiovascular disease and cancer. It is another curiousfact that cancer and cardiovascular diseases associatedwith lifestyle choices are not viewed with the same“jaundiced eye” as those associated with alcoholism.

The total burden of disease related to chronic alcohol useaccounts for 7% in North America. Worldwide, the bur-den can be broken down into the following problems:

The totalburden ofdisease relatedto chronicalcohol useaccounts for7% in NorthAmerica.


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• Cirrhosis: 32%• Motor vehicle accidents: 20%• Traumatic brain injury patients that have been

drinking: More than 50%• TBI patients are three times more likely to sustain a

second head injury. After their second TBI, they areeight times more likely to sustain a third head injury.

• Mouth and oropharyngeal cancers: 19%• Esophageal cancer: 29%• Liver cancer: 25%• Breast cancer: 7%• Homicides: 24%• Suicides: 11%• Hemorrhagic stroke: 10%• Leading cause of death among persons under 44

A standard drink is defined as one 12-ounce beer, one5-ounce glass of wine, or one mixed drink containing1.5 ounces of spirits (80 proof ); the relative risk for thenoted maladies with consumption of four or moredrinks daily is as follows:

• Cirrhosis: for men, 7.5; for women, 4.8• Injuries: for men, 1.3• Ear, nose, and throat cancer; esophagus cancer; liver

cancer: for men, 2.8; for women, 3

Drinking more than one standard drink daily appearsto increase the risk of breast cancer in women. Recentdata suggest an increase in coronary calcification withmoderate alcohol consumption in young adults. Bingedrinking exacerbated this effect. Binge drinking isdefined as four drinks in a row in women and fivedrinks in a row in men. In men 18 to 25 years old, 60%report that they binge drink. This activity significantlyincreases the risk of injury, the risk of acquiring a


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Half of allviolent crimesare alcohol ordrug related,and 60% to70% ofdomesticviolenceincidentsinvolvealcohol.

Epidemiological

the basic science ofpublic health, havingto do with epidemi-ology.

sexually transmitted disease, the risk of assault, the riskof unwanted pregnancy, and the risk of harming anunborn child (see Questions 75 and 76). Half of allviolent crimes are alcohol or drug related, and 60% to70% of domestic violence incidents involve alcohol. Astrong association exists between alcohol and tobaccouse. People who start smoking early are more likely todevelop problems with alcohol, and those who developalcohol-related problems will have a harder time quit-ting smoking.

26. What is the link between alcoholismand violence?The association between drinking and crime was firstmade in London during the 18th century during anera known as “the gin craze,” although overcrowdingand unemployment may have played a larger role thancheap gin. Whether or not it was drinking or povertyand overcrowding, the era engendered the notion thatalcoholism was the cause of the poor becoming vio-lent. In the past century, research has consistentlylinked alcohol intoxication and violence. This hascome from both epidemiological as well as experi-mental studies. For example, a positive correlationexists between the quantity of alcohol consumed andthe frequency of a wide variety of violent acts, includ-ing sexual assault, child abuse, and homicide. This isparticularly true for people with antisocial personalitydisorder (ASPD), or what is better known as sociopa-thy. As a group, antisocial individuals have higher ratesof alcohol dependence and more alcohol-related prob-lems than the general population, but alcoholism makesconstitutionally aggressive individuals more aggressive

Antisocial personality disorder (ASPD)

an enduring patternof inner experienceand behavior thatdeviates markedlyfrom the expecta-tions of the culture ispervasive, inflexible,and most often hasan onset in late ado-lescence.


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whether or not they are antisocial. Violent offenders instate prisons frequently report having used alcohol beforetheir offense. Approximately 50% of sexual assaultsinvolve alcohol consumption by the perpetrator, the vic-tim, or both. Alcohol is a factor in 60% to 70% of homi-cides, 40% of suicides, and 38% of fatal motor vehicleaccidents.

Likewise, in laboratory studies, people with ASPDshow greater increases in aggressive behavior after con-suming alcohol than people without ASPD. The asso-ciation between ASPD and alcohol-related aggressionmay result from biological factors, such as ASPD-related impairments in the functions of certain brainchemicals (e.g., serotonin) or in the activities of higherreasoning, or the executive brain regions. Alternatively,the association between ASPD and alcohol-relatedaggression may stem from some undetermined factor(s)that increases the risk for aggression in general.

Not all people exhibit increased aggression under theinfluence of alcohol. There is an enormous variation inthe way people behave when they drink. In someScandinavian and Anglo-American societies, alcohol isassociated with violent and antisocial behavior, where-as in Mediterranean and some Asian societies, drink-ing behavior is largely nonviolent. This variation isclearly related to different individuals, as well as culturalbeliefs about the expectations of how alcohol intoxica-tion affects behavior. In other words, alcohol consump-tion promotes aggressive behavior in individuals orsocieties where it is expected to and the society acceptsit as a consequence. This has been borne out by researchthat studied the effects of people who believed they

Executive functions

brain functionsinvolving planningand decision making.


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had drunk alcohol and then began to act more aggres-sively, regardless of whether they actually consumedthe alcohol. Societal expectations that alcohol pro-motes male aggression against both other males andtoward females, combined with the widespread per-ception that intoxicated women are sexually receptive,probably account for the association between drinkingand sexual assault.

27. Is there a gateway drug that can leadto alcoholism?The concept of a gateway drug has always been con-troversial. For many years, it was identified as mari-juana. To a large extent, this has been debunked;however, children are continuing to experiment withdrugs of all types, and the drug that is most availableand easily accessible becomes the drug that is firstused. For those children who are at risk for developingalcoholism, their first drug does not seem to matter somuch as the fact that they use it. Children 12 to 17years old who use marijuana are 85 times more likelyto use cocaine; children who drink are 50 times morelikely to use cocaine, and those who smoke are 19times more likely to abuse other drugs. Additionally,these numbers increase the younger the child is at firstuse. Because alcohol is often found in peoples’ homes,it often becomes the first drug that children use.Because of its accessibility, the number one problemfor children remains alcohol abuse. Lately childrenhave been using inhalants and over-the-counter med-ications to get high because those are easier to obtain.Finally, never underestimate the use of tobacco. This istruly a gateway drug that leads to other drug and alco-


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hol use. For one reason, it is generally not associatedwith intoxication or behavioral impairment, and thus,parents are sometimes more accepting of its use. Foranother reason, children are much more willing toreport tobacco use then they are other drug usebecause it is more socially acceptable. Tobacco is per-haps the most addictive substance known. It hasunique properties through dose titration of being botha stimulant and an antianxiety agent. It is therefore adrug for all occasions, but tobacco’s neurochemicaleffects are similar to other drugs in boosting dopaminein the brain, which stimulates the reward system.

28. I read somewhere that drinkingalcohol was good for you. Is that true?Maybe. Experts for many years have discussed the ideathat a moderate intake of alcohol may actually be benefi-cial to one’s health, although it has only recently receivedany major press coverage. There has been concern aboutthe potential for misinterpretation of the message if itwere spoken too openly. The concept that moderate alco-hol may be beneficial, after all, flies in the face of thosewho preach complete abstinence. So what exactly are thebenefits? Statistical analysis has shown that total mortal-ity is reduced with moderate alcohol consumption butnot with heavy alcohol consumption. This is thought tobe due to reductions in the risk of developing diabetesand cardiovascular disease. The amount of alcohol associ-ated with the lowest mortality appears to be two standarddrinks per day in men and one standard drink or fewerper day in women. More recent studies refute that, how-ever, stating that the previous studies were flawed andthat moderate alcohol use confers little to no benefit,

Neurochemical

a broader name forneurotransmitter.Any chemical thathas effects on nervecells.


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whereas greater use clearly confers greater risk of manydiseases. The window between health “giving” andhealth “taking” is very narrow.

29. What is a safe level of alcoholconsumption?If a person is alcohol dependent, then no level issafe. If an individual is concerned that he or she maybe a problem drinker, it is important to understand theinformation in Table 7. Even individuals who neverexceed the daily or weekly limit are not entirelyimmune from the possibility of alcohol abuse ordependence, however low the risk. For individuals whoexceed the daily and weekly limits regularly, however,only one in five will develop abuse, and one in four willdevelop dependence. Although these numbers are dra-

Table 7 Amount of Alcohol Associated with Risk of Dependence or Abuse

Drinking patternno more than 4 perday and 14 per weekfor men and 3 per Prevalence in U.S. Dependenceday and 7 per week adults 18 years and Abuse without with orfor women up (%) dependence without abuse

Never exceedsweekly or dailylimitExceeds only theweekly limitExceeds only thedaily limit onetime per weekExceeds only thedaily limit morethan one time perweekExceeds both theweekly and dailylimits

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1

16

3

9

Less than 1in 100

1 in 17 (6%)

1 in 8 (12%)

1 in 5 (19%)

1 in 5 (19%)

Less than 1in 100

1 in 100 (1%)

1 in 20 (5%)

1 in 8 (12%)

More than 1in 4 (28%)


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matically higher, the fact that a person drinks thatmuch is still no guarantee that he or she will becomeill. As stated in Question 16, the reason is thatalthough increasing amounts of consumption mayincrease the odds of developing the disease, it is notdependent on the frequency or the amount of use, butrather the consequences of one’s use. These facts areprobably the strongest evidence that supports the con-cept of alcoholism as a disease because although thedisease of alcoholism is clearly linked to alcohol use,there is no guarantee that one will develop thedisease—just as smoking cigarettes does not absolutelydetermine that the individual who smokes will developlung cancer or emphysema even though both areclearly the consequences of chronic smoking. The risksincrease dramatically when the daily limits areexceeded, as demonstrated in Table 7.

30. What is a dry drunk?The concept of a “dry drunk” is controversial. No sys-tematic personality studies have demonstrated thevalidity of this concept, yet its application persists inthe recovery field. The concept of a dry drunk is gen-erally linked with Alcoholics Anonymous (AA) and isused to describe the individual who has stopped drink-ing but continues to display the thinking and behaviorof an active alcoholic. Its origins are derived from twosources. The first source is from the early founders ofAA, and the second source can be found in the workof Dr. Elizabeth Kubler-Ross, the first physician toelucidate the stages of grief and loss. A dry drunkexhibits specific personality traits, and these individu-als are thought to be “one-steppers”—that is, they haveonly completed the first step toward abstinence, with-out achieving true sobriety. AA has developed 12 steps

The concept ofa dry drunk isgenerallylinked withAlcoholicsAnonymous(AA) and isused todescribe theindividualwho hasstopped drink-ing but con-tinues todisplay thethinking andbehavior ofan activealcoholic.


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that an individual must complete in order to reachsobriety and a full recovery. The traits of a dry drunkor one-stepper consist of the following:

• Grandiose behavior• A rigid, judgmental outlook• Impatience• Childish behavior• Irresponsible behavior• Distorted rationalization• Projection• Overreaction• Exaggerated self-importance and pomposity

Another source that can be used to understand the phe-nomenon of the dry drunk may be from the work regard-ing the stages of grief and loss that ElizabethKubler-Ross developed. Dr. Kubler-Ross purported thatany loss that significantly impacts a person’s daily life isaccompanied by a number of stages of grieving, whichinclude denial, anger, bargaining, depression, and finallyacceptance. To an alcoholic, abstinence usually consti-tutes a big loss. Unfortunately, according to the theoryof the dry drunk, alcoholics often get stuck in the stage ofanger. Thus, they are constantly irritable and find it diffi-cult to engage interpersonally. Although the validity ofthis remains hazy at best, it does make intuitive sense.Alcoholics and all addicts, in order to maintain absti-nence, lose a huge part of what constituted their dailyactivities, in terms of thinking about, pursuing, andengaging in alcohol consumption. Many alcoholics andaddicts also lose friends who were their “drinking bud-dies.” The only possible way to get over a consumingactivity is to replace it with other activities. Until thathappens the ever-present feeling of loss will remainextremely palpable. The chances of being irritable and


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edgy as a result of the frustration at not acting on thosedesires will continually plague the recovering addict oralcoholic. Irritability often leads to poor interpersonalinteractions with family, friends, and other acquain-tances. Thus, the consequences of alcoholism both med-ically and socially can continue even though sobriety hasbeen achieved.

31. My mother has been drinking winedaily since my father died. Could she bean alcoholic, or does she need treatmentfor depression?The possible risk of an untreated depression is thedevelopment of co-morbid substance abuse, includingalcohol abuse. Alcohol and drugs make people feelbetter temporarily; unfortunately, however, this effectis only temporary. As the high wears off, despair canset in. After the death of a spouse or other close familymember, if excessive drinking develops, depressionmay be present. Alcohol abuse can often be missed inolder women, particularly if it involves only wine orbeer consumption. Alcohol abuse can cause depressionitself—in such circumstances, recovery from the sub-stance abuse usually leads to resolution of the depres-sion. Depression often precipitates the abuse of alcoholand/or drugs as an attempt to relieve the emotionalpain and thus acts as a treatment for the depression;however, traditional medical treatment for depressionwill be necessary in order to promote the recoveryfrom the substance abuse (see Question 68 for furtherdiscussion on mood disorders and alcoholism).

Alcoholism is an arguable risk factor associated withdepression or other mood disorders because it remains

Alcohol abusecan causedepressionitself—in suchcircumstances,recovery fromthe substanceabuse usuallyleads to resolu-tion of thedepression.


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scientifically unclear how the two are associated. Gen-erally, in patients with true depression, the symptomsexist independently of the amount of alcohol con-sumed, and the symptoms will not improve simply bymaintaining abstinence. Second, in individuals inwhom alcohol is clearly playing havoc with theirmoods, generally a lot of environmental stressors existas a consequence of the alcoholism that impacts onmood independently of alcohol’s direct biologicaleffects. Losing a job, a broken marriage, poor financialsupports, or a lack of housing as a result of the single-minded pursuit of alcohol all impact a person’s mood.In this situation, merely taking an antidepressant med-ication with the thought that the problem is depres-sion is akin to ignoring a broken leg by treating it withonly pain medication. Generally, if in one’s past a per-son has had significant periods of sobriety in whichmood symptoms have abated, then the depression ismore likely caused by the alcohol than an underlyingmood disorder. This is not definitive, just more likely.

Regardless of whether alcoholism causes depression ordepression causes alcoholism, alcohol to a depressed per-son is clearly like throwing an incendiary device on a dry,brittle forest. The chances of a depressed person attempt-ing suicide are doubled when that person drinks. There-fore, for any improvement in mood to occur, the personmust stop drinking immediately; for many people withdepression, however, this simple task seems not onlyabsurd (it often becomes their only pleasure), but alsoclose to impossible. As a result, the alcohol problem mustbe treated along with the depression. For most people,just telling them to stop drinking will not suffice. Sup-port and persistence are required. Support may or may

Regardless ofwhether alco-holism causesdepression ordepressioncauses alco-holism, alcoholto a depressedperson isclearly likethrowing anincendiarydevice on adry, brittleforest.


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not come from programs such as AA, but it must comefrom family and friends. The more support systems thatan alcoholic has, the better his or her chances are for asuccessful recovery.

32. Am I at risk for other kinds ofaddictions if I have been addicted toalcohol?Alcohol shares many properties in common with otherdrugs of abuse. Chemically it acts on dopamine, the finalcommon pathway of all drugs of abuse and the instru-mental chemical in the brain’s reward system. Alcoholalso acts on opiate receptors, which are the target ofopium and its variants, namely heroin. There is a theorybased on the discovery of a chemical found in the brainsof alcoholics known as tetrahydroisoquinolone(THIQ). The theory is that THIQ, which is a break-down product of heroin and is also highly addictive, isuniquely produced in alcoholics. THIQ leads to bothintoxication and withdrawal, similar to other sedativehypnotics and opiates. Physiologically, alcohol addic-tion and heroin addiction share a similar chemical incommon leading to euphoria, tolerance, dependency,and craving. Environmentally, alcohol and heroin sharemany of the ritualized behaviors that become linked tothe pleasure of using other substances. Although manypeople have a drug of choice, the likelihood of devel-oping an addiction to another substance when one isaddicted to alcohol is certainly higher than when aperson is not addicted at all. If an individual is inrecovery, all of the doctors must know so that they canchoose medications with the least addictive potential

Tetrahydroiso-quinolone (THIQ)

a chemical com-pound that can beformed by combiningacetaldehyde (thetoxic breakdownproduct of alcohol)and dopamine (theneurotransmitter). Itis thought to be spe-cific for alcoholicsand has opioid-likeactivities causingeuphoria, therebyexplaining theirincreased propensitytoward addictionwhen compared tothe normal popula-tion.


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and so that they can monitor the effects of the medica-tions and therefore reduce the potential for addiction.

33. What are some of the triggers torelapse?The triggers to relapse are numerous but can be boileddown to extremes in emotion. Feeling sad or angry orlet down or disappointed may lead to frustration and acareless attitude toward one’s current success. “Whocares?” is a sentiment that can echo in the bottle.Euphoric feelings from achievement or success canlead to complacency and a desire to “celebrate.” Analcoholic’s excuses to drink are endless. As one alco-holic said to another, “Don’t give me any of that BSabout why you drink! You drink because you’re thirsty!”

Although triggers are the final common pathwaytoward drinking again, specific triggers differ for eachindividual. Identifying the triggers is critical becauseyou can then put into place a crisis plan to deal withthem. The plan should include steps to be taken andwho to turn to for support in order to avoid slipping,as well as a plan for an evaluation and the possibility ofre-entry into treatment if a slip leads to the old pat-terns of drinking. Both your family and primary carephysician should know the plan. If you are attendingoutpatient treatment, the staff should know the crisisplan. Relapse can rapidly progress to the point of evengreater problems than before sobriety was attained.The chances for adverse effects are too great to takethe chance of drinking again. The adverse effectsinclude social, psychological, and physical problems,which often occur the second time to an even greaterdegree of severity.

Euphoric

a happy and elatedmood.


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Susan’s comment:

I have had many conversations with Ben about what makeshim relapse. His answer is twofold: He “picks up,” as they sayin AA circles, as a result of what is referred to as frustrationand carelessness. He expresses his sentiment as, “What the —?”He then explains the sad reality that after he starts, he mustcontinue, so that he won’t get sick. Only a severe case ofaddiction can cause someone to drink so that they stay well.




TreatmentWho is qualified to diagnose and treat alcoholism?

What is AA, and how does it work?

What is ASAM, and what are the criteria for placement in a particular program?

More . . .

PART IV


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34. Who is qualified to diagnose andtreat alcoholism?Many clinicians of various educational backgrounds arequalified to diagnose and treat alcoholism. The choice ofthe type of practitioner will depend on the need for ther-apy, medication, or both. Your internist or family practicedoctor can diagnose and treat alcoholism to a limiteddegree, as can a nurse practitioner. This usually entailsmanaging the medical consequences of heavy drinking,but may also include prescribing medication specificallyindicated for alcoholism (see Questions 47–52). Theywill also refer you to a mental health specialist for a morein-depth evaluation. Some internists have specialty certi-fication through the ASAM. Psychiatrists can alsoreceive ASAM certification but often receive advancedfellowship training in addiction psychiatry through theAmerican Board of Psychiatry and Neurology.Internists and psychiatrists typically oversee programsand evaluate and treat symptoms of withdrawal and anyunderlying medical and psychiatric problems that occuralong with the alcohol problem.

Psychologists, licensed clinical social workers who havespecialized in addiction treatment, or other therapistswho have received certification through one of a varietyof programs depending on the discipline and the partic-ular state in which they work provide most types of psy-chotherapies—individual, family, and group.Certification as an addiction counselor usually requires aminimum number of hours of supervised work (typi-cally in the thousands). Addiction counselors may haveonly a high school diploma before they complete theirsupervised clinical work, but more typically, they have

The choice ofthe type ofpractitionerwill depend onthe need fortherapy, med-ication, orboth.

American Board of Psychiatry and Neurology

the governing bodythat oversees clinicalstandards for bothpsychiatrists andneurologists and thevarious subspecialtyfellowships such aschild and adolescentpsychiatry and addic-tion psychiatry.


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either an associate’s degree or a bachelor’s degree. Occa-sionally, they can also have a masters’ degree, but thesedegrees are more often associated with licensed clinicalsocial workers. Addiction counselors are not authorizedto specifically diagnose, but they do participate in evalu-ations and treatment. Mental health specialists who canevaluate for and treat alcoholism include the following:

• Social workers• Psychologists• Psychiatric clinical nurse specialists or nurse practi-

tioners• Psychiatrists

Social WorkersSocial workers provide a full range of mental healthservices, including assessment, diagnosis, and treat-ment. They have completed undergraduate work insocial work or other fields, followed by postgraduateeducation to obtain a Master’s of Social Work or adoctorate degree. A Master’s of Social Work isrequired in order to practice as a clinical social workeror to provide therapy. Most states require practicingsocial workers to be licensed, certified, or registered.Postgraduate education includes 2 years with coursesin social welfare, psychology, family systems, childdevelopment, diagnosis, and child and older personabuse/neglect. During the 2 years of coursework, socialwork students participate in internships that are con-cordant with their interest. After completion of themaster’s program, direct clinical supervision is usuallyrequired for a period of time to apply for a license,which may vary from state to state.


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PsychologistsPsychologists have completed undergraduate work fol-lowed by several years of postgraduate studies in orderto receive a doctorate degree (Ph.D. or Psy.D.) in psy-chology. Graduate psychology education includesstudy of a variety of subjects, notably statistics, socialpsychology, developmental psychology, personalitytheory, psychological testing (paper and pencil tests tohelp assess personality characteristics, intelligence,learning difficulties, and evidence of psychopathol-ogy), psychotherapeutic techniques, history and phi-losophy of psychology, and psychopharmacology andphysiological psychology. After the coursework, a yearis spent in a mental health setting providing psy-chotherapeutic care and psychological testing underthe supervision of a senior psychologist. Psychologistsmust demonstrate a minimum number of hours (usu-ally around 1,500) before eligibility to sit for state psy-chology licensure exams.

The Psychiatric Clinical Nurse Specialists orthe Nurse PractitionersProfessional nurses, prepared with a minimum of abaccalaureate degree in nursing and advanced practicenurses, prepared at the master’s level, work with alco-holic and drug abuse patients. The baccalaureatedegree in nursing most often works with patents in aninpatient setting and may or may not be certified inalcohol addiction, depending on the requirement ofthe agency. The professional nurse provides the directcare for the patient 24 hours per day. Both the nursepractitioner and the clinical nurse specialist work in bothinpatient and outpatient settings; however, they are morefrequently involved in community-based care. All three


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are schooled in general nursing, including psychiatricnursing, and have studied alcoholism. The focus of thenurse practitioner’s practice is on the physical health ofthe alcoholic or drug abuser. The nurse practitionerconducts physical assessments and prescribes medica-tions, as well as monitors the patient’s response to themedications. The clinical nurse specialist’s focus is onthe mental health of the patient and the family. Theclinical nurse specialist conducts mental health assess-ments and mental status exams, facilitates groups, andworks with both the patient and family to meet theirmental health needs. All advanced practice nurses,both the clinical nurse specialist and the nurse practi-tioner, are certified by the American Nurses Associa-tion Credentialing Center, after receiving theirmaster’s degree from an accredited college or univer-sity. All advanced practice nurses receive ongoing clin-ical supervision during their course of study. In manystates, both the state board of medicine and the stateboard of nursing license the nurse practitioner, whereasthe clinical nurse specialist is not under the jurisdictionof the board of medicine. The state board of nursinglicenses all nurses.

PsychiatristsPsychiatrists are medical doctors with specializedtraining in psychiatry. They have completed under-graduate work followed by 4 years of medical school.Medical education is grounded in basic sciences ofanatomy, physiology, pharmacology, microbiology, his-tology, immunology, and pathology, followed by 2years of clinical rotations through specialties thatinclude medicine, surgery, pediatrics, obstetrics andgynecology, family practice, and psychiatry (as well asother elective clerkships). During this time, medical

American Nurses Association

the American NursesAssociation is a pro-fessional organiza-tion of nurses toadvance the profes-sion of nursing.


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students must pass two examinations toward licensure.After graduation from medical school, physicians havea year of internship that includes at least 4 months in aprimary care specialty such as medicine or pediatricsand 2 months of neurology. After internship, physi-cians must take and pass a third exam toward licensurein order to be eligible for licensure (and subsequentlypractice) in any state. Psychiatrists in training have 3more years of specialty training in residency, the suc-cessful completion of which makes them eligible forboard certification. After residency, many psychiatristspursue further training in a fellowship that can last anadditional 2 years. Such fellowships include child andadolescent psychiatry, geriatric psychiatry, consultation–liaison psychiatry, addiction psychiatry, forensic psy-chiatry, and research. To become board certified,psychiatrists take both a written and an oral examina-tion. Certain psychiatry specialties also have a boardcertification process. Board certification is not arequirement to practice and may not be obtainedimmediately on completion of residency, althoughmany hospitals and insurance companies do requirephysicians to be board certified within a specifiednumber of years in order to treat patients.

35. What is AA, and how does it work?AA, or Alcoholics Anonymous, grew out of the Chris-tian temperance movements in the 19th century. Thesemovements were connected to local churches, and self-professed alcoholics who pledged abstinence formedthem. A drinking buddy introduced the eventualfounder of AA, Bill W., to one of these church groups.The buddy falsely claimed that he had been treated byDr. Jung, who told him that he was a lost cause unless


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The 12-stepapproachworks ondevelopingstrong socialsupport net-works and theuse of rolemodels.

he experienced a religious epiphany. AA grew slowlyout of the roots of the Christian temperance move-ment, and in 1938, the Big Book was written and pub-lished. The AA name was first used along with the 12steps that Bill W. developed.

The 12-step approach works on developing strongsocial support networks and the use of role models.Thus, obtaining a sponsor is an important componenttoward successful sobriety. The sponsor should beolder, sober, and the same gender in order to provide amentoring role. The concept of a higher power deterspeople because they attribute a higher power to “God”and assume it is “faith based”; however, the requiredfaith is in the 12-step process. The concept of faith isgeneric. For example, faith in a variety of authority fig-ures is required in order to depend on their guidance,including doctors, other professionals, even mechanics,spouses, parents, and so forth. The type of faith thatAA seeks to instill in its members has to do with theAA community and should not be mistaken for anyspecific religious faith. The important concept is thatone cannot recover on one’s own. Thus, the “higherpower” is the power that comes from faith in the com-munity and the recovery process. It is important forthe recovering alcoholic to understand his or her ownpersonal limits in order to enlist the support of a com-munity of members and have faith in the recoveryprocess to achieve and maintain sobriety. The higherpower is different for each person because everyone hasunique challenges to achieve and maintain sobriety.

The first several AA meetings may be uncomfortableand may seem foreign. The usual response is this: “Iam not like these people.” They are too old, too young,

It is importantfor the recov-ering alcoholicto understandhis or her ownpersonal limitsin order toenlist the sup-port of a com-munity ofmembers andhave faith inthe recoveryprocess toachieve andmaintainsobriety.


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Table 8 The 12 Steps

1. We admit we are powerless over alcohol—that our lives havebecome unmanageable.

2. We believe that a Power greater than ourselves can restore us tosanity.

3. We have made a decision to turn our will and our lives over to thecare of God as we understand Him.

4. We have made a searching and fearless moral inventory of our-selves.

5. We have admitted to our God, to ourselves, and to another humanbeing the exact nature of our wrongs.

6. We are entirely ready to have God remove all of these defects ofcharacter.

7. We humbly ask Him to remove our shortcomings.8. We have made a list of all persons we have harmed and become

willing to make amends to them all.9. We have made direct amends to such people wherever possible,

except when to do so would injure them or others.10. We have continued to take a personal inventory and when we are

wrong promptly admit it.11. We have sought through prayer and meditation to improve our

conscious contact with God, as we understand Him, praying onlyfor knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as a result of these steps, we havetried to carry this message to alcoholics and to practice these prin-ciples in all our affairs.

too ethnic, too white, too rich, or too poor. To addressthe initial reaction, there are a variety of meetings thatcomprise individuals of similar demographic back-grounds so that one can feel “more at home.” Althoughthis may temper the initial discomfort, it is often thepeople that initially seem the most different thatinevitably have the greatest impact in helping to main-tain sobriety. The important lesson is to stick with itthrough the initial discomfort. Studies have shownthat patients who attend regularly, as little as once aweek, have better success rates than those who dropout (Tables 8 and 9).


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Table 9 The 12 Traditions

1. Our common welfare should come first; personal recovery dependson AA unity.

2. For our group purpose there is but one ultimate authority—a lov-ing God as He may express Himself in our group conscience. Ourleaders are but trusted servants; they do not govern.

3. The only requirement for AA membership is a desire to stopdrinking.

4. Each group should be autonomous except in matters affectingother groups or AA as a whole.

5. Each group has but one primary purpose—to carry its message tothe alcoholic who still suffers.

6. An AA group ought never endorse, finance, or lend the AA nameto any related facility or outside enterprise, lest problems of money,property, and prestige divert us from our primary purpose.

7. Every AA group ought to be fully self-supporting, declining out-side contributions.

8. AA should remain forever nonprofessional, but our service centersmay employ special workers.

9. AA, as such, ought never be organized, but we may create serviceboards or committees directly responsible to those they serve.

10. AA has no opinion on outside issues; hence, the AA name oughtnever be drawn into public controversy.

11. Our public relations policy is based on attraction rather than pro-motion; we need always maintain personal anonymity at the levelof press, radio, and films.

12. Anonymity is the spiritual foundation of all our traditions, everreminding us to place principles before personalities.

36. What is ASAM, and what are thecriteria for placement in a particularprogram?ASAM is the American Society of Addiction Medi-cine, the major certifying body for physicians trainedin addiction medicine. ASAM sets the criteria for howpatients are placed in particular treatment settings.The ASAM Patient Placement Criteria, 2nd Revision,or PPC-2R, provides two sets of guidelines, one foradults and one for adolescents, and five broad levels of

American Society of Addiction Medicine (ASAM)

its mission is to trainmedicine studentfaculty and residentsto provide treatmentand rehabilitationand to developstrategies for preven-tion of alcoholism.


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care for each group. Generally, two distinct types ofcare exist: detoxification and rehabilitation.

Here are the brief descriptions of settings and levels ofservices:

• Level I: outpatient treatment. An organized outpa-tient treatment clinic or an office practice with des-ignated addiction professionals providing alcohol ordrug treatment. This treatment occurs in regularlyscheduled sessions usually totaling fewer than 9contact hours per week. An example includes weeklyor twice-weekly individual therapy, weekly grouptherapy, or a combination of the two in associationwith regular participation in self-help groups.

• Level II: intensive outpatient treatment. This is alsoknown as an outpatient rehabilitation program. It isan organized program in which addiction profession-als provide several treatment modalities. Treatmentconsists of regularly scheduled sessions within a struc-tured program, with a minimum of 9 treatment hoursper week and up to 6 hours daily. Examples includeday or evening programs in which patients attendhighly structured group and individual services.

• Level III. This ranges from a halfway house tomedically monitored intensive inpatient treatment.This is what is commonly thought of as rehabilita-tion and is an inpatient or residential program. It isan organized service conducted by addiction profes-sionals who provide a planned regimen of around-the-clock professionally directed evaluation, care,and treatment on an inpatient setting. A multidisci-plinary staff functions under medical supervision.


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• Level IV: medically managed intensive inpatienttreatment. This is commonly thought of as acuteinpatient care, but can also include either an emer-gency room or an inpatient psychiatric unit. It is anorganized service in which addiction professionals —medical and psychiatric clinicians—provide aplanned regimen of 24-hour medically directedevaluation, care, and treatment in an acute careinpatient setting. Patients generally have severewithdrawal and/or medical, emotional, or behav-ioral problems that require primary medical, psychi-atric, and nursing services.

Detox levels of care:

• Level I-D: Ambulatory or outpatient detoxification• Level II-D: Ambulatory detoxification with

onsite monitoring• Level III.2-D: Clinically managed residential

detoxification• Level III.7-D: Medically monitored inpatient

detoxification• Level IV-D: Medically managed intensive inpatient

detoxification

Clinicians have expressed a concern that placementstandards may restrict some individuals from receivingthe required level of care. Other concerns include thepotential stifling of innovative treatment approaches.In response to those concerns, a study was conductedto examine the utility of the patient placement proto-cols, using a standardized computer algorithm as wellas the input from a group of clinicians in placingpatients in particular levels of care. The hypotheses


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Rehabilitationis a therapeu-tic interven-tion thatattempts toprovide thepatient withthe tools thathe or sherequires inorder to main-tain sobrietyafter return-ing to thecommunity.

tested were that patients matched to the recommendedlevel of care would have better outcomes than thosepatients who were mismatched and received eitherundertreatment or overtreatment. The mismatchedgroup of patients had no better outcomes than thosematched to the appropriate levels of care. The meannumber of days of any alcohol use during the last 30days decreased for all groups, although those withmatched care and overtreatment had better results.Surprisingly, the computer-driven algorithm assignedpatients to overtreatment more frequently thanclinician-recommended levels of care. In both cases,however, the study concluded that in general theASAM patient placement criteria were effective inreducing both undertreatment and overtreatment.

37. What is rehabilitation, and how is itdifferent from AA?Rehabilitation is a therapeutic intervention that attemptsto provide the patient with the tools that he or sherequires in order to maintain sobriety after returning tothe community. Rehabilitation programs offer severallevels of intensity of care as the patient placement proto-cols suggest. Rehabilitation generally offers very struc-tured programs that include individual and grouptherapy as well as educational programming and occupa-tional/vocational support. Additionally, either a psychia-trist or an internist who specializes in addiction medicineis available for consultation. These programs range in thedegree of intensity from as little as 9 hours per week asdefined by an intensive outpatient treatment program(IOP) to inpatient 24 hours a day 7 days a week for up toseveral months. AA is relatively unstructured, does not

Intensive outpatient treatment program (IOP)

a program usuallyrun by inpatient per-sonnel, as part of thedischarge plan forcontinuing follow-uptreatment for theirinpatients, upon dis-charge.


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follow a specific didactic program, and relies completelyon the fellowship of its members to provide the supportnecessary to maintain abstinence. Most addiction medi-cine specialists feel that AA alone is generally inadequatebut is a critical adjunct to a well-structured rehabilitationprogram. AA is also required for follow-up after com-pleting a rehabilitation program. These two treatmentmodalities are seen as complementary and not mutuallyexclusive. Rehabilitation is more comprehensive and fol-lows a medical model. This has meant, at least in thepast, that the concept of addiction as a disease was heldto more strongly by rehabilitation programs and the useof medication more readily administered and accepted asan adjunct to care for the alcoholic. Only recently has AAbecome more accepting of that model, although mem-bers remain generally divided on which medications theyare willing to consider as reasonable. Some AA memberscontinue to condemn the use of various medications foreither a psychiatric condition or their alcoholism.

38. What are the different kinds ofoutpatient and inpatientrehabilitations?IOPs and partial hospital programs (PHPs) generallydiffer in the amount of time that a person spends inthem during the day. Insurance companies definethose differences and thus determine whether they arewilling to pay for one or the other. An IOP provides 3hours of treatment daily for up to 9 total hours weekly(Monday, Wednesday, and Friday). A PHP offers a 4-hour program daily for a total of 20 hours weekly(Monday through Friday). PHPs are generally used asa stepdown from an inpatient psychiatric stay, and then

Partial hospital program (PHP)

a program usuallyrun by inpatient per-sonnel as part of thedischarge plan fortheir inpatients.


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the amount of time the individual spends in the pro-gram rapidly decreases over the following weeks (suchas decreasing by a day each week over 4 weeks). Mostprograms do not offer ambulatory or outpatient detox-ification but require detoxification to occur before theindividual is accepted into the program. GenerallyIOPs and PHPs require patients to attend daily AAmeetings in addition to the treatment that they offer.

Most insurance plans will pay for inpatient programsbased on the patient placement protocol, which usuallyrequires a patient to have failed an outpatient programfirst. Such inpatient programs range in the length ofstay from 2 weeks to several months. Insurance benefitsusually also determine this. Most private insurancecompanies will pay for up to 2 weeks of inpatient reha-bilitation annually. Inpatient rehabilitation is lessrestrictive than an inpatient psychiatric facility, and forthat reason, it should really be regarded as a residentialprogram rather than an inpatient program. First, reha-bilitation programs are entirely voluntary. Manypatients hospitalized psychiatrically with drug or alco-hol problems are hospitalized involuntarily because aphysician has considered them to be at high risk forharming themselves or others as a result of a mental ill-ness and not merely because of their drug or alcoholuse. Second, rehabilitation programs generally do notprovide daily physician contact as occurs in the acutepsychiatric or medical setting; patients in rehabilitationprograms are considered to be medically and psychiatri-cally stable. The only long-term (i.e., more than 1month and up to 6 months) residential programs avail-able to patients are those that accept either private pay,payment from state general assistance, or a combination


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of those two along with an opportunity to work for yourkeep. Finally, even within inpatient rehabilitation pro-grams, varying levels of support exist. Halfway housesare a less intense form of residential care and offerapproximately 5 hours of professional services weekly.The expectation is that while the patient is in thehalfway house, he or she will find work, attend AAmeetings regularly, and attend the program. In contrast,sober houses offer no programs to their residents. Bothhalfway houses and sober houses require residents tosupport their stay financially through either working forthe program or obtaining employment on the outside.

39. What is the difference between afaith-based program and others?The idea of faith-based treatment for alcoholismcomes out of the AA movement but is more religiouslybased and historically Christian in its orientation.Unfortunately, “faith-based” has become a politicallycharged term, suggesting on the one hand a zealous,narrow-minded approach to care, and on the other anexcuse to cut government funding for addiction treat-ment. This is the work of politicians and not the work ofthe treatment centers. “Faith-based” programs supportan underlying religious belief and commitment to spe-cific doctrinal principals. Faith-based programs do notview addiction problems as simply a crisis of faith thatcan be remedied just by the word of God alone. Typi-cally, the concept of dual diagnosis is understood, includ-ing both the medical and psychiatric co-morbidities, andthe need to appropriately treat them. Although the pri-mary goal is addiction treatment, faith-based programshave the ultimate goal of demonstrating the power of


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Although theprimary goalis addictiontreatment,faith-basedprograms havethe ultimategoal ofdemonstratingthe powerof the word ofGod and thepower thatfaith plays inone’s life, notjust in termsof addictionbut also inother aspects of life.

the word of God and the power that faith plays inone’s life, not just in terms of addiction but also inother aspects of life. “Faith-based” programs are animportant option for anyone considering treatment.

40. Does it matter how long I stay in aninpatient program? How successful arethey?Although the evidence demonstrating “treatment” effi-cacy in alcoholism is overwhelming, the type of treat-ment or the environment of care remains debated. Anyintervention is better than no intervention, but exactlywhat that intervention should constitute beyond somekey elements is unclear. Studies have shown little dif-ference in success rates between outpatient and inpa-tient rehabilitation programs. The patient placementprotocols described in Question 36 help clinicians todetermine which care setting will have the greatestchance of success for a particular patient. They outlinea general structure and setting with parameters on fre-quency and intensity of treatment without clearlyspecifying duration. Regardless of setting, the durationof care clearly improves abstinence rates. It is not clearwhether the environment of care (i.e., inpatient versusoutpatient) plays a role in that. The two long-terminpatient programs can be divided into residential pro-grams that follow a 12-step model and are generallyshorter stay programs and therapeutic communities,which are greater than a year in duration and oftenexpect patients to seek employment as part of theirrecovery program. Intuitively, it would make sense thatthe longer one is out of the environment that sup-ported one’s addiction the better the chance of successwhen one eventually returns to that environment.

Therapeutic communities

the environment onan inpatient unit thatis developed to be ahealthy milieu forstaff and patientsand that facilitatesthe development andimplementation oftreatment.


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Cognitive behavior therapy

a therapeutic inter-vention that rein-forces “positivethinking” and extin-guishes “negativethinking” (i.e.,changing undesirablecognitive function-ing).

Unfortunately, no real “geographical cures” are avail-able for those struggling with addiction. Thus, itappears that the critical factor is length of successfultreatment rather than length of stay.

41. How successful are the varioustreatment options?Regardless of the type, it is well known that treatmentworks. In fact, in a large California study, it was foundthat for every $1 invested in treatment, $7 in lost rev-enue was saved from various illnesses, accidents, hospi-talizations, and loss of productivity. In a study on threetypes of treatments, including cognitive behaviortherapy, motivational enhancement therapy, and 12-step facilitation, the number of drinking days over a12-month follow-up was reduced from a baseline of 78to approximately 20. The number of hospitalizationsfor physical health problems, overdoses, and mentalhealth problems was also reduced by as much as 60%,and the number of doctor visits, emergency room vis-its, and hospital days was reduced by as much as 40%.

A large study of 65,000 patients conducted in 1994demonstrated that 60% of those who completed treat-ment maintained sobriety a year later. With respect toAA attendance, of those who attended at least weekly,73% remained abstinent; of those who attended occa-sionally, 53% remained abstinent, and of those whodropped out, 44% remained abstinent. Durationclearly had an effect as well; 85% who remain in treat-ment maintained abstinence. For those who droppedout between 6 and 12 months, 70% maintained absti-nence. For those who dropped out in 5 months or less,55% maintained abstinence. In a random survey of AA

Motivational enhancement therapy

cognitive interven-tions are used toenhance the sub-stance abuser’sdesire to stop using.


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members, 35% were sober for more than 5 years, 34%between 1 and 5 years, and 31% for less than a year.

42. How is treatment different forsomeone with a dual diagnosis?Over half of all individuals struggling with alcoholismare also struggling with some other underlying psychi-atric disorder. This has been partly addressed in Ques-tion 31 and is addressed further in Question 68. Thequestion of whether one condition causes the other iscontroversial and fraught with misunderstanding.Although it is likely that depression can lower one’sability to maintain abstinence, it is unlikely that treat-ing the depression will cause the alcoholic to remainabstinent. Alternatively, if one has struggled withlong-standing depression even when sober for severalmonths, the likelihood that sobriety will “cure” thedepression is extremely low. It is best not to ask “thechicken or the egg” question of what came firstbecause after a while it is a moot point.

For successful treatment, both alcoholism and mentalillness need to be treated simultaneously. Patients andtheir family members too often wish to attribute one’sbehavior problems all to one diagnosis or the other,thinking and hoping that somehow less stigma isattached to a diagnosis of depression or alcoholism.Therefore, treatment is different only in so far as theunderlying mental illness must be managed in conjunc-tion with an appropriate rehabilitation program, notbefore or after the completion of treatment in therehabilitation program. Some rehabilitation programsdo not treat anyone who is on a psychotropic medica-tion and demand that the medication be tapered and

Over half ofall individualsstrugglingwith alco-holism are alsostrugglingwith someother underly-ing psychiatricdisorder.


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discontinued during one’s stay. If discontinuation ofthe medication is done before a detailed psychiatricassessment is completed to evaluate the appropriate-ness of the medication, then this type of program isnot appropriate for the individual suffering from bothalcoholism and a psychiatric disorder. Alternatively, if apsychiatric assessment is performed and tapering med-ication appears to be indicated, then that is a reasonablerehabilitation program; however, the patient must askthe psychiatrist for the rationale behind the decision todiscontinue the medication. If the patient doesn’t get areasonable explanation, then the patient cannot provideinformed consent to taper and discontinue the medica-tion. Shop around for a different treatment program,one that will address both the problem of addiction andthe underlying mental health problem.

43. All of the programs I attend aregroup based. I really feel I need someindividual treatment. What should I do?Many, if not most, patients express an initial reluctanceto attend group therapy, thus preferring individualtherapy. They think they will feel more at ease and getbetter care. Although individual therapy provides moreindividual attention, it generally cannot provide thedaily treatment that group therapy can. Publishedstudies generally show no differences in success ratesbetween these two forms of therapy. Group therapy ismore cost-effective. The likelihood of getting individ-ual therapy is low unless one is willing to pay at one’sown expense. The focus should be on outcomes. Realsuccess depends more on staying in treatment than onthe type of treatment. Group therapy can offer some-thing individual therapy cannot: an opportunity to find


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a support group. At least one person in the group willbe the person that one can really connect with in a waythat supports sobriety unlike any other connection. Thefeeling that a professional therapist just doesn’t under-stand often leads to mistrust and an easy excuse to stoptreatment. With group therapy, everyone understands,and often one individual really understands in a waythat is both supportive and profoundly helpful. Alco-holism can be combated only with strong support sys-tems. The more people the individual reaches out to, thegreater the likelihood of finding those key supports.After a brief period of time, everyone overcomes the ini-tial reticence to speaking up in a group. The cohesive-ness that develops among the group members isunparalleled in its power for the individual feelingunderstood and supported.

44. I understand that some programsteach alcoholics to drink moderately.How successful are those programs?Treatment in the United States as AA and the temper-ance movements were developed emphasized completeand permanent abstinence from alcohol and all intoxi-cating substances. The concept of a return to moderateor controlled drinking is rejected. Alternatively, Euro-pean and Commonwealth countries have offered con-trolled drinking therapy as an option for quite sometime. When attempting to study success rates, how-ever, little to no distinctions are made between individ-uals suffering from alcohol dependence, alcohol abuse,and problem drinking. Another confusing factor is thedefinition of relapse. Many studies place little empha-sis on the amount that is drunk and the consequencesof an episode of drinking when defining relapse or areturn to use. Does drinking one glass of wine at a


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Motivational interviewing

a brief treatmentapproach designed toproduce rapid inter-nally motivatedchange in addictivebehavior and otherproblem behaviors.

Christmas dinner constitute relapse? If not, wheredoes one draw the line? Most clinicians define thatone glass constitutes a slip, whereas a return to one’sprevious pattern of out-of-control drinking is arelapse.

George Valliant defined abstinence as drinking less thanonce a month and including a binge lasting less than aweek each year. Ninety percent of alcoholics will eitherslip or relapse in the first 4 years of treatment. Because ofthese staggering numbers, some clinicians feel that thedemand for complete abstinence is at best unrealisticand, at worst, possibly detrimental, as it may evencause the alcoholic to reject treatment, altogether.Defining patient types (i.e., problem drinker, alcoholabuser, alcohol dependent) and patterns of drinking isdifficult to credibly sort out whether or not a return tocontrolled drinking is possible for the alcoholic. Clini-cians, who emphasize harm reduction, are happy whena patient’s alcohol use is on the wane, even if it contin-ues; however, others feel drinking in moderation is asetup for disaster. Motivational interviewing, a typeof therapy for addictions, attempts to begin where thepatient is in terms of his or her own beliefs about alco-hol use, and through slow but persistent psychothera-peutic work, the patient is moved through variousstages of recovery from (a) precontemplation to (b)contemplation and ultimately (c) acceptance. Duringthese stages, an individual’s commitment to abstinencewill differ while treatment continues. (See the glossaryfor principles of motivational interviewing.)

Research demonstrates that patients who slip are atgreater risk for repeated relapse compared withpatients who are completely abstinent. Ironically, stud-ies also show that a return to controlled drinking is

Researchdemonstratesthat patientswho slip are atgreater risk forrepeatedrelapse com-pared withpatients whoare completelyabstinent.


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more common among alcoholics who reject treatmentaltogether. The single biggest determinant for the abil-ity to maintain controlled drinking appears to be theseverity of the alcohol problem, rather than whetherthe individual has sought treatment. Individuals whohave severe alcohol problems require abstinence orthey will lose everything, including their own lives. Incontrast, individuals who are alcohol abusers or prob-lem drinkers and the severity of their drinking has notbeen extreme enough to threaten their livelihood if nottheir lives may be able to drink in moderation. Theseindividuals are less likely to end up in treatment andare more likely to be able to control their drinking.Moderation management may be good for some and acomplete disaster for others.

45. Is the treatment approach foradolescents different than adults?Many differences exist between adolescent and adultalcoholics. Adolescents typically tend to be problemdrinkers or alcohol abusers and have not yet developeda pattern of regular daily heavy drinking. Conse-quently, they are rarely alcohol dependent and aretherefore less apt to develop physiological withdrawalsymptoms compared with adult alcoholics. Adoles-cents generally have not settled on one or two drugs ofchoice. They tend to abuse many drugs in addition toalcohol. Additionally, adolescent alcoholics havehigher rates of secondary psychiatric disorders, partic-ularly anxiety disorders and most notably PTSD, asmany of them have a history of physical and/or sexualabuse. Another psychiatric disorder associated withhigher rates of alcoholism and other addictions amongadolescents is attention deficit hyperactivity disorder

Another psy-chiatric disor-der associatedwith higherrates of alco-holism andother addic-tions amongadolescents isattentiondeficit hyper-activity disor-der (ADHD).

Attention deficit hyperactivity disor-der (ADHD)

a persistent patternof inattentionand/or hyperactivityand impulsivity thatis seen more fre-quently in childrenwith ADHD than inchildren at compara-ble developmentallevels.


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Psychostimulant

“Psycho” pertains tothe brain and its cog-nitive functions. Astimulant is an agentor drug that increasesthe functional activ-ity or efficiency of anorgan.

Ritalin

the trade name formethylphenidate. Itis used to treat ADHD.

Dexedrine

a psychostimulantthat is prescribed totreat ADHD.

ReVia

trade name for nal-trexone.

Campral

a drug used to main-tain alcohol absti-nence.

(ADHD). A great deal of controversy has been arousedaround the use of psychostimulant medications suchas Ritalin or Dexedrine in treating ADHD, with somepeople believing that these medications may leadto problems with addiction. These medications arefrequently abused, and these medications may causeaddiction problems. Many studies have repeatedlydemonstrated that having the diagnosis of ADHD is anindependent risk factor for the development of substanceabuse and alcoholism whether or not the ADHD istreated with psychostimulants. In fact, more recent stud-ies have demonstrated that the risk of drug and alcoholuse increases without treatment for ADHD.

Alcohol Treatment for AdolescentsBecause of the differences between adolescents andadults, treatment tends to be more aggressive in itsapproach to the underlying psychiatric conditions,whereas it is more conservative in treating the substanceabuse or alcohol problem. Peer-oriented groups focus onthe adolescent’s developmental challenges. Medicationssuch as naltrexone (ReVia), acamprosate calcium (Cam-pral), or disulfiram (Antabuse) for drug or alcohol prob-lems, as described in Questions 47–52, have not beenexamined thoroughly in this age group and should beused only in the most extreme treatment-resistant cases.Psychotherapeutic approaches are paramount andinclude all forms from 12-step down to individual ther-apy. Although improved function despite continued usemay satisfy some clinicians, controlled use in this popu-lation should never be the goal of treatment. Mostadolescents will interpret this as permission to continueto use as long as they function better. ASAM patient

Disulfiram

generic name forAntabuse, which isthe most widely usedmedication foralcoholism in thiscountry.


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placement criteria also exist for adolescents and generallyfollow similar guidelines as those used for adults.

46. What exactly is an “intervention”?Interventions have become the subject of sitcoms andsoap operas as depicted in Seinfeld and the Sopranos.Regardless of the humor or bathos associated withthem, they can be an effective approach at getting aloved one into treatment. Interventions should beorchestrated in advance, preferably by a professionalwho is a skilled interventionist so that nothing is leftto chance and all anticipated countermeasures havebeen considered and are ready to be implemented. Thekey term is leverage. Unfortunately, most alcoholics arein denial about their problem and stridently object tothe idea that they have a problem with alcohol untilthey are in jeopardy of losing something more valuablethan their alcohol.

The major touchstones include the following:

1. The intervention should be linked in time to arecent alcohol-related incident so that the connec-tion between the drinking and the negative conse-quences are blatantly obvious.

2. The intervention needs to occur when the individ-ual is sober.

3. A specific narrative should be prepared as to howthis, as well as past incidents of drinking, has nega-tively impacted you. The reason for the interven-tion is to get the alcoholic into treatment.

4. Explain the future consequences of continueddrinking in terms of your relationship with him or


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her. Tell the person that until he or she seeks spe-cific treatment to maintain sobriety you are pre-pared to carry out your plans. Do not threaten!Threatening will be viewed as merely inflamma-tory. Make only promises that you are absolutelyprepared to act on and explain that you are doingthis to protect yourself. This may range from refus-ing to go to any alcohol-related social activities tomoving out of the house. Involving other lovedones who have also been directly affected by theperson’s alcohol use may strengthen the leverage.They should be prepared to discuss their own nega-tive experiences with the alcoholic. Having someloved ones who are also in recovery can be particu-larly persuasive.

5. Be prepared to have treatment options. Plan tohave a bed ready in advance for inpatient detoxifi-cation and/or rehabilitation. If outpatient treatmentis appropriate, names and appointments should bemade in advance. Offering to accompany the alco-holic to the initial appointment or first AA meetingis very helpful, as it demonstrates your support.

47. What different kinds of medicationsare available for alcoholism?Medications for alcoholism can be divided into severalcategories: (1) Medications can treat alcohol with-drawal syndromes. These syndromes are medicalemergencies and medication is a medical necessity. (2)Medications can treat the underlying psychiatric disor-ders that may be contributing to though not causingone’s alcoholism. (3) Medications or treatments canoffer a behavior modification approach. The individual


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needs to know that if he or she drinks while takingsome of the medications he or she will become vio-lently ill. (4) Finally, medications can directly act onthe brain to reduce craving or maintain abstinence.The Federal Drug Administration (FDA) has ap-proved only three of these medications specifically forthe treatment of alcoholism, whereas all other medica-tions used for the treatment of alcoholism are off-label(i.e., currently not a medication that the FDA approvedfor that particular use). The three approved are dis-cussed in greater detail in the next three questions.Medications that treat alcohol withdrawal are covered inQuestion 56 under detox.

The degree to which individuals and clinicians believein the importance of taking medications varies witheach category. Everyone in the profession understandsand agrees that detoxification is a medical problemrequiring medication. Most agree that treating underly-ing psychiatric illnesses such as schizophrenia, bipolardisorder, or depression is necessary, even though the useof these medications can entail some degree of contro-versy. This is true particularly among those alcoholismspecialists who zealously believe that all medicationused to modify behavior cause a form of dependency.The use of medications that are prescribed specificallyfor alcohol dependence or abuse varies dramatically withthe philosophy of various clinicians and treatment pro-grams. In some hospitals, no patients are offered med-ications, whereas in others, no patient leaves without aprescription for a medication. Historically, 12-step pro-grams have frowned on individuals receiving any psy-chotropic medication. In this more enlightened era,

Bipolar disorder

a mental illnessdefined by cyclicepisodes of mania orhypomania, classi-cally alternating withepisodes of depres-sion; however, thecondition can takevarious forms, suchas repeated episodesof mania only or onlyone episode of maniaand repeatedepisodes of depres-sion or rapid cyclingbetween mania andsevere depression.


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there is an increased understanding of psychiatric co-morbidities and this attitude has mostly disappeared.

48. What is Antabuse, and how doesit work?Antabuse is the first medication that the FDA approvedfor the treatment of alcoholism. It is in the class of med-ications that are used for behavior modification. Asmentioned in Question 22 (Table 6), a correlation existsbetween those groups of individuals who are able tometabolize alcohol and the rate at which they are proneto alcoholism. The enzyme that metabolizes alcohol isaldehyde dehydrogenase. The groups of people who aremore prone toward alcoholism have more aldehydedehydrogenase available in their bodies to break downthe alcohol, whereas people who are less prone towardalcoholism have less aldehyde dehydrogenase available.Thus, a decrease in aldehyde dehydrogenase leads to areduction in the tendency toward alcoholism. Disulfiram(Antabuse) was developed to mimic this genetic varia-tion by reducing the relative amount of aldehyde dehy-drogenase. This medication inhibits or blocks aldehydedehydrogenase, which reduces the amount of thisenzyme in the body that is available to break down alco-hol, thereby resulting in an accumulation of acetaldehydewhen one drinks alcohol. Acetaldehyde causes nausea,low blood pressure, flushing, headache, and weakness.This can last anywhere from 30 to 60 minutes. The reac-tion varies with the amount of alcohol that is consumed.More severe reactions can include cardiovascular prob-lems and convulsions. Other potential risks includeperipheral nerve damage and hepatitis. One needs to

Antabusea drug given to alco-holics that producesnausea, vomiting,dizziness, flushing,and tachycardia (a fastheart rate) if alcohol isconsumed; thus it is adeterrent to drinkingand acts as a negativereinforcer.


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Table 10 Disulfiram Details

Drug Name

Adult Dose

Pediatric Dose

Contraindications

Interactions

Pregnancy

Precautions

Disulfiram (Antabuse)—Decreases number ofdrinking days but does not increase abstinence.Directly observed therapy might be more benefi-cial but has not been studied in a good random-ized trial.250 mg PO qdNot establishedDocumented hypersensitivity, severe myocardialdisease, coronary occlusionDo not administer with metronidazole; use withcaution in patients on phenytoin (levels ofphenytoin might increase)C—Safety for use during pregnancy has notbeen established.Adverse effects are uncommon, but hepatitis,optic neuritis, neuropathy, and skin rashreported

wait at least 72 hours before his or her last drink beforestarting the medication because of the risk of having abad reaction. Any food or medicine containing alcohol,including after-shave lotion, can potentially cause a reac-tion. Because of these risks, Antabuse is rarely, if ever,offered to people who are beginning treatment. A fullmedical history must be taken along with a battery ofblood tests to rule out other medical conditions that pre-clude its use, such as liver or kidney disease, hypothy-roidism, or diabetes. Patients rarely drink while takingthis medication. Alcoholics who are motivated to main-tain abstinence stay on the medication, and those whoare not stop the medication and resume drinking. Inother words, rarely does an Antabuse reaction ever occurto produce the negative consequences necessary to pre-vent continued drinking (see Table 10 for details).

Metronidazole

Generic name forFlagyl, an antibioticmedication thatrarely can have anAntabuse-like effectfor patients taking itand drinking alcohol.


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Reverse agonism

a chemical (drug)that has reverseactivity on the recep-tor rather than justmerely blocking thereceptor.

49. I understand that ReVia is anopiate. I have never been addicted toopiates. Why would that be prescribed,and will I become addicted?Medications do two things: (1) They attach to a spe-cific receptor, and (2) they alter the receptor in a spe-cific way. Opiates are a class of medications thatspecifically target opiate receptors in the body. Nor-mally one thinks of opiate receptors as pain receptorsand opiates as pain medications. Hence, the termderives from Opium, the poppy and its analgesic prop-erties. In fact, however, there is more than one opiatereceptor, and each opiate receptor can be altered inmore than one way. It is commonly known that someopiate receptors alter pain. It is not well known whichother opiate receptors alter other physiological andpsychological properties.

By thinking about the various physiological effectsof opium, we can understand that better. Besidesreducing pain, opiates can also cause sedation (neuro-logical effects), can lead to respiratory depression (res-piratory effects), can make us nauseous and constipated(gastrointestinal effects), and can produce euphoria(psychological effects). Each of these varying proper-ties appears to be affected by its own set of opiatereceptors. In addition to these specific receptors, vari-ous changes can occur in each receptor with a particulardrug. For example, a drug can cause the receptor torespond positively or more strongly through agonism, aterm used in pharmacology for stimulation, or a drugcan cause the reverse effect or have the receptorrespond in the opposite direction, known in pharma-cology as reverse agonism. A drug can also block a


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Antagonism

the mechanism thatcauses the blockingof the biologicalresponses at a givenreceptor site, due to adrug or other chemi-cal.

Agonist

a drug capable ofcombining with areceptor on a cell andinitiating a reactionor activity.

Endogenously

functional causesoccur from internalfactors in the mind orthe body.

Partial agonist

a chemical (e.g.,drug) that can bothblock and stimulate areceptor dependingon the relativeamount of neuro-transmitter presentin the synaptic cleft.

receptor, rendering it completely inactive. This is knownin pharmacology as antagonism. Finally, a drug can becreated that acts as either an agonist or antagonist,depending on the local environment (i.e., the amount ofendogenously available neurotransmitter). When theamount of neurotransmitter is low, the drug acts as anagonist. When the amount is great, the drug acts as anantagonist. Such a drug is known as a partial agonist.

Thus, an entire array of effects can be produced oneach particular receptor with varying chemicals, almostlike fine-tuning a radio station to provide the bestreception. As an example, when patients come to theemergency room because of a heroin overdose, theywill receive a medication known as naloxone (Nar-can), which is an antagonist that blocks the effect ofheroin on all the opiate receptors. Thus, respiratorydepression, the cause of death from heroin overdose, aswell as all of the other effects, is reversed. The down-side of this is that if the patient is heroin dependent,he or she will go into immediate withdrawal because,again, all of the effects of heroin are reversed.

ReVia is the trade name for a medication genericallyknown as naltrexone (see Table 11). It is the secondmedication that the FDA approved and has been in usesince 1994. Naltrexone is an opiate antagonist thatblocks opiate receptors and thereby decreases the crav-ing for alcohol, resulting in not only less interest inalcohol but also in less alcohol consumption. (See ques-tion 32 on p. 89 for additional information about thelink between alcohol and opiates.) Consequently, theremay be slips but fewer relapses. Studies in nonhumananimals clearly demonstrate that alcohol consumptioncauses an increase in endogenous opiates, and thus, it is

Naloxone

generic for Narcan. Itis an opioid antago-nist and competeswith opioids at theopiate receptor sites.

Narcan

an opioid antagonistand antidote to opi-ate overdoses.


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Table 11 Naltrexone: An Opiate Antagonist

Drug Name

Adult Dose

Pediatric Dose

Contraindications

Interactions

Pregnancy

Precautions

Naltrexone (ReVia)—Patients must be abstinentfor 5–7 days before beginning therapy. Monitorliver function during treatment. Expensive,approximately $4.50 per pill. Pure antagonistand is not addicting.50 mg PO qdSome physicians give 25 mg for the first 2 daysof therapy; some believe 100 mg works betterthan 50 mg, but no trials demonstrate this.Not establishedDocumented hypersensitivity, acute hepatitis,liver failureInhibits effects of opiates; patients currently tak-ing opiates or who have been on long-term opi-ate therapy in previous 7 days can experiencesevere opiate withdrawalC—Safety for use during pregnancy has notbeen established.Nausea/vomiting, abdominal pain, daytimesleepiness, and nasal congestion were more com-mon versus placebo in largest randomized trial todate; discontinuation due to adverse effects wasuncommon in most clinical trials.

postulated that naltrexone blocks the effects of thisincrease on the brain; thus, the “rush” associated withdrinking alcohol is not felt. A recent brain-imagingstudy showed that alcoholic persons have increased opi-ate receptors in a part of the brain associated withreward and pleasure and that the number of receptorscorrelates with the degree of craving. Additionally, nal-trexone indirectly increases the amount of dopamine,the major neurotransmitter associated with reward (seeQuestion 6). Unfortunately, the effect in reducingrelapses is a modest 12% to 20%, depending on thestudy. Combining medications with other forms oftherapy improves the outcomes by a third.

Naltrexone use is controversial, which stems from thefact that it appears to moderate the amount of alcohol

Naltrexone

generic for ReVia. It isan opioid antagonistthat competes withnarcotics at opiatereceptor sites, block-ing the opioid anal-gesics.

Studies innonhumananimalsclearlydemonstratethat alcoholconsumptioncauses anincrease inendogenousopiates, andthus, it ispostulatedthat naltrex-one blocks theeffects of thisincrease on thebrain; thus,the “rush”associatedwith drinkingalcohol is notfelt.


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consumed rather then actually preventing one fromconsuming alcohol altogether. Thus, it paradoxicallyappears to be more effective for people who continueto drink alcohol and want to control their consump-tion rather than those who are attempting to achievecomplete abstinence. The idea of a medication to mod-erate one’s alcohol consumption rather than to eliminateit altogether, however, is abhorrent to many and hasled others to fear that it will not assist in attaining theultimate goal of complete abstinence, which defeatsthe entire goal associated with alcoholism treatment.Remember that although there seems to be a contin-uum from problem drinker to alcohol abuser to alcoholdependence, when one looks at all alcoholics, itremains to be determined whether the continuumexists within individual alcoholics. Whether any indi-vidual with alcohol abuse will ultimately become alco-hol dependent if left unchecked remains hotlydebated. The abstinence-only model argues for thiscontinuum, whereas the controlled-drinking modelsargue that at least some alcoholics can control theirdrinking and will never become alcohol dependent.Naltrexone may be most effective for the alcoholicwho wants to continue to drink, through a processknown as pharmacological extinction, where it acts onthe opiate receptors to block the pleasurable effectsthat come from regular drinking thereby reducing thepleasure associated with the activity.

The main side effects of naltrexone are nausea and/orvomiting, abdominal pain, sleepiness, and nasal con-gestion. Pregnant women, individuals with severe liveror kidney damage, or those who cannot achieve absti-nence for at least 5 days before starting should not use

The main sideeffects of nal-trexone arenausea and/orvomiting,abdominalpain, sleepi-ness, andnasal conges-tion.


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it. Also, people who are dependent on opiates such asheroin or morphine must stop their drug use at least 7days before starting naltrexone or they risk precipitat-ing withdrawal. Aside from side effects, which are usu-ally short lived and mild, alcoholics report that they arelargely unaware of being on this medication. Naltrex-one usually has no psychological effects and patientsdon’t feel either “high” or “down” while they are onnaltrexone. It is not addictive. Naltrexone does notcause physical dependence, and it can be stopped atany time without withdrawal symptoms. In addition,available findings regarding cessation do not show a“rebound” effect to resume alcohol use when naltrex-one is discontinued. If naltrexone is tolerated and thepatient is successful in reducing or stopping drinking,the recommended initial course of treatment is 3months. At that time, the individual and his or herphysician should evaluate the need for further treat-ment on the basis of the degree of improvement, thedegree of continued concerns about relapse, and thelevel of improvement in areas of functioning otherthan alcohol use.

50. I heard of a new injectable form ofmedication for alcoholism. What is it,and what are its advantages?The FDA has recently approved an injectable form ofnaltrexone (known by its trade name as Vivitrol) thatis a long-acting form of the drug and thereforerequires only monthly injections. The purpose of themonthly injection is to enhance medication adherence,which is the biggest stumbling block for many patientsstruggling with mental illnesses. The approval, based

Vivitrol

an injectable, longacting form of nal-trexone.


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on a study published in the Journal of the AmericanMedical Association in April 2005, demonstrated thatVivitrol resulted in a 25% decrease in the event rate ofheavy drinking days. A heavy drinking day is definedas equal to or greater than five standard drinks a dayfor men and four standard drinks a day for women.The event rate of heavy drinking is defined as thenumber of heavy drinking days divided by the numberof days at risk for heavy drinking. The injections werewell tolerated, with few adverse events and no evi-dence of liver disease, which had previously been aconcern regarding this medication. Not surprisingly,the average decrease in heavy drinking days was great-est in those individuals who drank the most during thestudy. (The more one drinks, the greater opportunitythere is to cut down.) The placebo group also receivedtherapy in addition to sham injections. This group alsodemonstrated improvement in event rate of heavydrinking days but not to the same degree as those onthe injectable naltrexone. The general conclusion wasthat injectable naltrexone offers a very important alter-native to oral naltrexone by increasing adherence andtherefore improving outcomes. Table 11 provides asummary of naltrexone.

51. How is acamprosate different fromother medications?Acamprosate (Campral) is the third and final medica-tion approved for the treatment of alcoholism. Itsmechanism of action is unknown, although it isreferred to as a glutamate receptor blocker. As you mayrecall from Question 6, glutamate is the major excita-tory neurotransmitter in the brain. It is believed thatchronic alcohol ingestion adds to the effects of the


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major inhibitory neurotransmitter, GABA. In order tocompensate for this, the brain decreases GABA effec-tiveness and improves the effectiveness of glutamate inorder to achieve a balance. When alcohol is suddenlyremoved from the rebalanced system, GABA is nowleft in a deficient state while glutamate is overactive.This is believed to cause many of the craving andwithdrawal symptoms that people experience withalcohol dependency. It is thought that acamprosateenhances GABA transmission and inhibits glutamatetransmission in order to restore the brain to its previ-ous uncompensated state.

Unlike naltrexone, which focuses on reducing problemdrinking, acamprosate targets abstinence. Acamprosatehas been studied thoroughly in Europe, and very goodresults were demonstrated with 1-year abstinence ratesof 18% compared with placebo-controlled abstinencerates of only 7%. At 2 years, the acamprosate group’sabstinence rates fell to 12%, whereas the placebogroup’s abstinence rates fell to 5%. Some preliminarystudies have suggested that using acamprosate in con-junction with naltrexone is better than using eitheralone. Acamprosate is well tolerated and can be pre-scribed for even patients with liver disease. Diarrhea,which eventually improves with time, is the most com-mon side effect.

An intriguing use of acamprosate has been proposedbased on a study conducted in 2001. Animals thatwere experiencing alcohol withdrawal symptoms weregiven the medication. It was shown to reduce gluta-mate’s excitatory effects, thus possibly providing aneuroprotective effect and reducing the impact ofwithdrawal on the brain. Thus, the potential of using

Neuroprotective

a protection of thenervous systemagainst toxic sub-stances.


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Table 12 Acamprosate (Campral): A Drug to Maintain Alcohol Abstinence

Drug Name

Adult Dose

Pediatric Dose

Contraindications

Interactions

Pregnancy

Precautions

Acamprosate (Campral)—Synthetic compoundwith a chemical structure similar to that of theendogenous amino acid homotaurine (structuralanalogue of GABA). Mechanism of action tomaintain alcohol abstinence not completelyunderstood. Hypothesized to interact with gluta-mate and GABA neurotransmitters centrally torestore neuronal excitation and inhibition balance.Not associated with tolerance or dependencedevelopment. Use does not eliminate or diminishalcohol withdrawal symptoms. Indicated to main-tain alcohol abstinence as part of a comprehensivemanagement program that includes psychosocialsupport. Available as a 333-mg tablet.666 mg PO tid; initiate as soon as possible afteralcohol withdrawal when abstinence has beenachieved; if < 60 kg, may need to decrease dose by333–666 mg/day.CrCl 30–50 mL/min: 333 mg PO tidNot establishedDocumented hypersensitivity; severe renal impair-ment (i.e., CrCl < 30 mL/min)Coadministration with naltrexone increases acam-prosate Cmax and AUC, but no dose adjustmentnecessaryC—Safety during pregnancy has not been estab-lished.Diarrhea is most common adverse effect (20%),but dropouts are few; additional common adverseeffects are dizziness, itching, nausea, flatulence,headache, and increased sexual desire; depressionand anxiety incidence slightly higher than that ofplacebo in one study.

this medication as an adjunct to detoxification remainsan open question; however, it would be an off-labeltreatment (see Questions 52 and 53 for other medica-tions that are prescribed off-label). For further infor-mation regarding the reasons for detoxification and themedications necessary to manage detox effectively,please see Questions 55 and 56 and Table 12.

Off-label

prescribing of a med-ication for indicationsother than those out-lined by the Food andDrug Administration.


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Prozac

see fluoxetine.

Zofran

trade name forondansetron. It is anantiemetic that pre-vents nausea andvomiting by blockingserotonin peripher-ally, centrally, and inthe small intestine.

Trade name

the name given todrugs by the com-pany that has thepatent rights to thedrug, either throughpurchasing thepatent rights fromanother company, orhaving discovered ordesigned them. Thetrade name is thecompany name.

52. What other medications areprescribed for alcoholism?Other medications are used off-label specifically forthe treatment of alcoholism. One of the earliestthought to improve abstinence was lithium, althoughthis has since proven to be false. Other studies investi-gating psychotropic medications have looked at theselective serotonin reuptake inhibitors (SSRIs), ofwhich fluoxetine (Prozac) is the best known. Theeffects have been generally disappointing; however,when attempting to sort out alcoholics who are type Ifrom those who are type II, there appears to be anoticeable though modest effect in type I alcoholics(see Question 18). This is thought to be because type Ialcoholics more often suffer from anxiety and depres-sion in addition to their alcoholism, and SSRIs arevery effective antianxiety medications in addition totheir antidepressant properties.

Two other medications have promise based on scien-tific evidence. These include Zofran, the trade namefor ondansetron, and Topamax, the trade name fortopiramate. Interestingly, just as SSRIs appear toimprove abstinence rates in type I, or late-onset alco-holics, ondansetron appears to decrease preferentiallythe number of drinks consumed per day and improveabstinence rates in type II or early onset alcoholics.

OndansetronOndansetron blocks a specific serotonin receptor thatis involved in nausea and vomiting and is commonlyused in patients receiving cancer chemotherapy,where this is a common side effect. This particular

Topamax

the trade name fortopiramate. An anti-convulsant. Themechanism of actionis unknown. It is usedto control seizures.


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serotonin receptor appears to play a role in reinforce-ment for alcohol consumption in animals. Blockingthis receptor reduced alcohol consumption in ani-mals. This was also demonstrated in early-onset ortype II alcoholics, but was found to be no better thanplacebo when administered to late-onset or type Ialcoholics. The preferential response to differentmedications based on one’s subtype of alcoholismfurther supports a biological difference betweenthese two types.

TopiramateTopiramate is the other medication that appears toreduce craving and consumption in alcohol-dependentpatients who are not yet abstinent. Topiramate is ananticonvulsant that is approved for use in the treat-ment of epilepsy. It was initially thought to also helpwith bipolar disorder, but studies have been disap-pointing. Topiramate can lead to decreased appetiteand weight loss. The mechanism by which it reducesappetite is as yet unknown. Topiramate facilitatesGABA function and antagonizes glutamate. In thismanner, it appears to be similar to acamprosate. Itseffects on GABA and glutamate, in turn, have aneffect on dopamine and thus reduce craving and with-drawal feelings. Daily doses generally need to be 200mg or greater. Initial studies have suggested that it hasa greater effect on drinking than the currently FDA-approved medications, although it is also associatedwith more severe side effects. These side effectsinclude slowing of thought, short-term memory prob-lems, and word-finding difficulties. People were notrequired to be abstinent before initiation of topiramatefor it to be effective.

Topiramate

an anticonvulsantused to decrease theoccurrence ofseizures. Off label, itmay be used as anadjunctive mood sta-bilizer, especially inbipolar disorders.


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TreatmentOff-label is

used when theFDA has notapproved amedication.Does thismean themedication isexperimental?

53. I have been prescribed a medicationoff-label. Does that mean that it isexperimental?Off-label is used when the FDA has not approved amedication. Does this mean the medication is experi-mental? No, absolutely not. This means simply that nostudies have been submitted to the FDA for approvalof the medication for a particular use. It does not meanthat no studies have been done. There are many stud-ies that may not have been submitted to the FDA orthat have been submitted and approved by Europeangovernments. It does not mean that the medication isnot widely prescribed for a use other than what theFDA approved. It does not mean that doses under orover the recommended range approved by the FDAare neither effective nor safe. It does not mean that themedication is not safe in age groups younger or olderthan what the FDA approved. It merely means thatwhen the company submitted the medication forapproval to the FDA, it submitted studies that speci-fied a diagnosis, a dose range, and an age group thattheir study subjects reflected.

Drug research and development have a fascinating his-tory. Psychiatric drugs are often discovered serendipi-tously. Most drugs have multiple effects on the body,and focusing on one particular action to the exclusionof another is often as much a matter of marketing as itis drug action. For example, a trauma surgeon who wasspecifically interested in finding a medication thatcould prevent surgical shock, a condition with a highmortality rate at the time, developed and tested thefirst antipsychotic medication. It was only through

Most drugshave multipleeffects on thebody, andfocusing onone particularaction to theexclusion ofanother isoften as mucha matter ofmarketing asit is drugaction.


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Monoamine oxi-dase inhibitors

an antidepressantthat is not used asfrequently as otherantidepressants,namely because ofthe side effects,which include anti-cholinergic effects,such as a dry mouthand the danger ofhigh blood pressure(a hypertensive crisis)if a low tyramine dietis not followed.

clinical observation that it was discovered to haveantipsychotic effects as well as a variety of other effectson the body. The company that originally introduced itto the United States did not believe that there would bea market for it as an antipsychotic and thus released it tothe public as an antiemetic. Only through multiplephysician-driven lectures were psychiatrists in theUnited States comfortable enough to try it on patientssuffering from schizophrenia. Perhaps even odder is thefact that the first antidepressant effects were observed inmedications developed to treat tuberculosis. Only laterwas it discovered that these medications inhibited, orblocked, monoamine oxidase, an enzyme that breaksdown norepinephrine, serotonin, and dopamine at thesynaptic cleft.

To call any particular medication an antihypertensive,an antipsychotic, an antidepressant, or an anticonvulsantis actually a misnomer and really reflects the target clini-cal problem a particular medication is geared towardwhen released to the public and not the broad range ofeffects for which the medication is capable. It alsoreflects the expense the companies go through in orderto obtain FDA approval. The FDA requires that eachmedication target a specific diagnosis in order to receiveapproval. This is a hugely expensive enterprise for onediagnosis, much less for multiple diagnoses. Therefore,it is unlikely drug companies will submit studies forapproval for more than one or two diagnoses, unlessthey can see some return on their investment. As aresult, clinical practice is often very different from whatthe Physician’s Desk Reference publishes. Clinicalpractice moves at a much faster pace than clinical trialsand published studies can keep up with. Although clini-cal trials are considered to be the definitive evidence of

Physician’s Desk Reference

a compendium of allof the drugs availableto legal prescribers(MDs, DOs, and NPs)in the United Statesand Canada, alongwith guidelinesabout their actions,how each drug isgenerally used, thedrug interactions,side effects, and con-traindications.


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any particular medication’s efficacy, astute clinical obser-vations have brought the biggest drug discoveries to theworld and should not be discounted simply because nostudy has yet to be published.

There are two broad reasons why off-label use makessense in psychiatry. First, psychiatric diagnoses do notfit into the neat little categories that the DSM-IV-TRattempts to define. They generally have many overlap-ping symptoms. For example, anhedonia, or loss ofinterest, can be seen in a number of conditions thatinclude depression, schizophrenia, and frontal lobedamage. Many psychiatrists believe that medicationsshould be prescribed to target the particular neuro-chemicals underlying such specific symptoms regard-less of the DSM-IV-TR diagnosis. Off-label use ispracticed with a clear rational for another reason aswell. Human nature defies categories. Although broadsimilarities may exist between two individuals suffer-ing from depression, it is doubtful that any one indi-vidual is suffering in exactly the same way as anotherfrom both a biochemical and psychological standpoint.Thus, a person may respond to a particular therapy orantidepressant and not the other. The reasons are dueto the therapies’ and antidepressants’ biochemical dif-ferences, not their similarities. For these reasons, off-label use in psychiatry is more often the rule than theexception. Consider this example: A man sought out acardiologist because he noticed he was getting palpita-tions from one particular brand of cola and notanother. The cardiologist dismissed him outright. Theman sought out another cardiologist who agreed toperform a stress test after he ingested the differentbrands, and sure enough, the man experienced prema-ture ventricular beats with one particular brand of cola


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Open-label

a term used todescribe the type ofstudy where both theresearcher and thevolunteer/subjectsknow the drug ortreatment that thesubjects are receiv-ing.

Double-blind study

a drug study thatconsists of an experi-mental group ofpatients/volunteerswho receive theexperimental drug,medical device, ortreatment and a con-trol group whoreceives a placebo orthe current and stan-dard drug, medicaldevice, or treatment.

and not another. Never underestimate the power ofone.

54. What is the Prometa® treatmentprotocol for alcoholism?Experimental clinical trials are an ongoing option forindividuals struggling with drug and alcohol depend-ency. For example, a Los Angeles-based health careservices company known as Hythiam developed thePrometa Treatment Protocol, which is currentlyundergoing clinical trials through the National Insti-tutes of Health. Early open-label studies of the pro-tocol with methamphetamine-dependent individualshave yielded positive results, and double-blind,placebo-controlled studies are currently under way.Current use in alcoholics, although favorable, hasbeen anecdotal at the time of this writing. The proto-col relies on two well-established medications thathave an impact on GABA: gabapentin (Neurontin)and flumazenil (Romazicon). The FDA has cur-rently approved neither for use in alcoholism.Gabapentin is an anticonvulsant medication that theFDA approved for treating seizure disorders as well astreating neuropathic pain and may be beneficial inhelping with anxiety and certain sleep disorders, asboth are affected by GABA. Flumenazil is a GABAreceptor antagonist and as such blocks the effects ofanxiolytics such as Valium or Ativan. This is com-monly used for individuals who present to the emer-gency room with benzodiazepine overdoses, as itreverses the effects. Gabapentin made national newsover its controversial use in treating bipolar disorderbefore adequate trials had been conducted. It proved

Placebo

a drug, medicaldevice, or treatmentthat looks similar tothe experimentaldrug, medical device,or treatment, but it isin fact an inactivedrug, liquid, device,or treatment and willnot affect the volun-teer’s health or ill-ness.


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Flumazenil (Romazicon)

a benzodiazepineantagonist that isused to reverse thesedative effects ofbenzodiazepines inthe management ofan overdose.

to be of limited value in treating this condition. Thatdid not mean, however, that some individuals withbipolar disorder did not benefit from the drug, onlythat large studies failed to separate it from placebo.Although its use in treating bipolar disorder is nowlimited, it continues to play a role as an off-labeladjunctive treatment for patients with various psychi-atric illnesses, and its use in treating addiction is butone example of that.

Clinical trials such as the Prometa® treatment protocolare valuable resources for people who have limitedmeans and/or who have failed previous standard treat-ments. Medical institutions such as universities,research foundations, pharmaceutical companies, andfederal agencies often sponsor such trials. An institu-tional review board, which is made up of at least fivemembers who include physicians, other health careprofessionals, and lay people, supervises and monitorsclinical trials. Institutional review boards are estab-lished to protect the volunteer patients’ health andsafety as well as to protect them from unethical prac-tices. One of the main benefits of participating in aclinical trial is the opportunity to help others whilehelping one’s self. Additionally, having access to newexperimental treatments while one’s health is beingmeticulously monitored is invaluable. The major risk,of course, is that an adverse effect may occur puttingone’s own health at risk. The other major drawback istime. The enrollment process is often long and com-plicated, and few get accepted. After acceptance, thetime and behavioral requirements can be equally ardu-ous, but the potential payoff is great. It is important toalways enter into a trial with a clear understanding ofboth the risks and benefits before engaging in one.

Clinical trialsare valuableresources forpeople whohave limitedmeans and/orwho havefailed previousstandardtreatments.


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Alcohol withdrawal delirium

also known as DTs ordelirium tremors, asyndrome that occursafter the amount ofalcohol that is usuallyconsumed hasdecreased, after pro-longed and heavy useof alcohol, whichleads to the follow-ing: changes in theindividual’s vitalsigns and adversegastrointestinal andcentral nervous sys-tem symptoms inconjunction with dis-orintation and hallu-cinations.

55. What is detoxification, and how do Iknow whether I need it?The concept of detoxification or “detox” has multipleiterations. In this day and age of concern regarding avariety of potential toxins that we routinely ingesteither wittingly or unwittingly, “detoxification centers”now exist as a cottage industry that often combineslaxatives and purgatives. This treatment is not what ismeant by alcohol detox. Alcohol detox requires med-ical management if the person is at risk for seriousmedical problems during the detoxification phase.Medical management includes monitoring signs andsymptoms of alcohol withdrawal and the administra-tion of medication to reduce or eliminate those signsand symptoms should they become too severe. Themost serious medical problems include seizures andalcohol withdrawal delirium or DTs (see Questions62 and 63 for a fuller explanation of DTs and alcoholwithdrawal seizures). Seizures occur in less than 5% ofindividuals and DTs in about 5%. The good news isthat most individuals with alcoholism do not requiremedication for their withdrawal symptoms. In fact,only about 8% of patients require it. That is not to saythat one will not suffer from some kind of withdrawalsymptoms. The bad news is that if DTs are nottreated, the mortality rate is 15%.

Withdrawal symptoms from regular heavy alcohol useoccur around 8 hours after the last drink. These symp-toms include tachycardia or rapid heart rate, tremor,nausea, and insomnia. Over the next couple of days,anxiety, agitation, sensitivity to light and sound, sweat-ing, headache, and high blood pressure will develop inconjunction with the other symptoms. Between days 2and 4, symptoms may continue to get worse, includinghigh blood pressure, a rapid pulse and fever, disorien-

The good newsis that mostindividualswith alco-holism do notrequire med-ication fortheir with-drawalsymptoms.


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tation, hallucinations, and delusions. These last cogni-tive symptoms define the DTs. Seizures may occuranywhere from days 2 to 6.

There are specific risk factors that increase the proba-bility that one may have serious withdrawal symptomsrequiring detox medications. Risk factors that are asso-ciated with the development of seizures or DTsinclude the following: If you had either a previous his-tory of DTs or seizures from any cause, this increasesyour risk. The higher the amount of daily alcohol usethe greater your risk. The older you are the greateryour risk. Being male increases your risk. Elevated liverenzymes associated with hepatitis increase your risk.Other medical problems such as pancreatitis, othergastrointestinal problems, and pulmonary or cardio-vascular problems increase your risk.

56. What medications are used fordetoxification?Alcohol Withdrawal SyndromeAs discussed above, detox is medically necessarybecause of the possibility of developing alcohol with-drawal syndrome (discussed in greater detail in Ques-tion 61). The symptoms can be lessened or evenprevented with appropriate medication, or the symp-toms may progress (though not always) to the pointwhere one suffers from DTs or has a withdrawalseizure. A rating scale known as the CIWA-A (Clini-cal Institute Withdrawal Assessment for Alcohol) isused to assess the symptoms and their severity inorder to guide treatment (see Table 13). Treatmentgenerally lasts approximately 5 days, although morecomplicated and severe symptoms may warrant moreprolonged treatment.


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Table 13 Clinical Institute Withdrawal Assessment ToolAddiction Research Foundation Clinical Institute Withdrawal Assessment-Alcohol (CIWA-Ar)This scale is not copyrighted and may be used freely.

Patient: ___________________ Date: /___/___/___ Time: ___ : ______(24 hour clock, midnight = 00:00)

NAUSEA AND VOMITING—Ask “Do you feel sick to yourstomach? Have you vomited?”Observation. 0 no nausea and no vomiting1 mild nausea with no vomiting234 intermittent nausea with dry heaves567 constant nausea, frequent dry heaves, and vomiting

TACTILE DISTURBANCES—Ask “Have you any itching, pins andneedles sensations, any burning, any numbness, or do you feel bugscrawling on or under your skin?”Observation.0 none1 mild itching, pins and needles, burning or numbness2 mild itching, pins and needles, burning or numbness3 moderate itching, pins and needles, burning or numbness4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

TREMOR—Arms extended and fingers spread apart.Observation.0 no tremor1 not visible, but can be felt fingertip to fingertip234 moderate, with patient’s arms extended567 severe, even with arms not extended

AUDITORY DISTURBANCES—Ask “Are you more aware of soundsaround you? Are they harsh? Do they frighten you? Are you hearinganything that is disturbing to you? Are you hearing things you know arenot there?”Observation.0 not present1 very mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

PAROXYSMAL SWEATS—Observation.0 no sweat visible1 barely perceptible sweating, palms moist234 beads of sweat obvious on forehead567 drenching sweats

VISUAL DISTURBANCES—Ask “Does the light appear to be toobright? Is its color different? Does it hurt your eyes? Are you seeinganything that is disturbing to you? Are you seeing things you know arenot there?”Observation.0 not present1 very mild sensitivity2 mild sensitivity3 moderate sensitivity4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

ANXIETY—Ask “Do you feel nervous?”Observation.0 no anxiety, at ease1 mildly anxious234 moderately anxious, or guarded, so anxiety is inferred567 equivalent to acute panic states as seen in severe 3 delirium or acute schizophrenic reactions.

HEADACHE, FULLNESS IN HEAD—Ask “Does your head feeldifferent? Does it feel like there is a band around your head?”Do not rate for dizziness or lightheadedness. Otherwise, rate severity.0 not present1 very mild2 mild3 moderate4 moderately severe5 severe

6 very severe7 extremely severe

AGITATION—Observation.0 normal activity1 somewhat more than normal activity234 moderately fidgety and restless567 paces back and forth during most of the interview, or 3 constantly thrashes about

ORIENTATION AND CLOUDING OF SENSORIUM—Ask “What day isthis? Where are you? Who am I?”0 oriented and can do serial additions1 cannot do serial additions or is uncertain about date2 disoriented for date by no more than 2 calendar days3 disoriented for date by more than 2 calendar days4 disoriented for place and/or person

Total CIWA-A Score ____

The medication most commonly used to treat alcoholwithdrawal is lorazepam (Ativan), although chlor-diazepoxide (Librium) was historically used routinely.


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Both of these medications are benzodiazepines, aclass known as antianxiety medications. They act onthe GABA receptor, modifying it to be more sensi-tive to the effects of GABA, the brain’s majorinhibitory neurotransmitter (discussed in greaterdetail in Question 6). This is identical to what alco-hol does to the GABA receptor. Previously, alcoholitself was used to detox patients, but the developmentof benzodiazepines has led to safer management withgreater control over dosing than alcohol allowed.Three differences distinguish benzodiazepines fromone another.

Differences Distinguishing theBenzodiazepines From One AnotherThe first difference is the half-life, or the amount oftime the drugs circulate in the body before they are elim-inated. The longer the half-life, the longer the medica-tion stays in the body. Librium has a very long half-liferelative to Ativan, and for that reason, it is generally pre-ferred, as there is less chance of having symptoms returndue to a missed dose. The second difference is how thedrug is metabolized for elimination from the body.Some drugs are metabolized by that part of the liveraffected by hepatitis and cirrhosis. Under those circum-stances, the liver cannot effectively metabolize the drugfast enough, and it can build up to toxic levels in thebody. For that reason, Ativan has generally supplantedLibrium for patients hospitalized for DTs because themajority of these patients have liver impairment. Thethird difference is the route of administration. The moreroutes of administration that are available, the more flex-ible the medication is in its administration, thus allow-ing for continued use even when the patient is unable totake oral medication for a variety of reasons. Ativan, for

Half-life

the time it takes for half of the bloodconcentration of amedication to beeliminated from thebody. The half-lifedetermines the timeto achieve equilib-rium of a drug in theblood and deter-mines the frequencyof dosing to maintainthat equilibrium.


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example, can be given orally, intravenously, or intramus-cularly; Librium can only be given orally. Ativan is pre-ferred in the hospital setting as a result of its flexibility inaddition to its safety.

Although most of the evidence favors the use of ben-zodiazepines in the treatment of alcohol withdrawalsyndromes, detractors do exist. Some physicians preferthe use of anticonvulsants, many of which also targetGABA, although in a less direct manner than the ben-zodiazepines. Their opposition to benzodiazepine usefor detoxification is based on a variety of concerns, notthe least of which is the idea that benzodiazepines mayactually “prime” alcoholics to start drinking again. Atleast one study compared patients receiving Ativanwith those receiving the anticonvulsant carbamazepine(Tegretol). In this study, both drugs were equally effec-tive in managing the withdrawal symptoms, althoughAtivan was superior in managing anxiety and insom-nia. However, the Ativan treatment group had agreater risk of rebound of alcohol withdrawal symp-toms after cessation of treatment. Additionally, theirrisk of having a first drink was three times greater.Finally, with respect to outpatient detox, there is a riskthat the patient will drink on top of the benzodi-azepine, which places them at even greater risk foralcohol poisoning. Despite this one study and its con-cerns, benzodiazepines remain the standard of care inthe United States.

Other medications have also been used to managealcohol withdrawal symptoms, but these are used pri-marily as adjuncts and not alternatives to a benzodi-azepine. Propanolol (or Inderal), a beta-blocker, is anantihypertensive medication that can lower bloodpressure and slow the heart rate in these patients.


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Haloperidol (Haldol), an antipsychotic medication, isoccasionally used for severe agitation and psychoticsymptoms such as delusions and hallucinations insome patients, although there is a small risk of causinga seizure. Phenytoin (Dilantin), an anticonvulsant, isthe most commonly recommended medication foralcohol withdrawal seizures. Alcohol seizures are dis-cussed further in Question 65. Finally, multivitamins,thiamine, and folate are routinely administeredbecause of the high incidence of vitamin deficienciesthat accompany alcoholism.

57. If I am suffering from continuedanxiety after achieving sobriety, can Icontinue to take Ativan or similarantianxiety medication?Anxiety, Insomnia, and DepressionThe level of anxiety and insomnia that one continuesto experience after successful detox can remain highfor several months afterward. This is sometimesreferred to by it’s acronym, PAWS, for Post AcuteWithdrawal Syndrome. Depression usually liftssooner. These symptoms may be one of many reasonsthat the risk of relapse remains high. The use of sedative/ hypnotic agents during this period of time only pro-longs the symptoms; however, the patient must bemonitored and evaluated for an underlying mood oranxiety disorder that may be independent of residualwithdrawal symptoms. If the symptoms persist, thelikelihood of having an underlying anxiety or mooddisorder increases with each passing month of sobriety.Most clinicians agree that a period of 12 months ofsobriety in which one may or may not experiencemood or anxiety symptoms is the best determinant of

The level ofanxiety andinsomnia thatone continuesto experienceafter successfuldetox canremain highfor severalmonths after-ward. This issometimesreferred to byit’s acronym,PAWS, forPost AcuteWithdrawalSyndrome.Depressionusually liftssooner.


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an underlying disorder independent of alcoholism;however, this does not necessarily mean that treatmentof the mood disorder should be withheld for those 12months. It will depend partly on the severity of thesymptoms and the level of disability that can resultfrom them. Depression is generally easier to treatunder these circumstances, particularly because noneof the medications used is addictive. If there is anunderlying anxiety disorder, the next question is this:What is the most appropriate treatment?

TreatmentAlthough psychotherapy may be the optimal treatmentapproach, either through groups such as AA or individ-ual treatment, sometimes it is just not enough to managethe symptoms. The natural inclination would be to turnto an antianxiety agent that works immediately andeffectively such as the benzodiazepines, which are a classof antianxiety medications known best by one of theiroriginal medications, Valium, or diazepam, and Librium,or chlordiazepoxide. These agents are used for detoxifi-cation and were discussed in Question 56. The issue ofwhether one can continue to take benzodiazepines foranxiety in the face of a history of alcoholism remainshighly controversial. The general rule is no. The reasonfor this is based on their physiological effects. Benzodi-azepines enhance GABA activity by making the GABAreceptor more sensitive to GABA’s effects. This is exactlywhat alcohol does to the GABA receptor. Thus, benzo-diazepines, in a sense, are a substitute for alcohol. This iswhy they are so effective for detoxification from alcohol.For this reason, alcoholics tend to abuse these medica-tions at greater rates than the general population. Physi-ological tolerance does develop from chronic use, and therisks of developing either a withdrawal delirium or with-drawal seizure are just as high. Additionally, long-term


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use of benzodiazepines can impair memory and cogni-tion, as well as contribute to depression.

Long-Term Treatment with BenzodiazepinesThere are instances in which patients with a history ofalcoholism are maintained on benzodiazepines longterm. Although there are very specific reasons for this,the use of benzodiazepines long term is a rarity. First,patients who are on benzodiazepines have a clearlydocumented anxiety disorder independent of theiralcoholism. Second, their alcoholism is typically lim-ited to either problem drinking or alcohol abuse butnot alcohol dependence. Finally, all other medicationsthat treat the anxiety disorder have been tried andfailed for a variety of reasons. Only in this very limitedinstance are benzodiazepines prescribed to a formeralcoholic on a long-term basis, and not without somedegree of trepidation and close monitoring.

It is important to bear in mind that the evidence sug-gesting that benzodiazepines are highly addictive drugsis simply not there. Although it is true that drug andalcohol abusers are more likely to abuse these medica-tions than the general population, it is not true that thegeneral population is as susceptible to becomingaddicted to benzodiazepines as they are to alcohol orother drugs of abuse. Everyone will develop toleranceand withdrawal symptoms to one degree or another withlong-term use of benzodiasepines, although few will endup dependent as the DSM-IV-TR defines it. In fact,even among alcoholics, it is less common to find themusing benzodiazepines at ever-increasing amounts in thesame manner that they escalate their alcohol use. This isone of the primary reasons these medications remain socontroversial. Those addicted to alcohol often destroy


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their bodies and lives in its pursuit; rarely do they destroytheir bodies and lives in pursuit of a benzodiazepine. Infact, most moderate their benzodiazepine use in a man-ner one could only wish for in their alcohol use. Forthose who happen to be both alcohol and benzodi-azepine dependent, benzodiazepines are rarely ever acomplete substitute for the pursuit of alcohol.

If not benzodiazepines, what medication is appropriateto manage anxiety?

Alternatives to Benzodiazepines in theManagement of AnxietyThis list is long, and most are off-label, although themost prominent medications that treat anxiety disor-ders are the SSRIs, which are FDA approved andgenerally effective in managing underlying anxiety dis-orders. As most type I or late-onset alcoholics sufferfrom a primary anxiety disorder that often drives theiralcohol use, the SSRIs can help them secondarily tomoderate their drinking or even help them to achieveabstinence, as discussed in Question 18. Unfortunately,the anxiety that often accompanies alcoholism is quitetenacious and difficult to treat, leading to rather heroicefforts on the part of physicians to try medications off-label. The most common of these most recently hasbeen a class of medications known as atypical antipsy-chotics. These include most prominently quetiapine(Seroquel), which is discussed further in managinginsomnia; however, other atypical antipsychotics havealso been tried with varying degrees of success. Theseother agents include olanzapine (Zyprexa), risperidone(Risperdal), ziprasidone (Geodon), and aripiprazole(Abilify). All of these medications are FDA approved

Unfortunately,the anxietythat oftenaccompaniesalcoholism isquite tenaciousand difficultto treat, lead-ing to ratherheroic effortson the part ofphysicians totry medica-tions off-label.


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for schizophrenia and bipolar disorder so they areclearly used off-label when prescribed for anxiety. Andtheir use comes with a price. First, weight gain can bean issue. Second, metabolic changes can also occur,including increased blood sugar, cholesterol, andtriglycerides. Finally, in older people, there is a smallincrease in the risk of having cerbrovascular accidents.Despite these drawbacks, they can be safe and effectiveagents in their own right, and their use should be con-sidered when the anxiety is severely debilitating andnot responding to more traditional regimens. Anticon-vulsant medications are used off-label to treat anxiety.These include valproic acid (Depakote), gabapentin(Neurontin), carbamazepine (Tegretol), and the neweranticonvulsants lamotrigine (Lamictal), tiagabine(Gabatril), and pregabalin (Lyrica). Table 14, whichalso includes medications from Question 56, containsa general list of some of the medications used in thetreatment of anxiety and insomnia.

Distinguishing Discontinuation SyndromesMany of these medications, including the SSRIs, theatypical antipsychotics, and some of the anticonvul-sants, cannot be discontinued abruptly or else variousside effects can occur. The side effects are known col-lectively as discontinuation syndromes. It is importantto distinguish between four types of discontinuationsyndromes that can occur when you stop a medicationthat you have been taking daily for an extended periodof time. These four syndromes include withdrawal(which we have previously discussed), rebound, recur-rence, and medication specific. Withdrawal is accom-panied by clear physiologically measurable changes,including vital signs changes, skin color and tempera-ture changes, and psychological distress. For some


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Table 14 Medications for Anxiety/Insomnia

Medication Class FDA-Approved Use Off-label Use Major Drawback

Zolpidem, et al.

Lorazepam, et al.

Fluoxetine, et al.

Trazadone

Ramelteon

MirtazepineDoxepine

Quetiapine

Olanzapine

Risperidone

Non-BZDP hypnotic

BZDP

SSRI

Atypical Antidepressant

Melatonin ReceptorAgonistAtypical AntidepressantTricyclic Antidepressant

Atypical Antipsychotic



Short term treatment forinsomniaShort term treatment foranxiety, seizuresDepression, anxiety

Depression

Insomnia

DepressionDepression

Schizophrenia, bipolardisorder



Chronic insomnia

Chronic anxiety

OCD, prematureejaculationAnxiety, insomnia

None

Anxiety, insomniaInsomnia, anxiety, panic,neuropathic painImpulsivity, angermanagement, anxiety,insomniaImpulsivity, angermanagement, anxiety,insomniaImpulsivity, angermanagement, anxiety,insomnia

Rebound and chronicinsomniaDependency, tolerance,and withdrawalSexual dysfunction

Low blood pressure,hangoverNonsedating

Dry mouth, constipationDry mouth, constipation,weight gainWeight gain, metaboliceffects

Weight gain, metaboliceffects

Weight gain, metaboliceffects, increased pro-lactin, extra pyramidicalside effects*

(continued)*Include muscle spasms, tremors, restlessness, and other abnormal movements.


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Table 14 Medications for Anxiety/Insomnia (continued)

Medication Class FDA-Approved Use Off-label Use Major Drawback

Ziprasidone

Aripiprazole

Carbamazepine

TiagabineValproate

Gabapentin

Lamotrigine

Pregabalin

Diphenhydramine



Anticonvulsant

AnticonvulsantAnticonvulsant

Anticonvulsant

Anticonvulsant

Anticonvulsant

Over-the-counter allergymedication



Seizures, neuropathicpainSeizuresSeizures, bipolar disorder,neuropathic painSeizures, neuropathicpainSeizures, bipolardepressionSeizures, neuropathicpainAllergies, sleep

Impulsivity, angermanagement, anxiety

Impulsivity, angermanagement

Bipolar disorder,depressionAnxiety, maniaAnxiety, panic

Anxiety, insomnia,restless legsUnipolar depression,anxietyInsomnia, anxiety

None

Weight gain and meta-bolic effects less, lesssedatingWeight gain and meta-bolic effects less, lesssedatingToxic in overdose, bloodlevels requiredDeliriumWeight gain, birthdefectsGenerally of limitedeffectivenessDangerous rash ifincreased too rapidlyDelirium

Weight gain, hangover,dry mouth


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drugs, such as benzodiazepines, this can be a life-threatening emergency. For this reason, one needs toalways consult a physician when deciding to discon-tinue a medication to see whether such a withdrawalsyndrome could occur. Rebound occurs when thesymptoms for which one was receiving the medicationbecome transiently worse than the symptoms one hadbefore treatment commenced. This is a potential riskfor any sleep medication from which rebound insom-nia can be very severe; however, this is a transienteffect that abates within days. Unfortunately, mostpeople don’t realize that rebound is expected and tran-sient and immediately they go back on their sleepingmedications. Physiological changes generally do notaccompany rebound. Recurrence is simply the return ofsymptoms for which one originally received the medica-tion. Recurrence is more delayed in the time line afterstopping a medication than either withdrawal orrebound. Finally, medication-specific discontinuationsyndromes occur with respect to the SSRIs. Symptomscan start abruptly and last for days to weeks dependingon the medication one stopped. The symptoms includeheadaches, dizziness, electrical sensations running downthe arms and legs, and feeling like you are coming downwith the flu. Often the symptoms are misinterpreted asa recurrence of depression. Typically, if one begins toexperience symptoms as early as a few days after stop-ping antidepressant medications, these actually repre-sent rebound or a discontinuation syndrome (nomeasurable physiological changes). Rarely is it due torecurrence. Thus, it is a good idea to taper the medica-tions. When the medications are appropriately tapered,any symptoms that return can properly be attributed torecurrence, and thus, increasing the medication back to


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Lack of sleep isprobably thesingle mostunsettlingsymptom thatformer alco-holics have tostruggle with,sometimes ona chronicbasis.

Sleep architecture

a predictable patternduring a night’s sleepthat includes the tim-ing, amount, and dis-tribution of rapid eyemovement (REM)sleep and non REM.

Slow-wave sleep

a state of deep sleepthat occurs regularlyduring a normalperiod of sleep withintervening periodsof rapid eye move-ment (REM) sleep.

a therapeutic dose may be a wise choice. In summary,although these medications can cause various discon-tinuation syndromes, they are not addictive.

58. Ever since I quit drinking I can’tsleep at night. What should I do?Lack of sleep is probably the single most unsettlingsymptom that former alcoholics have to struggle with,sometimes on a chronic basis. Even after months oryears of sobriety, many alcoholics continue to complainof a lack of restful sleep and excessive daytime sleepi-ness. Lack of sleep can have serious implications,including breathing difficulties and heart and moodproblems. Additionally, excess daytime sleepiness canaffect the ability to focus and concentrate and toremember and perform normal daytime functions, themost serious being automobile driving.

Sleep ArchitectureSleep has a characteristic pattern in adults, known assleep architecture, as measured by an electroen-cephalogram. The two most prominent componentsinclude slow-wave sleep and rapid eye movement(REM) sleep. Alcohol has an initial stimulant effectamong nonalcoholics, followed by a decrease in sleeponset. This prompts many to use alcohol as a sleepinducer. The sedative effects of alcohol wear off afterabout 6 hours, usually leading to a rebound effect caus-ing people to wake up. Chronic consumption of alco-hol over time only magnifies this problem, promptingever further increasing amounts of alcohol to “chase”this problem. In alcoholics, the general sleep patternbecomes a decreased sleep onset, frequent awakenings,

Rapid eye movement (REM)

rapid eye movementsthat occur during astage of sleep thatappears on EEG as ifthe subject is awake.Dream sleep.


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and excessive daytime sleepiness. In this instance, ifalcohol is stopped, withdrawal symptoms lead to aworsening of the pattern. Often there is no restfulsleep. Even after withdrawal has ended, slow wave, orrestful sleep, can only return after a bout of heavydrinking, further reinforcing dependency.

Chronic InsomniaAlcoholics who suffer from chronic insomnia are twiceas likely to turn back to alcohol in order to sleep asthose who don’t report insomnia. They therefore sufferfrom more severe alcohol dependence and depression.One study demonstrated that alcoholics who hadhigher levels of REM or dream sleep after cessation ofalcohol predicted relapse within 3 months after hospi-tal discharge in 80% of patients. Sleep problems,whether verbalized by patients or documented in asleep lab, clearly predict higher rates of relapse.

Treatment for InsomniaThe need to treat insomnia therefore is paramount inpreventing relapse. Three options are available: (1)behavioral treatments, (2) over-the-counter medica-tions, or (3) prescription medications. No particularbehavioral treatment has been found to be superiorover another, although all are useful. These includeprogressive muscle relaxation, guided imagery, andword and imagination games (e.g., counting sheep).Behavioral treatment tends to improve sleep onsetmore than medication, although overall improvementin sleep is no different between the three options. Themost common over-the-counter medication is any ofthe variety that contains diphenhydramine (Benadryl).


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This is not a good medication for sleep because of itstendency to disrupt all stages of sleep, and it can causea hangover effect along with other side effects, includ-ing dry mouth, constipation, and increased appetite.

The final option for insomnia is prescription medica-tion. The ideal medication would be one that has aquick onset of action, a short half-life (body eliminatesit rapidly), does not interact with other medications, isnot metabolized by the liver, and finally, does not leadto another problem with addiction. As mentioned inQuestion 57, benzodiazepines are a poor but ever pres-ent choice in the battle against insomnia. Recent focushas been on the use of a new class of sleeping agentsthat allegedly meet these criteria. These agents are spe-cific to the benzodiazepine receptor, which affects onlysedation and not memory or anxiety, and therefore areallegedly not addictive. One cannot miss the ads forzolpidem (Ambien), zaleplon (Sonata), and eszopi-clone (Lunesta). Unfortunately, there are growing casereports of multiple problems with these medications,including addiction as well as sleep walking, makingthese potentially problematic for insomnia related toalcoholism. Other possibilities exist for treatinginsomnia, including trazadone (Desyrel), mirtazepine(Remeron), doxepine (Sinequan), gabapentin (Neu-rontin), and quetiapine (Seroquel). Each medicationcan induce and sustain sleep. Each has the potentialfor significant adverse effects (Table 14 shows a list ofmedications for insomnia). At least one study has beenconducted using gabapentin for alcoholism-inducedinsomnia. It probably has the fewest adverse effectsassociated with it, and 300 to 1,800 mg have beenfound to be superior to either placebo or trazadone.

Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta)

these are all sleep-enhancing or sleep-inducing medicationsthat are not benzodi-azepines but do acton one of the GABAreceptors in a man-ner similar to benzo-diazepines.


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Finally, the FDA has recently approved a novel sleepmedication called ramelteon (Rozerem). This medica-tion uniquely acts on the receptor involved with mela-tonin, a long-standing natural sleep remedy used forthe treatment of insomnia. Melatonin is thought toassist in regulating the body’s sleep/wake cycle.Ramelteon is a different molecule than melatonin.Because of that, its attachment to the melatonin recep-tors involved in regulating sleep and circadian rhythmsis three to five times greater than for melatonin. Addi-tionally, ramelteon is up to 17 times more potent atthose receptors than melatonin. It is not addictive;however, neither does it cause drowsiness. It must betaken regularly for it to be effective. This often leadsto frustration among people suffering from insomniawho have tried other sleep medications because theyare looking for the feeling of sedation that usuallycomes with a sleeping pill and they do not get thiswith ramelteon. As a result, they often discontinue thedrug prematurely. This is unfortunate, as studiesdemonstrate that ramelteon is safe and effective intreating chronic insomnia. Whether ramelteon has aplace in treating insomnia associated with alcoholismremains to be seen, but it is certainly an option to beconsidered.

59. Are there any alternative treatmentsor herbal remedies for alcoholism?There is no natural remedy to detoxification fromalcohol other than alcohol itself, which is not recom-mended. Alcohol withdrawal is a medical emergencywith significant morbidity and mortality and requiresclose medical monitoring and the judicious use of ben-zodiazepines. Some promising studies suggest at least

There is nonatural rem-edy to detoxi-fication fromalcohol otherthan alcoholitself, which isnot recom-mended.


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Treatment

two herbal remedies that may help reduce the amountof alcohol consumed. Finally, there may be some natu-ral remedies for insomnia related to alcoholism.

General nutritional deficiencies often occur from alco-holism, including thiamine and vitamin B deficiencies.Patients with alcohol dependence often obtain themajority of their calories from alcohol and thus foregobasic nutritional requirements. Additionally, alcoholicsare prone to develop pancreatic and liver disease as aresult of alcohol’s toxic effects, which can also lead topoor nutrition. These vitamin deficiencies must bereplaced; otherwise, there is a risk of developing ane-mia and/or dementia as a result of severe deficiencies(see Question 61 for further details). Milk thistle(Silybum marianum) extract has been thought tocounteract the harmful effects of alcohol on the liver.In one study, milk thistle extracts reduced death ratesdue to alcohol-induced cirrhosis of the liver, althoughanother double-blind study did not confirm this find-ing. Milk thistle extract may protect the cells of the liverby both blocking the entrance of harmful toxins and byhelping remove these toxins from the liver cells. Milkthistle has also been reported to regenerate injured livercells.

Two herbs may directly aid in alcoholism itself. Pres-ently, the most promising natural remedy appears to bekudzu (Pueraria lobata), an herb that grows in thesoutheast United States, China, and Japan. Chinesetraditional medicine men have been using it for cen-turies to treat alcohol intoxication and hangovers. Arecent study published in the Journal of Alcoholism:Clinical and Experimental Research demonstrated thatkudzu led to reduced consumption of alcohol among

Kudzu (Pueraria lobata)

a plant used in alter-native medicine toreduce alcohol crav-ings.


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St. John’s Wort (Hypericum -perforatum)

a plant used in alter-native medicine as analternative to antide-pressant medica-tions.

binge drinkers by as much as 50%. The mechanism wasthought to occur by making alcohol more readily avail-able to the brain by increasing blood flow to the brain,thereby leading to a more potent effect with a reducedamount. No real adverse effects were noted, but furtherresearch was advised before a recommendation for itsuse could be made. Currently, however, the formula-tion that the researchers used is not available in healthfood stores. Another herb with promising effects inreducing alcohol consumption appears to be St. John’sWort (Hypericum perforatum), commonly thought tohave mild antidepressant properties. The effectivenessof St. John’s Wort is not without side effects and caninteract with other medications such as SSRIs.

Insomnia (see Question 58) can be a chronic disablingproblem. Aside from the remedies already described,some natural remedies may aid in sleep. Melatonin is anatural food supplement that is available over thecounter and is produced by the brain to regulate thesleep/wake cycle. It has been used with modest success,although studies generally fail to show overall efficacy.Valerian (Valeriana officinalis) is an herbal productthat improves one’s sense of quality sleep when takenover a 1- to 2-week period for people struggling withmild to moderate insomnia; however, there have beenno studies using this herbal product with patients suf-fering from insomnia related to alcoholism.

60. Are vaccines available for variousaddictive drugs?The idea that one can become vaccinated againstalcoholism or any other addiction is an intoxicatingnotion. The idea is to have the body produce antibod-

Valerian (Valeri- ana officinalis)

an alternative medi-cine that is used inplace of sedativedrugs.


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Treatment

ies against the addictive drugs. Antibodies are mole-cules produced by the body’s immune system thatattach to foreign invaders, in this case, the intoxicatingdrugs, such as alcohol, cocaine, or nicotine, renderingthem incapable of either entering the brain altogetheror attaching to the receptors that lead to the sensation ofintoxication. Many pharmaceutical companies havedeveloped such agents, and they have begun human clin-ical trials. As exciting as that line of research is, no fruit-ful vaccine against alcoholism or any other addiction hasyet to be either discovered or invented although attemptshave been made. To date, however, the vaccines havebeen disappointing. A Google search on the Internetyields nothing beyond the year 2002. Aside fromwhether such vaccines may be effective, investing in theirdevelopment by pharmaceutical companies has somemore practical issues to contend with. Who will pay forthe treatment? Most people with substance abuse prob-lems lack the resources. The other issue has to do withthe simple fact that it is hard to run a clinical trial withthis population because of issues of compliance (i.e.,staying in the study, taking the medication, following theinstructions, and getting to the appointments). A 30% to50% dropout rate can spell disaster for a clinical trial.

Antibodies

occur in response toan antigen, as largernumbers of proteinsthat have highmolecular weights.Antibodies are a nor-mal immuneresponse to fightinfection.




AssociatedConditions

What are the medical consequences of alcoholism?

Can alcoholism cause dementia?

Are there other neurological effects of alcoholism?

More . . .

PART V


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61. What are the medical consequencesof alcoholism?The medical consequences of alcoholism are manifold.Until clearer criteria were developed to diagnose alco-holism, these conditions allowed for the definitive diag-nosis of alcoholism. The most obvious and directmedical consequences are the injuries resulting fromintoxication and its resulting impact on impulse andjudgment. Everyone is acutely aware of the impact ofdrunken driving, but alcohol has a devastating impact onthe human body, leaving few organ systems free of itstoxic effects. These organ systems include the respiratorysystem, the gastrointestinal system, the cardiovascularsystem, the hematological system, the immune system,the musculoskeletal system, the genitourinary system,the endocrine system, metabolism, and finally, the cen-tral nervous system. The most important issues of eachsystem (excluding the central nervous system, discussedin Questions 62 and 63) are covered in this question.

Respiratory SystemBefore going into alcohol’s chronic and perniciouseffects on various organ systems, you must understandthat acute alcohol intoxication or alcohol poisoningcan kill, and it does so with alarming regularity partic-ularly in adolescents and young adults. A year does notgo by where an article in a local paper discusses ayouth who is found dead in a fraternity room, a dormroom, a friend’s house after a high school party, ortheir own home after a binge drinking episode. Thisoccurs simply because alcohol in high doses can lead tounconsciousness and can suppress respiratory drive,

The mostobvious anddirect medicalconsequencesare theinjuries result-ing fromintoxicationand its result-ing impact onimpulse andjudgment.


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Associated Conditions

Hypertension

high blood pressure,which can appearwithout an apparentcause. Hypertensioncan damage otherorgans in the bodyand is frequently thecause of strokes.

Coronary artery disease

the build up ofplaque in the coro-nary arteries con-stricting blood flowto the heart muscle,leading to chest pain(angina) and thepotential for muscledeath (myocardialinfarction).

leading one to stop breathing. This is one of thebiggest risks that alcohol has when consumed rapidlyin large quantities, and young people are forever igno-rant of this potential danger.

Gastrointestinal SystemThe most commonly known effects on the gastroin-testinal system are alcoholic hepatitis and eventual cir-rhosis, which ultimately culminates in liver failure anddeath. Everyone has also heard of the alcoholic devel-oping stomach ulcers. This is due to the fact that alco-hol promotes the growth of the bacteria H. pylori inthe stomach, well known to be the cause of pepticulcers. Less well known are its effects on the pancreas,leading initially to pancreatitis and over time pancre-atic failure and a panoply of illnesses associated withit, not the least of which is insulin-dependent dia-betes, as the pancreas is the source of the body’sinsulin production.

Cardiovascular SystemChronic heavy drinking can lead to hypertension(high blood pressure). It can also raise cholesterol andtriglycerides in the bloodstream, all risk factors for thedevelopment of coronary artery disease, or the buildup of plaques, which clogs the coronary arteries. Thisbuildup increases the odds of suffering from a heartattack. Additionally, the poor nutrition that is oftenassociated with chronic alcoholism can lead to vitamindeficiencies that can lead to heart muscle damage,particularly thiamine, which causes a rare conditioncommonly known as alcoholic beriberi or thiamine-dependent cardiomyopathy.

Beriberi

from Sri Lankan for “Icannot, I cannot.” Acondition caused bythiamine deficiency,leading to damage tothe central nervoussystem and causingmemory and emo-tional disturbances(Wernicke’sencephalopathy),weakness and pain inthe limbs, and peri-ods of irregular heartbeats. Swelling ofbodily tissues is com-mon. In advancedcases, the diseasemay cause heart fail-ure and death.


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There is a more direct and pernicious impact thatchronic heavy drinking has on the heart, however. Thisaffects up to one in four individuals who have a greaterthan 10-year history of sustained alcohol dependency.Alcohol is directly toxic to heart muscle, thus bypass-ing the eventual buildup of coronary artery–cloggingplaque that causes heart muscle damage from coronaryartery disease. This direct toxicity causes an inflamma-tion to the heart muscle called myocarditis, just like itcauses inflammation to the liver called hepatitis. Even-tually, the inflammation can lead to heart muscle deathjust as chronic inflammation to the liver can lead toliver cell death known as cirrhosis. When too muchheart muscle dies off, whether from coronary arterydisease or from the toxic effects of alcohol, the hearteither pumps irregularly or fails to pump. Irregularpumping is known as an arrhythmia or dysrhythmia,which can be fatal. Alternatively, when the heart failsto pump an adequate amount of blood to the body,it leads to a condition known as congestive heart fail-ure. The most distressing event occurs when conges-tive heart failure causes a buildup of fluid in the lungs,making it difficult to breathe. This is particularly acuteat night when one is lying down and gravity doesn’thave the opportunity to pull the fluids away from thelungs.

Hematologic and Immune SystemsAlcohol is also toxic to the bone marrow or the hema-tological and immune systems both directly and indi-rectly through the various vitamin deficiencies thatresult from poor nutrition and alcohol’s direct toxiceffects to bone marrow itself. The hematological sys-tem produces and maintains red blood cells that carryoxygen throughout the body, white blood cells, or cells

Congestive heart failure

the heart is unable tomaintain adequatecirculation of bloodto the body’s tissuesand is unable topump out venousblood via the venouscirculation system.


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Leukopenia

a condition in whichthe number of leuko-cytes (white bloodcells) circulating inthe blood stream islow, commonly dueto a decrease in theproduction of newcells in conjunctionwith various infec-tious diseases, drugreactions, otherchemical reactions,or radiation therapy.

responsible for fighting infections and other foreignintruders, and various clotting factors that allow forblood to clot properly preventing excess blood loss.Anemia is the result of loss of red blood cells. Manytypes of anemias occur because of chronic alcoholism.Leukopenia (leuko is a root word for white, and peniais a root word for loss) is the medical term for loss ofwhite blood cells, which can lead to an increase ininfections and cancers because these cells are instru-mental in fighting these ever-present threats. Leuko-penia is an immune deficiency syndrome of whichthere are many causes, the most famous being AIDS.Alcohol can increase the risk of cancer not only bylowering the body’s ability to fight off cancer cells butalso causing cancer cells to grow through its directtoxic effects on the mouth, throat, larynx (voice box),and esophagus. Alcohol increases the risk of colon andrectal cancer in a manner not currently well under-stood. In women, the risk of breast cancer increasesfrom as little as one drink daily.

Musculoskeletal SystemJust as alcohol has a direct toxic effect on heart muscle,it also has a direct toxic effect on skeletal muscle, caus-ing a condition known as alcoholic myopathy. The toxiceffects of alcohol can cause skeletal muscle to break-down. When muscle tissue breaks down at a rapid rate,the muscle proteins clog the kidneys in their attempt toeliminate them from the body, which in turn can leadto kidney (renal) failure. Slow muscle breakdown canlead to weakness and fatigue over time. Myopathy canalso occur from alcohol’s indirect effects on one’s nutri-tional status and from resulting endocrine abnormali-ties. Alcohol can also impact bone density and growth,causing osteopenia (remember the root “penia” for

Myopathy

a disorder of themuscle tissue, typi-cally causing wastingand weakness.


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Hyponatremia

low blood sodium.

Hypokalemia

low blood potassium.

Hypomagnesemia

low blood magne-sium.

Hypocalcemia

low blood calcium.

Hypophos-phatemia

low blood phospho-rous.

Parathyroid hormone

a hormone producedby the parathyroidgland that is next tothe thyroid.

ACTH

AdrenocorticotropicHormone. A hormonereleased by the pitu-itary gland, whichstimulates the adre-nal glands to releaseadrenalin.

Prolactin

a hormone found inthe anterior lobe ofthe pituitary thatinduces and main-tains lactation duringthe postpartumperiod in a female.

decreasing) and hastening osteoporosis, leading to anincreased risk of fractures or broken bones.

Genitourinary/Endocrine Systems andMetabolismHeavy alcohol consumption is never more devastatingthan when it plays havoc on the body’s metabolism.Because of alcohol’s chronic and pernicious effects onvarious organ systems, the body is exceptionally vul-nerable to various assaults that can occur metabolically.

Insulin SensitivityBoth alcohol intoxication and withdrawal can affectinsulin sensitivity, resulting in dangerously high or lowblood sugars. This, in turn, can impact other metabolicfunctions that lead to electrolyte abnormalities such aslow sodium (hyponatremia), low potassium (hypo-kalemia), low magnesium (hypomagnesemia), lowcalcium (hypocalcemia), and low phosphorus (hypo-phosphatemia). Additionally, endocrine abnormalitiescan occur. Parathyroid hormone, insulin, ACTH, pro-lactin, cortisol, and growth hormone levels may all bealtered. Sex hormones (such as testosterone, estrogen,and progesterone) levels may lead to sexual dysfunctionand infertility with chronic heavy alcohol use.

Alcoholics frequently come to the emergency roomwith intractable nausea and vomiting, accompanied byextreme abdominal pain. They usually are unable to eator drink anything for several days, and as a result, theirlast alcoholic drink will have been several days previ-ous to their presentation. They are is malnourishedand vulnerable to infection, and their liver, pancreas,heart, and immune systems are all compromised. Alco-holics are anemic; however, more critical is that the


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Cortisol

also called hydrocor-tisone. It is derivedfrom cortisone and isalso used to treatinflammatory condi-tions, includingarthritis.

Growth hormone

secreted by the pitu-itary gland and regu-lates growth.

Cerebral edema

swelling of the brainbecause of an abnor-mal accumulation offluid.

Central pontine myelinolysis

disintegration of themyelin sheath in thepons that is associ-ated with malnutri-tion, most often dueto alcoholism.

alcoholic now has dangerously low electrolytes, includ-ing potassium, sodium, magnesium, calcium, andphosphorus in addition to blood sugar. This person isbeginning to withdraw from alcohol, demonstrating arapid heart rate and high blood pressure. He or shemay also be disoriented to time and place and may behearing and seeing things that are not there. Correct-ing his or her electrolytes becomes urgent, particularlywhen it comes to sodium. This leads to a delicate bal-ancing act. Failure to correct the sodium can lead tocerebral edema, a buildup of fluid in the brain; braindamage occurs because of the increased pressure push-ing the brain against the skull and other support struc-tures, eventually leading to seizures and death.Correcting the sodium too rapidly can lead to a condi-tion known as central pontine myelinolysis, which isa loss of white matter in the brain known as myelinthat is critical for nerves to function correctly. Themyelin in the brain literally dissolves, leading to braindamage and possibly death.

62. Can alcoholism cause dementia?Everyone is aware of the phenomenon known as the“blackout”—a transient period of memory loss or amne-sia during intoxication with no real evidence of neuro-logical injury. It generally coincides with a rapid, ratherthan slow, elevation of blood alcohol and may be an earlypredictor of alcohol dependence. Repeated episodeshave long-term consequences with respect to memoryimpairment. Because of alcohol’s intoxicating effects,there can be long-term consequences to the brain in par-ticular and the nervous system in general. The damagingeffects can be far reaching. They are due both to alco-hol’s direct toxic effects, but also to its indirect effects

Everyone isaware of thephenomenonknown as the“blackout”—atransientperiod ofmemory loss oramnesia dur-ing intoxica-tion with noreal evidenceof neurologicalinjury.


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Anterograde amnesia

loss of memorywhere new eventsare unable to betransferred to long-term memory.

Confabulation

filling in the memorygaps through fabrica-tion (i.e., making upstories to cover theloss of memory).

Malabsorption

faulty absorption ofnutrients from thealimentary canal.

Neurotoxic

toxic or lethal to thenerve and/or nervoustissue.

through the various nutritional and metabolic abnor-malities as well as the resulting withdrawal syndrome.The various neurological effects are discussed.

Wernicke/Korsakoff ’s SyndromeProbably the most well-known, although not the mostcommon, form of memory disturbance caused by alco-hol is Wernicke’s encephalopathy and Korsakoff ’sdementia. Wernicke’s encephalopathy refers to anacute disease process caused by thiamine deficiency,leading to confusion, apathy, drowsiness, an unsteadygait, and visual disturbances, due to nerve palsy’saffecting the motor system of the eyes. When memoryloss for events after the onset of the disorder occurs ona chronic basis (known as anterograde amnesia), it isreferred to as Korsakoff ’s dementia. Often individualssuffering from this will fill these memory gaps withevents that never occurred. This is known as confabu-lation and is different from lying in that there is noreal ulterior motive behind it. Korsakoff ’s is not a truedementia in that it does not affect other areas of cog-nition in the same manner that Alzheimer’s diseasedoes. The more proper term for this condition there-fore is alcohol amnestic disorder. Both Wernicke’s andKorsakoff ’s begin when heavy drinking causes intes-tinal malabsorption and thiamine (vitamin B1) defi-ciency. Treatment involves administration of thiamine100 mg daily over 3 months. Untreated, it carries a mor-tality rate of 15%. Even with treatment, only a third ofthose with memory impairment fully recover.

Alcohol-Related DementiaAlcohol has a direct neurotoxic effect on the brain,accelerating to a generalized atrophy or shrinkage ofthe brain that often occurs with aging. Some studies

Atrophy

a decrease in the sizeof an organ or muscle,or a wasting away ofa body part or tissue.


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Glial

cells that support andnourish the brain’sneurons.

Vascular dementia

a cognitive diseasewith mental andemotional impair-ments, plus neuro-logical signs andsymptoms.

Thrombi

plural for thrombusor blood clot. If theclot detaches andmoves, it is known asan embolus.

suggest that this process may be reversible and thatabstinence may aid in halting the progression and evenreversing it. Apparently, alcohol attacks the coating ofthe nerve cells, known as glial cells that make up themyelin, or white matter, rather than the nerve cellsthemselves. Unlike neurons themselves, glial cells havethe capacity to regenerate. Other studies, however,have disputed this. What is known is that the progres-sion of alcohol dementia can be halted with absti-nence, unlike the progression of Alzheimer’s disease,which continues to progress. Most studies support thecontention that alcohol does not hasten the progress ofAlzheimer’s disease, and it is doubtful that alcohol is arisk factor in the development of early Alzheimer’s,although this remains somewhat controversial.

Vascular DementiaComplicating this picture, however, is the fact that manytimes the dementia is not reversible. Alcoholics candevelop Alzheimer’s disease, and any damage that alco-hol has caused to the brain of an Alzheimer’s patient willworsen the condition. What is not controversial is thefact that alcoholism can increase the risk of stroke for thevery same reason that it increases the risk of heart attack,as the two processes are essentially identical though theyinvolve different organs. One of the most commonforms of dementia is vascular dementia. Many timesstrokes are undetected because the blood clots orthrombi are so small that they affect only the tiniest ofblood vessels. This leads to a condition that can be seenon brain imaging scans known as microvascular changesthat can also lead to brain atrophy and dementia withoutthe obvious signs of stroke. Finally, alcoholics are proneto accidents that frequently involve the head. One head

Microvascular

the part of the circu-latory system madeup of minute vesselsor capillaries measur-ing less than 0.3 mil-limeters in diameter.


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Marchiafava-Bignami Syndrome

named after the twoItalian pathologistswho first discoveredthe condition. A syn-drome first identifiedin alcoholics of Italianorigin who died aftersuffering fromseizures resulting in a coma.

Dysphasia

the loss of the abilityto use or understandlanguage as a resultof an injury to thebrain or a disease.

Cerebellar system

the part of the nerv-ous system that hasto do with coordina-tion of muscles andthe maintenance ofequilibrium.

injury dramatically increases the risk for another headinjury. Multiple head injuries increase the risk of devel-oping traumatic brain injury, which invariably leads tomultiple cognitive and personality changes that can beviewed as dementia. Up to 30% of nursing home patientshave alcohol-related dementia due to any of the previ-ously mentioned problems.

63. Are there other neurological effectsof alcoholism?Numerous obscure neurological conditions, such asMarchiafava-Bignami Syndrome, which attacks winedrinkers of Italian heritage, appear to affect individualsfrom certain ethnic backgrounds. Very specific areas ofthe brain are affected, causing confusion, difficultyspeaking (dysphasia), seizures, and dementia. Alcoholcan more commonly impact on numerous other neuro-logical systems. Alcohol has a predilection for thecerebellar system of the brain, which is critical incoordinating voluntary movements. This occurs withacute intoxication, thus leading to the staggering gait.It can also lead over time to chronic degeneration ofthe cerebellar system, causing the gait disturbance evenwhen the individual is sober. This occurs in about 1%of chronic alcoholics. Central pontine myelinolysis,which was discussed in Question 61, results from rapidcorrection of low sodium, or hyponatremia, and cancause pseudobulbar palsy, which consists of an overe-motional state known as pathological laughing andcrying, speech difficulties, facial paralysis, quadriple-gia, confusion, and coma, if one survives.

Pseudobulbar palsy

condition caused bydamage to the cra-nial nerve pathwaysthat can lead tounprovoked out-bursts of laughing orcrying along withother neurologicaldeficits.


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Peripheral neuropathy

refers to degenerat-ing of the nerves out-side of the centralnervous system,including the cranialnerves but not theoptic or spinal nervesor the autonomicnervous system.

Finally, however, the most common neurological condi-tion is peripheral neuropathy. This occurs in anywherefrom 5% to 15% of alcoholics. Chronic alcohol intakecan destroy peripheral nerves, particularly the smallernerves in the hands, feet, and lower legs. The experienceis similar to those who suffer from diabetic neuropathy.There is a “stocking-glove” distribution of weakness,numbness, and burning of the hands and feet. One canfeel burning pain in the soles of the feet, particularlywhen walking. Later stages can lead to a foot or wristdrop with muscle wasting. This condition has thepotential of traveling up the limb, although rarely doesit cause complete paralysis of the affected limb.

64. What are DTs?Probably the most well-known, although rarest (affect-ing only about 5% of alcoholics), but a treatable eventcan result from daily heavy alcohol use followed byabrupt cessation. Delirium Tremens is an acute confu-sional state that affects a variety of cognitive processes.These include a waxing and waning of consciousness,disorientation to place and time, attention and concen-tration impairment, supersensitivity to extraneousstimuli, visual and auditory hallucinations, and para-noid delusions. Tremens is another word for tremors orshakes. The individual suffering from this conditionalso demonstrates severe tremors as well as high bloodpressure and a rapid pulse. This is a medical emergencywith upward of a 15% risk of mortality if untreated.Symptoms may begin a few hours after the last drinkand peak around 48 to 72 hours later.

As mentioned in Question 6, two primary brain chemi-cals are involved in the development of this condition:

Delirium Tremens (DTs)

an acute withdrawlsyndrome fromalcohol.


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As mentionedin Question 6,two primarybrain chemi-cals areinvolved inthe develop-ment of thiscondition:GABA andglutamate.

Downregulation

the process by whicha cell decreases thenumber of receptorsto a given hormoneor neurotransmitterto decrease its sensi-tivity to this mole-cule.

GABA and glutamate. With chronic use of alcohol, theGABA system attempts to compensate for its increaseduse by making itself less accessible to alcohol in what isknow as downregulation. Over time, in order for theGABA to function correctly, it will need alcohol regu-larly or risk shutting down altogether. Without GABA,an excited state emerges. This is compounded by theglutamate system, which is the brain’s major excitatoryneurotransmitter. As alcohol chronically pushes GABAdownward, glutamate also tries to compensate byincreasing its activity in what is known as upregulation.When alcohol is suddenly withdrawn, the combinationof GABA being shut down and glutamate runningamok leads to the brain being in an extremely hyperex-citable state. In terms of motor systems, tremors resultalong with tachycardia or a rapid heart rate and hyper-tension or high blood pressure. In terms of sensory sys-tems, overstimulation occurs without the ability toprocess and make sense of the overwhelming amount ofinformation from the environment bombarding it.Thus, the individual becomes disoriented and demon-strates hallucinations, insomnia, irritability, and para-noia. Benzodiazepines are the treatment of choice, asdescribed in Question 56.

Susan’s comment:

Nothing in the entire experience has “brought me to myknees” like psychosis and DTs. Even seizures, although hor-rific to witness, don’t last very long. All of the other experi-ences seem to pale in comparison to watching your offspringin wrist and ankle restraints. It is like watching a night-mare unfold, with your “baby” as the main character. Thedull look in his eyes and the mumbling about nonsensicalthings are shattering events for a mother. I have been ableto maintain my composure through everything else but

Upregulation

the process by whicha cell increases thenumber of receptorsto a given hormoneor neurotransmitterto improve its sensi-tivity to this mole-cule.


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Aura

a subjective sensa-tion of voices or col-ors prior to a seizure.

Status epilepticus

a state in a personwhereby seizuresoccur in rapid succes-sion without recoveryof consciousness.

that. I make myself very scarce at those times and limit myvisits to peeking in on him and talking to the nurses so thathe doesn’t hear my voice. I always drive home in tears.

65. I had withdrawal seizures. Doesthat mean that I now need to take ananticonvulsant?Alcohol withdrawal seizures may or may not occur withDTs but are certainly more common, affecting up toone third of patients with chronic heavy alcohol use. Ofthose patients who have alcohol withdrawal seizures,between 30% to 50% will end up developing DTs. Theseizures are generalized, meaning that they affect theentire body and occur within the first 24 to 48 hoursafter the last alcoholic drink. They tend to be brief andoccur in a cluster of one to three seizures in fairly rapidsuccession. Generally, there are no auras or warningsymptoms. An electroencephalogram and CT scan areusually normal, and the seizures usually do not recur.Electrolyte deficiencies can play a role in the intensity andduration of the seizures, particularly low sodium andmagnesium. The seizures generally cease spontaneouslyand do not recur, although in about 3% of individuals theseizures will be prolonged. This condition is known asstatus epilepticus. When this occurs, further investiga-tion is necessary to exclude other underlying medicalconditions such as a head injury, an infection, or thedevelopment of epilepsy. Seizures are generally well con-trolled with benzodiazepines.

Dilantin is often also initiated in the emergency roombut remains a controversial subject. The ASAM pro-vides the following clinical practice guidelines for theuse of Dilantin in alcohol withdrawal, as outlined inTable 15. (The grading of each recommendation is


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Table 15 Clinical Practice Guidelines for the Use of Dilantin in AlcoholWithdrawal

1. For patients with alcohol withdrawal syndrome and no history ofseizures, phenytoin is not recommended as routine prophylaxisagainst alcohol withdrawal seizures. (Grade A recommendation.)

2. For patients with alcohol withdrawal syndrome and a history ofseizures that are not alcohol related, phenytoin or other anticon-vulsant therapy appropriate for the seizure type, in addition toadequate sedative–hypnotic medication, is recommended. (Grade C recommendation.)

3. For patients with alcohol withdrawal syndrome and a history ofalcohol withdrawal seizure, evidence is limited and conflicting, andexpert opinion is mixed as to the benefit of adding phenytoin toadequate sedative–hypnotic medication. Therefore, sedative–hypnotics alone or with phenytoin are both options. (Grade C recommendation.)

4. Long-term phenytoin prophylaxis, except when indicated forseizure disorder unrelated to alcohol, is not recommended. (GradeC recommendation.)

5. For patients with alcohol withdrawal syndrome and other possibleepileptogenic factors, factors that may increase the risk of alcoholwithdrawal seizures, in addition to previous history of withdrawalseizure, include head injury, focal brain lesion, meningitis orencephalitis, and a family history of seizure disorder; however, noavailable research evidence clarifies the significance of these factorsor provides guidance for appropriate management, and there is noclear consensus among experts. Therefore, sedative–hypnoticsalone or with phenytoin are both options. (Grade C recommen-dation.)

6. For patients with acute alcohol withdrawal seizures, intravenousphenytoin is not recommended for patients with isolated, acutealcohol withdrawal seizure. (Grade A recommendation.)

7. For patients with alcohol-related status epilepticus, anticonvulsanttherapy, which may include intravenous phenytoin, is appropriatefor patients who develop alcohol-related status epilepticus. (GradeC recommendation.)

based on the amount and quality of the availableresearch to support each recommendation. Grade A isobviously the best.) Thus, the general consensus is thatshort of having recurrent seizures from an underlyingseizure disorder, the need for long-term Dilantin admin-istration is not recommended. The maintenance ofsobriety is the best anticonvulsant one can recommend.

Prophylaxis

preventing the occur-rence of something.

Epileptogenic

causing epilepticattacks or seizures.


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66. A family member hears voices evenwhen he is not drinking. Is it caused bythe alcohol, or does he have schizo-phrenia?In medical school, one is taught that visual hallucina-tions are generally indicative of an underlying medicalproblem, whereas auditory hallucinations are moreindicative of a psychiatric problem. This is only a generalguideline, however. Most patients suffering from delir-ium see and hear things that are not there. A variety ofmedical problems, including but not limited to alcoholwithdrawal, cause delirium. Some psychiatric patientsreport visual hallucinations that are clearly the result oftheir psychiatric illness. The idea that an alcoholic canhear voices, however, “seems” to cross the boundarybetween what is medical and what is psychiatric.

We have covered a number of devastating effects thatalcohol has on the brain. Is it any wonder that short ofdementia, delirium, seizures, metabolic derangements,and the high incidence of head injury someone mightnot hear voices as well? All of these conditions canbe the reason for hearing voices and can certainlyincrease the risk for hearing them, but hearing voices canoccur even without any of these conditions present. Infact, this rare but frightening symptom occurs in roughly3% of alcoholics during intoxication and/or withdrawaland can linger long after physiological withdrawal symp-toms (rapid heart rate, high blood pressure, tremors, andinsomnia) abate. The more frequently one “see-saws”through intoxication and withdrawal, the easier it is todevelop withdrawal symptoms such as seizures, DTs, andhallucinations with an ever-lessening amount of alcohol.Thus, for some patients, even a day’s worth of drinking


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Kindling

an effect on the brainwhereby repeatedelectrical or chemicalstimulation of thebrain eventuallyinduces seizures. Thismay explain whycocaine and alcoholpreviously did notlead to seizures butafter repeated usenow do.

followed by abstinence can set it off. The brain hasbecome sensitized. This process of heightened sensitivityto the neurotoxic effects of alcohol occurs through aprocess known as kindling. Kindling was first demon-strated in rats when it was shown that ever-lesseningdoses of either seizure-inducing electricity or drugscaused the rats to have ever more intense and prolongedseizures.

Although antipsychotic medication can treat the symp-toms and decrease the agitation associated with them,sustained abstinence is the only cure. If the voices failto clear after sustained abstinence, further investiga-tion of the underlying causes should be pursued. Alco-hol-related psychosis may be confused with otherpsychiatric disorders. Other street drugs, particularlythe stimulants and the hallucinogens, can cause hallu-cinations. Psychiatric causes can include schizophre-nia, but the diagnosis of schizophrenia is basedpredominantly on symptoms other than the presenceof hallucinations. Mood disorders, particularly manicdepression or bipolar disorder, can present with hallu-cinations. Patients with psychiatric disorders do tendto abuse drugs and alcohol to a greater degree than thegeneral population. The cause of alcohol-related psy-chosis is generally determined by the patient’s past his-tory and family genealogy. In general, however, forpatients with severe alcohol dependence, the mostlikely cause of his or her hallucinations is probablymedical and directly related to the consequences ofchronic heavy drinking.

Psychosis

a state in which anindividual experi-ences hallucinations,delusions, and disor-ganized thoughts,speech, and/orbehaviors.


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The rates ofdepression arethree timeshigher in maleaddicts andfour timeshigher infemale addictsthan in thegeneral popu-lation, and athird of alldepressedpatients sufferfrom anaddiction.

67. How are alcoholism and mooddisorders linked?A clear link exists between addiction and depression.The rates of depression are three times higher in maleaddicts and four times higher in female addicts than inthe general population, and a third of all depressedpatients suffer from an addiction. Men typicallydevelop a substance abuse disorder first, whereaswomen typically develop a mood disorder first. Thelink between these conditions has biological, psycho-logical, and social roots.

Biologically, many addictive substances are depres-sants, whereas many other addictive substances, whenwithdrawn, cause depression. Additionally, both addic-tion and depression run together in families, placingindividuals with family histories of both conditions atrisk. Psychologically, certain personalities are prone toaddiction and depression. People who have difficultywith impulse control and who are quick to anger andare abrupt seem to be more prone to addiction, perhapsas an attempt to help modulate their feelings. Unfortu-nately, these self-medication attempts are only tran-siently beneficial and generally backfire. Alternatively,people who are shy or reserved and who become veryanxious in social settings are more prone to depressionand addiction as well, again because they often usesubstances as a way of trying to feel more comfortable“in their own skin.” Socially, people who struggle withdepression and addiction find themselves isolated fromothers and unable to hold down a job. Social isolation,job loss, and loss of access to health care and housingcan lead people to further worsening symptoms ofdepression and addiction.

Self-medication

taking medicationsthat are not pre-scribed by a physicianor nurse practitioner,including alcohol orother drugs, to copewith emotional dis-tress (e.g., drinkingalcohol or smokingmarijuana to calmdown when one isfeeling anxious).


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Although addiction and depression are linked, treatingone problem will generally not resolve the other prob-lem; instead, the likelihood is high that if someone isreceiving treatment for one problem the other may alsobe present and require treatment simultaneously ifprogress is to be made (see Question 29). Althoughthe concept of self-medication remains controversial,some evidence supports it, as many patients describetheir use unwittingly as an attempt to “self-medicate”depression. Unfortunately, no evidence exists showingthat treatment with antidepressant medication aloneleads to abstinence. Although the “self-medicationhypothesis” may seem right for some individuals, afteran addiction develops, it takes on a life of its own. It isunlikely that medicating a mood disorder away willsimultaneously medicate the addiction away. On thecontrary, if one continues to use drugs or alcohol whilereceiving antidepressant medication, those substancesrender antidepressant medication essentially useless.

68. My spouse has mood swings alongwith his/her addiction problem. Couldhe or she have bipolar disorder?Because of the recent surge in interest in bipolar disor-der, this topic warrants separate attention than what wasdiscussed in Question 67. Bipolar disorder, or manicdepression, is a mood disorder affecting upward of 1% to5% of the population, depending on the diagnostic crite-ria. Traditionally, bipolar disorder was a very serious psy-chiatric condition with episodes of acute mania thatinvariably caused psychotic symptoms and led to hospi-talization. The major difficulty in diagnosing it wasdistinguishing it from schizophrenia, as the clinical man-ifestations of an acute manic episode and an exacerbation


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of schizophrenia were indistinguishable. With the ad-vent of lithium, such a distinction was imperative, aslithium was a specific treatment for bipolar disorder,whereas Haldol or other antipsychotic medicationstreated both mania and schizophrenia alike. Condemn-ing a patient to life-long antipsychotic medication withits attendant risks was not viewed as good practice whenthe patient could be effectively managed with lithiumalone.

Over the years, as the commitment laws changed andpsychiatry became increasingly focused on dangerous-ness, ever larger numbers of patients with seriousimpulsive behaviors became the focus. These patientsrarely if ever demonstrated full-blown mania or otherpsychotic symptoms. Historically, they were viewed aspersonality disordered, as impulsive behavior appearsto be inherent to the individual and less subject tochange with medical intervention. Clearly, however, agreat deal of overlap existed between these individualsand patients with mood disorders. Although many ofthese patients improved with antidepressant medica-tions, a good number of them were made worse andresponded better to anticonvulsant medications. Thepublication of DSM-IV broadened the category toinclude bipolar II disorder, a condition with predomi-nant depression and few, largely “under-the-radar”episodes of mania. These episodes generally were asso-ciated with irritability rather than euphoria and neverbecame severe enough for people around them toremark that they needed professional help or warrantedhospitalization. In fact, what was notable was more of amagnification of the worst aspects of their personality:moody, irritable, quick tempered, and impulsive. Thisjust drove family and friends away from them. It did


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not alert them that there might be some other underly-ing cause to their personality change.

Most of these patients presented to the psychiatrist’soffice depressed, and it was only through inquiry regard-ing past behavior that the diagnosis was generally estab-lished. This new category has relaxed the criteria andincreased the number of patients with this diagnosis. Thenew concern is no longer distinguishing bipolar disorderfrom schizophrenia, but rather distinguishing bipolar dis-order from either depression or a personality disorder.Complicating the problem is the fact that these patientsare more prone to drug and alcohol abuse, which onlyexacerbates their swings from depression to irritability toeuphoria, and the swings do not tend to be sustained, butrather wax and wane along with the substance abuse.These patients come to the emergency room not becauseof a psychotic break but because of intoxication, with-drawal, or an impulsive suicide gesture, following bingeuse and some interpersonal difficulty resulting from theirbinge use.

Alcohol, cocaine, heroin, PCP, and marijuana can allcause mood swings that make everyone using thesedrugs suspect of having a mood disorder in generaland bipolar disorder more specifically. When thesepatients are hospitalized psychiatrically as a result ofan impulsive, potentially dangerous behavior in thecontext of their drug and alcohol abuse, the likelihoodof their being discharged on a “cocktail” of psychiatricmedications and a diagnosis of bipolar disorder ishigh. With average lengths of stay in psychiatric hos-pitals decreasing annually to now less than a week, theaccuracy of such a diagnosis is suspect at best. Theproof is not even in the pudding because complicating


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More than 2million Amer-icans sufferfrom alcohol-related liverdisease.

Hepatitis

a liver disease due to a viral infection.

the picture is the fact that the medications one is dis-charged on are symptom and not diagnostic specific.Therefore, although one may benefit from a mood sta-bilizer or antipsychotic (increasingly, with the newatypical antipsychotic medications, these two terms arebecoming almost synonymous as both decrease irri-tability), that does not mean one has bipolar disorder.Unfortunately, the danger inherent in the diagnosis isthat all too often these patients and their families nowfocus entirely on this new diagnosis and attribute theircontinued relapse to their bipolar disorder and aninadequate medication regimen while doing nothingto get treatment for their substance abuse or alcoholdisorder. Any mood swings stand a far better chance ofimprovement from abstinence than from any psy-chotropic medication offered.

69. I have cirrhosis of the liver. Isthat reversible?More than 2 million Americans suffer from alcohol-related liver disease. The most common condition isalcoholic hepatitis, or inflammation of the liver (theroot “hepa” refers to liver, and the root “itis” refers to ageneralized inflammatory process) as a result of heavydrinking over a long period of time. The symptoms ofhepatitis may include fever; abnormal yellowing of theskin, eyeballs, and urine known medically as jaundice;and abdominal pain. These more commonly go unno-ticed until a lab test reveals elevated liver enzymes.Alcoholic hepatitis can cause death if drinking contin-ues. If drinking stops, the condition may be reversible.About 10% to 20% of alcoholics develop alcoholic cir-rhosis, or scarring of the liver, which is the result ofchronic hepatitis. People with cirrhosis should not

Cirrhosis

a liver disease wherethere is widespreaddisruption of normalliver functions. It is achronic progressivecondition that caneventually lead todeath.


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drink alcohol. Although treatment for the complica-tions of cirrhosis is available, a liver transplant may beneeded for someone with life-threatening cirrhosis.Alcoholic cirrhosis can cause death if drinking contin-ues. Cirrhosis is not reversible, but if a person with cir-rhosis stops drinking, the chances of survival improveover time. People with cirrhosis can feel better, and liverfunction can improve after they stop drinking. Anadded complication is the fact that drug and alcoholabusers are prone to developing viral hepatitis as a resultof their high-risk behavior (e.g., unprotected sex, intra-venous drug use). These viruses include hepatitis B andhepatitis C. About 4 million Americans are infectedwith the hepatitis C virus, which can cause liver cirrho-sis and liver cancer. Some alcoholics also have either thehepatitis B or C virus infection. As a result, their liversmay be damaged not only by alcohol but also by thehepatitis virus. People with either hepatitis B or C virusinfection are more susceptible to alcohol-related liverdamage and should think carefully about the risks whenconsidering whether to drink alcohol.

70. Am I eligible for a liver transplant ifmy liver failure is from my alcoholism?One of the biggest stories that came in the 1990s wasMickey Mantle’s liver transplant. Mantle, a famousbaseball player, was 63 years old in 1995 when his liverfailed, and he was placed on the list to receive a trans-plant. The average waiting time was 3 to 4 months.Mantle, however, received a liver transplant in a day.Unfortunately, the underside of his liver had cancerouscells. The transplant went ahead as planned; however,the cancer then spread to his lungs, and Mantle died 3months later from the cancer. Critics charged thatMantle was given a liver quickly because of his public


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prominence. Others charged that he should not havebeen given a liver because of either his history of alco-holism or his cancer, both of which are reasons not toplace someone on the list at some transplant centers.

Mickey Mantle had been an alcoholic since the age of20 years. He had been abstinent a year and a half, buthis liver was by then failing because of his alcoholismand the contraction of hepatitis C. Hepatitis C mayhave been contracted from a blood transfusion hereceived during surgery or may have been contracted asa result of his alcoholic high-risk behavior. He also had atumor in his liver, called a hepatoma, that had not beendiscovered prior to the time of his transplant.

Should people who are alcoholics receive transplants?Increasingly, transplant centers are not using a history ofalcoholism as a reason to deny patients a transplant.When liver transplants first became available in the1970s and 1980s, centers generally excluded alcoholicsbecause it was thought that they would have worse sur-vival rates because of their inability to maintain absti-nence. Since then, multiple studies have been conductedcomparing alcoholics with nonalcoholic patients whoreceived transplants. They have found that alcoholics doas well as or better than those whose livers have failedfrom other causes. Because the outcomes are the same orbetter, the only reason to deny an alcoholic a transplantwould be either the fact that he or she continues to drinkor for some other nonmedical reason. Most centerstherefore require that alcoholics be abstinent for at least6 months and to be actively engaged in a recovery pro-gram to maintain abstinence.

If we were going to reject a person with alcoholismfrom receiving a liver transplant because it was due to


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their own behavior, then we would have to rejectequally the sedentary, type A, overweight cigarettesmoker from receiving a heart transplant. If someoneneeded a liver transplant due to hepatitis C, we wouldhave to explore the way in which that person con-tracted hepatitis C to see whether some form of “irre-sponsible” behavior was involved as well. This could goon and on until one could foresee denying all kinds ofmedical care to individuals simply because of thechoices they made in their lives that did not accordwith our conception of a “healthy lifestyle.”

The first principle of organ allocation is making thebest use of the organ in order to save a life that is inimmediate danger, but also a life that has the bestchance for long-term survival. In this regard, alco-holism is no different from any other disease of lifestyle.

71. Are there any medications that Ishould avoid if I have hepatitis?The liver is a factory whose job is to process all sub-stances ingested for either utilization by the body orelimination from the body. All medications are thereforeprocessed through the liver; however, some medicationsare processed in such a manner that they have no effecton the liver, whereas others are processed in a mannerthat can potentially have a grave impact on the liver (asalcohol can). In fact, medications are the major cause ofliver disease, also known as drug-induced hepatotoxicity.This may account for up to 10% of hepatitis cases inadults overall, about 40% of cases in adults over the ageof 50 years, and 25% of cases of liver failure. More than1,000 medications and chemicals can cause this problem.


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The effects ofvarious med-ications andchemicals thatcan potentiallyimpact theliver nega-tively arecumulative;thus, if one hashepatitis fromanother causealready (suchas alcohol or avirus), it isextremelyimportant tobe aware ofwhat medica-tions canexacerbate thecondition.

The effects of various medications and chemicals thatcan potentially impact the liver negatively are cumula-tive; thus, if one has hepatitis from another causealready (such as alcohol or a virus), it is extremelyimportant to be aware of those medications that canexacerbate the condition. An already damaged liverthat is now subject to a potentially toxic medicationcan cause the liver to fail, a very dangerous situation. Itis critically important to provide your doctor withcomplete information concerning not only prescriptionmedications, but also over-the-counter medicationsand herbal and alternative therapies. Even medicationsthat do not have a negative impact on the liver mayneed to be adjusted, as the liver’s ability to processthem may be compromised to the point where themedications build up in the body causing increasedside effects or even potentially toxic effects themselves.

One class of pain medications, however, deserves spe-cial attention. The most common over-the-countermedication associated with hepatotoxicity is acetamin-ophen (Tylenol). The simultaneous use of alcohol withacetaminophen can be very dangerous. One tablet ofextra strength acetaminophen is 500 milligrams. Atherapeutic dose for minor aches and pains ranges from2 to 6 grams per day (4 to 12 tablets per day). In peoplewithout alcoholic liver disease, doses greater than 10grams (upward of 15 grams) over a 24-hour period maycause drug-induced hepatitis. In people with alcoholicliver disease, doses greater than 2 grams over a 24-hourperiod may increase the risk for liver damage. There-fore, if one has alcoholic liver disease, one needs tolimit acetaminophen use to no more than four tabletsin a 24-hour period. Using acetaminophen in this dose

The mostcommon over-the-countermedicationassociatedwith hepato-toxicity isacetamino-phen(Tylenol).


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range may be safer than taking aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs), suchas Motrin or Advil. These other NSAIDs can causebleeding, particularly in the gastrointestinal tract, andkidney disorders, in addition to liver injury, making themeven more unsafe. The most important aspect is to beaware that other over-the-counter and some prescriptionmedicines can contain acetaminophen, aspirin, or otherNSAIDs. Read the label of any medication prior to tak-ing it, and when in doubt, check with your doctor orpharmacist concerning the presence of NSAIDs in a par-ticular medication.

Certain risk factors make a person more prone to liverdisease, including age, being female, taking higherdoses of medication for longer periods of time, thepresence of pre-existing kidney disease, making it moredifficult to eliminate potentially hepatotoxic chemicals,cigarette smoking, certain autoimmune disorders such asrheumatoid arthritis or systemic lupus erythematosus,obesity, and poor nutritional status. The time it takes todevelop drug-induced hepatotoxicity is between 5 and 90days after initiation of the drug. Liver function tests areusually obtained during this time period, and if theenzymes increase threefold above their normal limit, themedication is usually discontinued. Liver enzymes usu-ally return to normal within 14 to 28 days after discon-tinuation of the offending agent.

72. What sexual problems does alcoholcause?Several problems of sexuality arise from alcoholism.The first is increased libido because alcohol lowersinhibitions. Although this may not be a problem, it

Nonsteroidal anti-inflammatory drugs (NSAIDs)

an extremely diverse group of anti-inflammatory andanalgesic drugs thatinhibit the enzymecyclooxygenase andreduce the synthesisof prostaglandins.


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can lead to consequences that are clearly problems,notwithstanding unwanted pregnancy or sexuallytransmitted diseases from unprotected sex. Anotherpotential problem is that alcohol intoxication can causea phenomenon euphemistically referred to as “thebrewers droop,” making it difficult to achieve and/ormaintain an erection. These two problems of increasedlibido and decreased performance can lead to behav-iors that may not only be troublesome but also down-right dangerous. Intoxication leading to increasedlibido increases the probability of sexual assault. Intox-ication leading to impotency increases the probabilityof physical assault. Why? Because studies have shownthat alcohol is related to sexual jealousy, which canreach pathological proportions when one is intoxicatedand then feels rejected by the woman either because ofhis intoxication or because of his inability to perform.Compounding that fact is the poor judgment resultingfrom intoxication, leading to misinterpretation of factsand acting irrationally based on the misinterpretation.This is particularly true in troubled marriages in whichsuspicions often lead to and are, in turn, fueled byintoxication. These are the potential consequences ofacute intoxication. What about any long-term conse-quences of alcoholism, however?

Alcoholism can do one of three things to potentiallyruin one’s sex life in the long run. First, alcohol lowerstestosterone, which is the hormone primarily responsi-ble for libido and sexual performance. Second, alcoholcan raise blood pressure and cholesterol, which aremajor risk factors for the development of vascular dis-ease and, in turn, another cause of impotency. Goodcirculation is essential for male sexual performance.Poor circulation is also a cause of sexual difficulties


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among women. Finally, alcoholism can cause periph-eral neuropathy, damaging the nerve supply to thegenitalia, again leading to impotency and anorgasmia.

73. When I stopped drinking, I startedsmoking a lot more. I’m afraid that if Itry to quit smoking I may go back todrinking. What can I do?Research supports the aphorism “smokers drink anddrinkers smoke.” The heaviest drinkers are also oftenthe heaviest smokers. This significantly increases therisk of heart disease, stroke, emphysema, and cancersof all forms. For example, the approximate risks fordeveloping mouth and throat cancer are 7 timesgreater for those who use tobacco, 6 times greater forthose who use alcohol, and 38 times greater for thosewho use both substances. Most drinkers started smok-ing first and adolescents who smoke are three timesmore likely to begin using alcohol. Smokers are 10times more likely to develop alcoholism than non-smokers! What is the link? Both drugs increase thepleasant effects and ward off the unpleasant effects ofeach other. Nicotine involves many of the same neuro-chemical mechanisms of the brain’s reward system thatalcohol involves. Nicotine can lead to tolerance, whichis the need for ever-increasing amounts to achieve thesame desired effects. Some level of cross-tolerance mayexist between nicotine and alcohol as well. In otherwords, the need for ever-increasing amounts of onesubstance leads to the need for ever-increasingamounts of the other substance and vice versa. Cross-tolerance may partly develop from one drug mitigatingthe negative effects of the other, such as nicotine’s abil-ity to lessen the sedative effects of alcohol and alco-

The heaviestdrinkers arealso often theheaviest smok-ers. This sig-nificantlyincreases therisk of heartdisease, stroke,emphysema,and cancers ofall forms.


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hol’s effects in calming the potential anxiety of smok-ing too much tobacco. Animal studies have born thisout, where nicotine has been shown to mitigate againstthe cognitive and motor effects of alcohol.

Historically, addiction specialists did not address theissue of nicotine addiction, fearing that asking an alco-holic to quit tobacco at the same time would be askingtoo much and thereby risking relapse. Research has notconfirmed this. One study compared two alcohol pro-grams, one that added a smoking cessation program andone that did not. Abstinence differences after 1 yearbetween the two groups were no different, but in thegroup engaged in smoking cessation, 12% had quitsmoking. Another study suggested that smoking cessa-tion actually enhanced motivation to stop drinking. As aresult, following along with the prevailing culture, manyaddiction programs are now smoke free.

Some caveats are as follows: It appears, because ofcross-tolerance, that alcoholics who engage in smokingcessation may require higher doses of nicotine replace-ment than the normal smoking population. Depres-sion and being female are risk factors working againstone’s ability to give up tobacco. Because nicotine in-duces liver enzymes, antidepressant and mood stabi-lizer blood levels may be lower than expected, makingthe medications less effective, which could contributenot only to continued depression, but also to contin-ued nicotine dependency. Thus, keep these factors inmind if you are about to quit. The motivation to stopdrinking should be used simultaneously to stop smok-ing, as the outcomes for both problems and the healthbenefits are many times greater than either alone! Finda program that is at least smoke free and secondarilyoffers a smoking cessation program. If no program is


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available, work with the medical director of the reha-bilitation center or your primary care physician to pro-vide nicotine or other medications such as Zyban(Wellbutrin) to assist you.

74. I got into a vicious cycle using alcoholto come down from cocaine. The doctorstell me that I’m an alcoholic, but my drugof choice has always been cocaine. Do Ineed to be concerned?Alcohol and nicotine are but one common combina-tion that appears to work together synergistically toincrease each other’s pleasurable effects and decreaseeach other’s unpleasant effects. Another combinationthat is quite popular is alcohol and cocaine. The feel-ings generated from the combination is beyond what isfelt by either drug alone. Again, the negative effects ofalcohol such as learning and motor performance are“improved” with the addition of cocaine, whereas theanxiety and paranoia that cocaine generates are“improved” with the addition of alcohol. People don’trealize the high cost that is associated with this combi-nation. Both are metabolized by the liver, which leadsto a metabolite known as cocaethylene, a potent drugin and of itself that has significantly more cardiotoxiceffects than using either drug alone. This new “drug”also appears to cause violent thoughts and behaviorsthat would not necessarily be present if either drugwere used alone. This new “drug” is thought to be themost common cause of drug-related deaths because ofcardiac effects and violence. Finally, cocaine may causeliver injury independent of alcohol.

Cocaethylene

a chemical producedby the liver whenprocessing cocaineand alcohol (ethanol)simultaneously thathas many pharmaco-logical propertiessimilar to cocaineexcept that it stays inthe body longer andis potentially moretoxic to the nervousand cardiac systems.


SpecialPopulationsI was drinking during my first trimester of pregnancy before I knew I was pregnant.What are the risks to my unborn baby?

My baby was born with fetal alcohol syndrome.What is that, and what does it mean for my baby?

How do I know whether my child is just experimenting with alcohol and drugs or

has a real problem with them?

More . . .

PART VI


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75. I was drinking during my firsttrimester of pregnancy before I knew Iwas pregnant. What are the risks tomy unborn baby?Because many pregnancies are unplanned, womenmay unintentionally expose their offspring to alcohol.Potential mothers need to be aware of the risks associ-ated with unplanned pregnancy and the use of alcohol.As noted in Question 85, alcohol is quickly absorbedinto a woman’s bloodstream, and if she is pregnant, alco-hol quickly passes through the placenta and exposes thebaby. Alcohol is broken down more slowly in a baby thanin the adult because of the baby’s size and immaturity.As a result, alcohol remains elevated in the baby’s bloodstream longer than it remains in the mother’s, potentiallycausing damage to the baby. Thus, even light to moder-ate drinking may affect the fetus in several ways, includ-ing premature birth, low birthweight, and cognitive andphysical deformities. Heart defects have been found inbabies whose mothers drank during the first trimester oftheir pregnancy. Sometimes a baby can appear normal atbirth, although subtle effects may present later in thechild’s development, even if the mother drank only onedrink per week during the pregnancy. One studyreported that children 6 and 7 years old exhibited moreaggressive behaviors and had other behavior problems,including delinquency, than children whose mothers didnot drink at all. Another study demonstrated that mod-erate alcohol consumption during pregnancy resulted ina higher incidence of offspring having problems withalcohol by the age of 21 years, even after controlling forfamily history and other environmental factors.

Potentialmothers needto be aware ofthe risks asso-ciated withunplannedpregnancy andthe use ofalcohol.


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Special Populations

Although a clear dose-dependent relationship existsbetween amounts of alcohol one drinks during preg-nancy and the extent of damage to one’s unborn child,no definitive answer is available regarding exactamounts of exposure. One or two drinks before youknew you were pregnant will most likely not affect yourbaby. The baby’s brain and other vital organs begindeveloping around the third week, so if you stoppeddrinking by then, the baby is probably safe. The baby isvulnerable, however, by the third week and thereafter;thus, continued exposure to alcohol will place thebaby’s brain and other vital organs at risk. To conclude,the risk is low within the first 2 to 3 weeks, increasesdramatically after that and throughout the firsttrimester, and then decreases, although not enough torecommend any alcohol until after the baby is born.The risk is that you may have a baby who in the begin-ning has serious physical, mental, or behavioral prob-lems or who seems normal and healthy at first but laterdevelops behavioral or cognitive problems. Speakopenly with the obstetrician about your drinking andyour fears about the baby. The most serious risk to yourunborn child is fetal alcohol syndrome (FAS), which isaddressed in the following question.

76. My baby was born with fetal alcoholsyndrome. What is that, and what does itmean for my baby?Fetal alcohol syndrome disorder (FASD) is one ofthe most devastating disorders found in newborn chil-dren. It results from exposure to alcohol by mothers

Fetal alcohol syndrome disorder (FASD)

a disorder that isfound in infantswhose mothersingested alcohol dur-ing pregnancy,resulting in the infantbeing mentallyretarded along withhaving other distin-guishing features.


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Teratogen

an agent, such as avirus, drugs or alco-hol, or radiation, thatcauses malforma-tions in a fetus orembryo.

who drink throughout their pregnancy. Experts believethat the degree of severity of the symptoms dependson the amount of alcohol circulating in the mother’sand baby’s bloodstreams, the timing of the toxic expo-sure, and genetic factors. Currently, no way is availableto determine which baby will be affected by exposure tofetal alcohol. Although only a few drinks may berequired at a crucial time during pregnancy to causesufficient damage to the fetus, how much alcohol andat what crucial time have yet to be determined. One inevery 750 babies has the full syndrome. It is the lead-ing known cause of mental retardation in newbornchildren. Alcohol, therefore, is the leading teratogencausing birth defects.

Most children exposed to alcohol in utero do not havethe full-blown syndrome, which includes not only cog-nitive and behavioral problems but also distinct physicalfeatures. FASD is manifested by specific birth defectscharacterized by low birthweight, failure to thrive,developmental and psychological delays, autism, andmild to moderate mental retardation (an IQ around 60),along with rather distinct physical abnormalities. Thirtyto forty percent of these children have heart defects,which occur in the first trimester of the pregnancy. Thedistinct physical abnormalities include a cranial malfor-mation known as microcephaly, a narrow forehead,flattening of the mid face, both the cheekbones, and thebridge of the nose, a short nose, and a long, thin upperlip. Other eye, ear, and occasionally hand malformationsmay also be present. Children who are the less obviouslydeformed may go undetected until later in life.

Some children show signs of cognitive and behavioralproblems after exposure to alcohol in the absence ofphysical features. When this occurs, the symptoms are

Microcephaly

an abnormally smallhead with associatedmental retardation.

Some childrenshow signs ofcognitive andbehavioralproblems afterexposure toalcohol in theabsence ofphysical fea-tures.


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Special Populations

Alcohol-related neurodevelop-mental disorder (ARND)

a disorder in thedevelopment of thenervous system in afetus. It is related tothe exposure of thefetus to alcohol.

referred to as alcohol-related neurodevelopmental dis-order (ARND). These children may go unrecognizedbecause they do not have the physical features, althoughthey have the developmental, cognitive, and behavioraldeficits. Some may suffer from minimal brain damage,have difficulty concentrating and focusing, may be irrita-ble and/or hyperactive, have difficulty in problem solv-ing, and may be emotionally labile. These children maybe diagnosed later on with psychiatric disorders such asattention deficit hyperactivity disorder (ADHD),depression, or bipolar disorder (or manic depression).Such children may not be identified until they are inschool. All children who have been exposed to alcohol inutero should have early screenings, close monitoring, andearly interventions.

The National Organization of Fetal Alcohol Syn-drome estimates that at least 12,000 children each yearare born with FASD, and as many as 36,000 morechildren have ARND. A smaller group of children hashad some developmental and cognitive effects, but theeffects are less severe than the other two syndromes.This population of mentally retarded/developmentallydelayed children who were exposed to alcohol whilethey were in uteri is larger than the number of childrenborn with Down’s syndrome, cerebral palsy, and spinabifida combined. FASD and ARND are the most pre-ventable of all of the mental retardation and physicaldeformities found in newborn children.

Early diagnosis has been shown to be effective in pre-venting secondary disabilities, such as school failure,juvenile delinquency, mental health problems, home-lessness, and unemployability. Individuals with undiag-nosed FASD often end up in institutional settings,including jails, mental health programs, psychiatric

National Organi-zation of Fetal Alcohol Syndrome

an organization toeducate youngwomen about thedangers of drinkingwhile pregnant,hopefully to preventthe incidence andprevalence of fetalalcohol syndrome.


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To conclude,FASD isentirely pre-ventable andis the onlyform of child-hood mentalretardationthat is pre-ventable.

hospitals, and homeless shelters. Early intervention iscritical. The earlier those children can be treated thebetter their outcomes will be. Families must be in-cluded in the therapeutic plan because parents oftenbecome overwhelmed by the difficulty in caring for amultiply handicapped child and they need to deal withthe guilt of having caused harm to the child. FASDchildren require environments that are stable, struc-tured, and nurturing. Caregivers must be creative, con-sistent, and compassionate. During the early life of thechild, helping the parents and the child to develophealthy relationships is the first and most importantintervention. To conclude, FASD is entirely preventa-ble and is the only form of childhood mental retarda-tion that is preventable. It is a life-long condition thataffects every aspect of the lives of the child and thefamily. Table 16 outlines Centers for Disease Controlcriteria that are guidelines for the diagnosis of FASD.

77. How do I know whether my child isjust experimenting with alcohol anddrugs or has a real problem with them?More than 90% of children will have tried alcohol bythe time they have graduated high school, whichmakes experimentation with alcohol a fairly normalexperience. Most young people are mature enough torecognize that heavy alcohol use is neither pleasurablenor in tune with their goals for pursuing jobs, families,or higher education. The children who get into troublewith alcohol are those who have begun to pursue it asan end in itself. As a result, school and family life suf-fer, and these children begin to associate only withthemselves or other children with similar problems. Ifan adolescent is caught using substances, acknowledges

Centers for Disease Control

a federally mandatedprogram that wasestablished in 1973to monitor thenation’s health.


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Table 16 Centers for Disease Control Criteria for FASD

Criteria 1:–Binge drinking (more than 2 to 3 drinks per occasion)–Daily use (1 to 2 drinks per day)–1st-trimester versus 3rd-trimester use

Criteria 2: Growth retardation–Decreased head circumference–Decreased height–Decreased weight

Criteria 3: At least two facial features–Indistinct philtrum–Short palpebral fissures–Thin upper lip

Criteria 4: Neurodevelopmental disorders–Impaired intelligence–Delayed speech development–Impaired fine motor skills–Attention deficit disorder–Attachment concerns–Learning disabilities–Hearing impairment

it, and is otherwise showing no problems with school,family, or friends, then the likelihood he or she has asubstance alcohol abuse disorder is low. Low, however,does not mean nonexistent, and some degree of vigi-lance must be maintained. Other risk factors raiseone’s suspicion, regardless of school or home life. Indi-vidual risk factors include other psychiatric disorders,such as ADHD, specific temperamental traits such asan interest in novelty seeking, irritability, impulsivity,and high motor activity. Other risk factors include afamily history of alcoholism or substance abuse, a lackof parental attachment, or parents who have a gener-ally permissive management style. Children who bondmore quickly to peers at an earlier age and follow their


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lead rather than their parents are also at greater risk.Finally, other environmental risk factors include lowersocioeconomic status and neighborhoods that havehigher crime rates. Accidents with automobiles, bicy-cles, and even skateboards should raise one’s degree ofsuspicion that alcohol or other drug use was involved.Other red flags include unsafe sexual activity or beinga victim or perpetrator of a violent act.

78. How old do my children need to be before I start talking to them about alcohol?You should talk to them as early as possible but shouldtake into consideration the developmental level of thechild. Often parents make the mistake of waiting untiltheir children are driving or in high school to talkabout drugs, tobacco, and alcohol. By then it may betoo late to prevent a serious accident or perhaps addic-tion. Parents should keep the communication openand ongoing; otherwise, children will go elsewhere toget their questions answered. The answers from theirpeers are usually erroneous. The following are guide-lines that include (1) some basic principles, (2) factsthat parents should know, (3) tips for helping childrencope with life’s stressors, and (4) suggestions for par-ents that are age appropriate for each developmentallevel.

Guidelines For Parents1. Basic principles on discussing drug and alcohol use

with your children• Listen to your child. Start talking early. Seek your

child’s opinions about tobacco, alcohol, and drug

Often parentsmake the mis-take of wait-ing until theirchildren aredriving or inhigh school totalk aboutdrugs, tobacco,and alcohol.


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use. Share your own opinions. Find out whatthey are learning in school and in the neighbor-hood and from their teachers, other children,and their own experiences. Ask children aboutwhat they think.

• Be a good example. Drink responsibly or not at all.Role modeling is a more powerful teaching toolthan talking. Children do what their parentsdo—not what their parents say.

• Keep communication open. Start talking to yourchildren about tobacco, alcohol, and drugs whenthey are young. If you find it difficult to talk toyour child about substance use and abuse, you arenot alone. Ask your doctor or pediatrician to dis-cuss drug use with your child. Pamphlets are help-ful. Give them to your child as a starting point fordiscussion. Encourage school officials to institutetobacco, drug, and alcohol-prevention programs.

• Immunize your children against drug and alcoholabuse. Parents have their children inoculatedagainst measles and mumps at an early age. Par-ents also need to immunize their children at anearly age against tobacco, drugs, and alcohol useby giving them the facts.

2. Facts parents should know• Many children have tried to use alcohol or drugs

before high school. Fifty percent of fourththrough sixth graders report being pressured bypeers to try alcohol. The average age when achild takes his or her first drink is about 12 years,which is the sixth or seventh grade. A 1998Washington State Survey found that amongsixth graders half of those who drank got theiralcohol at home and their parents knew about it.


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• The younger a person starts drinking alcohol, thehigher the risk for dependence in later years.

• Drinking alcohol before the brain is fully devel-oped may cause damage to the areas of the brainresponsible for learning and memory.

• Alcohol affects judgment and decision making.

• The leading cause of teenage injury and death isalcohol related.

• Beer and wine are not safer than “hard” liquor.

3. Tips for helping children cope with life’s stressors

• Tell the truth. Provide the facts. Do not exaggerate.

• Reassure children and allow them to expresstheir feelings. Feelings are okay. You want yourchildren to turn to you, not to a substance, whenthey are upset in order to feel better. Make surethey know that they are safe and loved.

• Make rules for your household clear; if the rulesare broken, make the consequences explicit.Consequences should be appropriate to the mis-deed. Remember rules for children convey themessage that you love them and care about them.

• Do not threaten.

• Provide opportunities for activities that are alco-hol free such as sports, theater, and music.Whenever possible, go to the child’s sports andschool events. Get to know their friends and theparents of their friends.

• Know where your children are and what activitiesthey are doing.

• Create ways for “family togetherness,” doinghealthy activities.


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• Freely offer praise. Take advantage of every oppor-tunity to build a child’s social and physical skills,which will enhance his or her self-confidence.

• Confidence helps children handle difficult situa-tions without turning to a substance to cope.

4. Suggestions for parents that are age appropriate foreach developmental level

a. Preschoolers

• Very young children are not ready for the factsabout alcohol or other drugs, but they areready to learn how to make decisions and howto solve a problem. For example, allow them topick out their own clothes. Support their deci-sions. Let them help you around the houseand thank them for their help.

• Parents can provide a good example for theirchildren by exercising and eating healthyfoods. Provide opportunities to eat with yourchild and to play with your child. Do healthyactivities together, such as playing ball, swim-ming, or biking.

• Watch television with your children, and talkabout the advertising messages. Ask your chil-dren questions about what they think of the ads.

• Monitor what your children watch on televi-sion. If a child sees something on a televisionshow about drugs, alcohol, or tobacco and hasquestions, be available to listen to his or herconcerns and answer questions.

• If there is an antidrug commercial on televi-sion or on a billboard or elsewhere, reinforcethe message “just say no.”


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• When giving a child medicine during an ill-ness, the parent can use this opportunity toteach a child about using the appropriateamount for the moment and the dangers ofhaving too much medicine at one time.

b. Ages 5–7• Children this age learn mostly by experience.

Conversations should involve experiences orevents that children are familiar with, such aswhat they have seen on television or what theyhave observed at home or other places.

• Teach your child about how the body worksand why every person needs good food, cleanwater, and exercise. Teach them the impor-tance of avoiding eating and drinking foods orsubstances that are not healthy.

• Inform your child in simple terms that alcoholcan hurt the body by altering the way it makesyou feel, the way you can see, and the way youthink because it impacts the brain and makeschanges in other parts of the body. Tell them itcan make them sick and might make themfeel like they had the flu with a headache,nausea, and vomiting.

• Children love stories at this age. Telling thefacts in story form may be more interestingand provide a more powerful message to gradeschool children.

c. Ages 8–12• Invite questions. Ask your child what he or

she knows about drugs and alcohol. If parentsstart giving the message to children early thatthey are available to talk about touchy sub-jects, children will be more open in the futureto come to the parents about their concerns.


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Ask the child about what his or her friendsknow about alcohol or drugs.

• Start talking about facts, such as the long- andshort-term effects and the consequences ofusing alcohol. Teach children why alcohol isespecially dangerous for them when they areyoung because of the impact of alcohol on thedeveloping brain.

• Teach children to say no to peer pressure.Practice with them on how to say no. Reassureyour child that he or she can say no withoutlosing friends.

• At this age, children are influenced by theirfriends. Be sure to meet their friends and fam-ilies and know what the children are doingwhen they visit one of their friends. Discussthe rules of the house at their friends’ homesand compare them with your rules. Discussthe differences.

• News items, such as steroid use in professionalsports, can be the stimulus for conversationsabout tobacco, drugs, and alcohol use.

d. Ages 13–17

• This is the age when children start experi-menting with alcohol or drugs.

• Continue to make your expectations clear andencourage the teen to come to you for help orto answer questions.

• By now, children should know what the rulesare and what the parents think about the useand abuse of tobacco, alcohol, and drugs.

• Focus on keeping the lines of communicationopen. Ask your child about their attitudes andtheir friends’ attitudes. Teens are more apt to


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want privacy. You can help the relationshipremain open by showing your respect, love,and concern. Avoid preaching or threatening.Remain nonjudgmental.

• Teenagers strive for independence and thusoften participate in risky behaviors. Knowwhat your child is doing. Warn him or herof any dangers.

• Parents should encourage their children toinvite friends to their home; however, do notpermit any alcohol or drugs in the home.

• By 16 years old, most children are driving. It’sa good idea to develop a written or unwrittencontract on the conditions for using the car.

• Discuss the rules about cars and drinking: (1)Do not drink and drive. (2) Do not get into acar with a driver who has been drinking. (3)Do call home to have parents come to get youand your friends, rather than driving homewith someone who has been drinking.

• Review how to say no to tobacco, drugs, andalcohol or other risky behaviors.

• Teach children to ask questions before ingest-ing anything that is an unknown.

• When in any uncomfortable situation, encour-age the teenager to call home. Praise him orher for good judgment.

e. Tips for helping teens to say “no”• Say it like you mean it.• You don’t have to give excuses. “No” is enough

of a reason.• Suggest doing something different.• If you continue to get pressured, walk away.


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No family is immune to the effects of the alcohol anddrug culture in our society. Some of the best childrenfrom the best homes can end up in trouble. Beinvolved in your children’s lives. Parents should recog-nize when a child is having a difficult time so that theparents can support the child if needed. Seek addi-tional help for the troubled child through participationin a drug program, counseling, or accessing otherresources. Parents should elicit the school’s assistanceand other community organizations to provide ahealthy community in which to raise a child. A sup-portive family, school, and community environmentworking together is the best for tobacco, drug, andalcohol prevention.

79. I grew up in another country wherealcohol was part of the culture andteenagers were allowed to drink. Whycan’t I continue that tradition with myown children?Although the drinking age may vary between one cul-ture and another, all cultures adhere to some restric-tions, especially for teenagers. Countries that areambivalent about drinking alcohol, such as the UnitedStates, are more rigid than are the more permissivecountries. The countries where wine and beer areserved regularly with meals in social settings are con-sidered the more permissive countries. These generallyinclude the Mediterranean countries such as Spain,France, Italy, and Greece. Most European countries,however, have a more relaxed attitude regarding teen-age drinking compared with the United States, and thelaws allow for drinking under the age of 21 years.

No family isimmune to theeffects of thealcohol anddrug culturein our society.Some of thebest childrenfrom the besthomes can endup in trouble.


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Before one jumps to the conclusion that Europe’srelaxed attitude is actually “healthier,” consider the factthat rates of alcohol-related diseases are similar to orhigher than the United States. The major concernwith underage drinking is underage driving. Between1970 and 1984 in U.S. history, when some states low-ered their drinking age, alcohol-related motor vehiclefatalities increased among teenagers. This has neverbeen as big a problem in Europe for two reasons. Euro-peans do not obtain their driver’s licenses until the ageof 21 years, and Europeans rely more heavily on publictransportation because of the higher cost of automo-biles and fuel and also because the public transportationsystem is more accessible.

When a person lives in one culture and then movesto another culture, culture adaptation must takeplace in order to survive in the new country success-fully. In the United States, the drinking age is 21years. Consequently, if you promote adolescent drink-ing by permitting your teenager to drink alcohol orby serving alcohol to your teen and his or her friendsin your home, you are breaking the law. If the policecatch you giving alcohol to minors, they will likelynot be interested in your cultural history. Set anexample for your children of how to be law abiding.You can still demonstrate how alcohol is used whenyou participate in a traditional celebration or festival.Thus, you can be a role model, showing the respon-sible use of alcohol. Discuss with your teen why it isnot appropriate to drink under the age of 21 years inthis culture, and share your ideas and values withhim or her. Listen to the adolescent’s opinions andconcerns (Question 78 discusses how to talk withyour children).


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80. My teenage child is taking a classtrip to Germany where drinking ispermitted. Is that a problem?Parents often feel conflicted between wanting theirchildren to spread their wings and be independent andtheir fears that their children are too young and naïveto be trusted. Parents are also wary of trusting howother people might influence their children. A poten-tial recipe for disaster is the lenient drinking and druglaws in foreign countries and unsupervised groups ofyoung people. The rising popularity of spring-breakexcursions has led to a growth in trip planners withwebsites specifically catering to this type of trip. Al-though the advertisers do not specifically condone theuse of alcohol or drugs among students, they promotethe use of these substances by advertising that anyone18 years old or older can drink alcohol legally and thatthe liquor laws are rarely enforced in many of thosecountries. They also encourage students to check outAmsterdam, which is advertised as a “pot-smokers’paradise” because of the liberal drug laws.

The concerns about your children drinking in a for-eign country are valid. The risk of binge alcohol anddrug use is high among teens. The accompanyinghigh-risk behaviors that result from these activitiescan ruin a child’s future and may take a child’s life.The general feeling on the part of the child is “thatwon’t happen to me.” Part of the focus then is toexplain that your child will be surrounded by a lot ofpeople who will be out of control and who your childhas no control over. We assume that if we are safedrivers our risk of having an automobile accident isvery low. Although it is low, we still have no control


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over other people’s driving behavior, and those otherpeople kill us at alarming rates. Exposing children tothat concept may help to a certain degree. Here issome further advice to parents:

• Do your homework, and know as much about thetrip as you can.

• Participate with school officials and the children inplanning the trip.

• Know how many chaperones there will be for thenumber of students who will be going. The suggestedratio is two adults to every seven or eight children.Each chaperone should be assigned to specific chil-dren who they are expected to accompany, even if it islate at night. Parents should get to know the chaper-ones before the trip so that they feel comfortable thatthese people will be accountable for each child’s wel-fare. The chaperones should assign each child to abuddy. Each buddy is responsible for the other.

• Volunteer to be a chaperone.• Review with your child the safety rules about drink-

ing and driving.• Warn them not go with strangers away from the stu-

dent group. Students should stay close to the peoplethey know and trust.

• Tell your children to be cautious. Parents must becandid with their children about their worriesand concerns.

• Provide alternative activities or vacations for stu-dents, such as family trips or working for humani-tarian organizations such as Habitat for Humanityas a volunteer.

• If you are not comfortable with the school plan for atrip abroad, then just say no to your child. It may bedifficult, but you probably will not regret it.


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81. My teenager has a serious problemwith marijuana. He constantly pointsout that I drink, and therefore, he doesn’tsee the problem with his marijuana use.What do I tell him?First, here are some facts about marijuana and a compar-ison of the characteristics of marijuana and alcohol: Mar-ijuana is the most common illegal drug used amongadolescents. Even if it is the most commonly used drug,most teens have not used marijuana. Marijuana sharessome of the same attributes and health consequences astobacco. Both marijuana and tobacco are plants and arecommonly smoked and consequently may damage thesmoker’s lungs. Marijuana and alcohol both have socialand economic consequences. Alcoholics often becomepoverty stricken and homeless. Chronic heavy marijuanausers who smoked beginning in high school may havetrouble graduating because of a combination of memoryloss and a lack of motivation to complete their education.Consequently, young adults who smoked marijuana and/ or drank alcohol excessively while in high school areoften unemployed.

Marijuana EffectsMarijuana has sedative, analgesic, anxiolytic (antianxi-ety), and hallucinogenic effects. It can, however, alsoprovoke anxiety and panic attacks, as it causes a rapidheart rate. Occasionally, paranoia, including frankparanoid delusions, may occur. Additionally, it maycause dizziness, giddiness, bloodshot eyes, and diffi-culty with short-term memory. Finally, it can either

Chronic heavymarijuanausers whosmoked begin-ning in highschool mayhave troublegraduatingbecause of acombinationof memory lossand a lack ofmotivation tocomplete theireducation.


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suppress or enhance appetite and suppresses nauseaand vomiting in patients suffering from serious ill-nesses, such as cancer or AIDS. Adolescents use mari-juana to achieve a mild, relatively short period ofeuphoric intoxication. Although it is not as addictiveas alcohol or tobacco, it can still lead to dependency oraddiction problems. Like alcohol, the individual effectsof the drug on each person depend on how proficientthe individual is at smoking, as well as its potency, theplace where it is used, what the user anticipates willhappen, and what other drugs it may be mixed with.

Children at this age normally compare themselveswith adults. Confronted with the teen’s marijuana useand the parent’s alcohol use, parents may need guid-ance as to how to steer the discussion in the directionthat is not defensive but is helpful. Table 17, whichcompares alcohol and marijuana, may be used to guidethe discussion. It is best for parents to stick to the factswithout exaggerating them.

One website called the Berkeley Parents Network pro-vides advice in a newsletter that reviews parental com-ments in a weekly discussion. Parents’ advice to eachother ranges from ignoring the child’s drug and/oralcohol use to being very punitive. The most cogentadvice that one set of parents gave to the others was tokeep discussions between the parents and their teensopen and ongoing. It is particularly important to findout the underlying causes of why the teen feels theneed to turn to drugs. Is it boredom, frustration withhome and/or school, feeling isolated, peer pressure, theneed for instant gratification, lack of self-confidence,


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Table 17 Alcohol and Marijuana Issues Compared

The Issue Alcohol Marijuana

Use among teensLegality

Is it addictive?

What are the affects of drinking or smokingon driving a motor vehicle?What are the statistics of accidental deaths orinjuries related to driving under the influenceof alcohol or marijuana?After drinking alcohol or smoking marijuana,how long do the effects last?What are the effects of mixing alcohol ormarijuana with other drugs?

Most teens do not drink alcohol.It is legal only for people over 21 to buy,drink, or sell alcohol in most states. It is illegalto buy or possess alcohol under the age of 21years.Yes, alcohol is physically and psychologicallyaddictive, but not everyone who drinksbecomes addicted; 100,000 people die fromalcohol addiction and its related causes eachyear.It is extremely dangerous and is the leadingcause of death among teens.One teen is killed or maimed per hour fromdriving while impaired after drinking alcohol.

They last for 1 to 2 hours per drink.

It is extremely dangerous and can lead todeath.

Most teens do not smoke marijuana.It is an illegal drug. The most important dif-ference regarding the use of the two sub-stances is the fact that it is illegal at any age tosmoke marijuana.It may be psychologically addictive and possi-bly physically addictive. Not everyone whouses marijuana becomes addicted. Marijuanais less addictive than tobacco or alcohol, but ithas serious, adverse side effects.It is extremely dangerous and is the leadingcause of death among teens.One teen is killed or maimed per hour fromdriving while stoned on marijuana.

One to four hours for the immediate effects.It takes 1 to 2 weeks to clear the body entirely.It may be dangerous, causing bodily harm.

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Table 17 Alcohol and Marijuana Issues Compared (continued)

The Issue Alcohol Marijuana

What are the effects of using either substanceon the brain and on the personality?

Can use of alcohol or marijuana cause cancerand other serious diseases?

Is alcohol or marijuana a “gateway drug,” thusleading to the use of other drugs that may beillegal?

The effects are slowed reflexes, distortedvision, memory lapses, and blackouts. Theycan eventually lead to brain damage. Judg-ment is impaired, and inhibitions lowered,leading to risky behaviors, including “at-risk”sexual behaviors. Depression may followchronic use or abuse.

Violence is frequently associated withalcohol use. Chronic use may lead to anorganic brain syndrome.Yes. Alcohol can damage every organ in thebody, risking a person for a variety of lifethreatening experiences, including cancer,liver disease, and so forth.

Teens who smoke and drink are more likely touse marijuana. People who use all three sub-stances are more likely to use other drugs.

Marijuana has similar effects as alcohol, interms of reflexes, coordination, and vision.The loss of memory and A-motivational syn-drome are both serious consequences thatadversely affect school performance. Mari-juana enhances sexual feelings, which maylead to risky sexual behaviors, resulting inadverse consequences. Depression, anxietyattacks, paranoia, or psychosis, including hal-lucinations, may follow its use.A variety of chemicals in marijuana containcarcinogens. One joint contains four times asmuch cancer-causing tar as cigarettes.

It affects the immune system leaving thebody more vulnerable to a variety of illnesses.It has not been proven that using marijuanaleads to using other drugs. It is a fact thatmost people who use illegal drugs did usemarijuana first.

Source: Adapted from the following sources: American Academy of Child and Adolescent Psychiatry, 2005; Anonymous Student, 2004; Focus Adolescent Services2001; Hyde, 2006; Long, 2005; Parents, The Anti-Drug, 2006; Tips for Teens, 2003.


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misinformation, or rebellion? After the underlyingcause is determined, then the teen and the parents canwork together toward a solution. A perfect example ofthis came from one set of parents who committedthemselves to abstinence (they previously drank winewith meals at home) in order to support their child’scommitment to abstinence. Additionally, they enteredfamily counseling and discovered that their teen usedmarijuana to relax. Consequently, healthy alternativesto marijuana for relaxation were pursued, and yoga andmeditation classes were offered to learn more appropri-ate relaxation techniques.

It is illegal to buy, sell, or possess marijuana in thiscountry, and doing any of these activities can lead toserious legal problems. Even a small amount may leadto fines or an arrest. Besides the issue of health, this isthe main reason for teens to abstain from using mari-juana. At the same time, drinking wine with dinnerand drinking responsibly, as an adult, is legal.

This may smack the teen as societal hypocrisy, and youneed to be aware that teens are ever alert to that notionand often use it as an excuse for their continued behav-ior. Society as represented by the law, however, has noregard for such allegedly ethical distinctions, and partof maturity is coming to grips with that simple fact.Continued use could place the teen’s future in jeopardyif caught by the police with an illegal substance.

It is illegal tobuy, sell, orpossess mari-juana in thiscountry, anddoing any ofthese activitiescan lead toserious legalproblems.


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82. My daughter refuses to take themedication prescribed and continues toabuse drugs and alcohol. She repeatedlypoints out that she doesn’t see anydifference between a drug that the doctorprescribed to help her moods and themore “natural” approach that she chooses.How do I counter that?One of the most common rationales teens give fortheir continued noncompliance is that they regard aprescribed psychotropic medication as synthetic andtherefore unsafe and marijuana as natural and there-fore safe. Additionally, because of that, they regard thepsychotropic effects of marijuana as a reasonable alter-native to continue to “medicate” their mood or anxietydisorder. How much of this is a lame excuse for con-tinued use as opposed to a legitimate concern dependson the teen making the claim. As mentioned in Ques-tion 81, teens are ever on the prowl for what they con-sider hypocritical thinking and behaving on the part ofadults, and this can be just another example of that.

First, the notion that because a drug is “natural” asopposed to “artificial” makes it healthier is rampant inour culture. Marketers have capitalized on this, andalternative medicine, herbal, and vitamin stores thriveon it. What makes something natural as opposed toartificial is often completely arbitrary, and the FDA hasno control over this type of labeling. Second, even whenwe are able to distinguish clearly between compoundsfound in nature from those synthesized in a laboratory,there is absolutely nothing about any particular com-pound that makes one safer than the other for that rea-


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son alone. A compound is safe or dangerous based onits actions on the body and not based on where it comesfrom. Before the development of organic chemistry andour ability to synthesize chemical compounds, plenty ofnaturally occurring compounds were available that werewell known to be either health giving or toxic. Many ofthe earliest poisons such as arsenic and strychnine arenatural. Many opiates and hallucinogens are natural.Others are manmade. The earliest antibiotics were nat-ural compounds. Many of the latest and most effectiveantibiotics are now synthesized.

Second, because an intoxicating substance is immedi-ately pleasurable, it should therefore be used to aidwith one’s mood or anxiety is a notion discussed inprevious questions (see Questions 67 and 68). Anyimmediate effects create a vicious cycle leading toaddiction and long-term negative effects as previouslyoutlined—including the underlying mood or anxietydisorder that the teen is now arguing can be treatedwith only marijuana. It is a paradox that the very sub-stance that one claims to be helping his or her moodand/or anxiety is actually perpetuating it. Trying toremind the child of this fact can often be an exasperat-ing experience. One’s memory for events preceding thedrug use and resulting mood swings is often lackingbecause of continued use. Medications used to treatthe underlying mood or anxiety disorder, alternatively,have the opposite effect on mood from marijuana oralcohol. They have little to no immediate effects andare not immediately rewarding. They have potentiallylong-term benefits; they serve to stabilize mood andanxiety over time so that the issues of drug addictioncan be dealt with more effectively. One has greateremotional resources to draw on when one’s mood andanxiety level are stable.


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Often, the issues of compliance have nothing to dowith previous reasons. If your daughter is angry withyou, what better way to express her anger than torefuse to comply? Teen rebellion is common at this ageand may be part of the reason for her noncompliance.You and your daughter can explore why she feels theneed to self-medicate with drugs or alcohol. Listencarefully without judging her. Ask her how you couldbest help her so that she does not have to turn to illicitdrugs to deal with her distress. Speak to her physicianabout the problem, and elicit his or her cooperation inworking with you to address her noncompliance. Askthe physician to discuss in greater detail the medicinehe or she is prescribing, including what it is for, how itis expected to be helpful, and how long it may take toreach its maximum effectiveness. Side effects and druginteractions should also be addressed. Let an allianceform between her physician and her so that she ownsthe decision. Help her to begin to assume greaterresponsibility for her medication and psychotherapeu-tic care so that the issue of noncompliance is less likelyto be viewed as a rebellious act against you. If, however,she still cannot comply, then a different, more compre-hensive approach is needed. The search for a drug andalcohol program for teens should be the next step.

83. I experimented with drugs andalcohol as a teen and grew out of itwithout the need for treatment. So whyare they telling me that my daughterneeds treatment?Each person’s makeup includes the genes from boththe mother and the father that are amalgamated in aunique way; therefore, a child might have a greater


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Each person’smakeupincludes thegenes fromboth themother andthe father thatare amalga-mated in aunique way;therefore, achild mighthave a greatergenetic predis-position toaddiction thaneither one ofthe parentsmay have had.

genetic predisposition to addiction than either one ofthe parents may have had. Although there is a stronggenetic predisposition to alcohol and drug abuse, itdoes not mean that a child definitely will or will notbecome addicted as an adolescent or adult. Justbecause you did not succumb to an addiction afterexperimenting with drugs as a teen does not necessar-ily protect your child from a substance-use disorder.

Other factors, including other social, psychological,and historical factors, may also increase the chancethat your child is at greater risk for addiction than you.Social factors may include immediate family issues,such as conflict, or environmental differences, such asneighborhood or school. If your family gave you emo-tional support and provided the opportunities to sub-stitute drug use with more appropriate stress releasersor you did not experience a lot of peer pressure to dodrugs or if you had specific goals that you wanted toaccomplish as a teen that were hindered by the use ofdrugs and alcohol, then it probably was easier for youto “grow out” of using drugs and alcohol than it mightbe for someone else. Peers play a critical role in thechoices that children make in their lives. Psychologicalfactors include depression, low self-esteem, depend-ency needs, inability to cope with overwhelming feel-ings of psychological pain, and a history of ASPD orhyperactivity. These traits may explain why the expertsare telling you that your daughter needs treatment.Finally, historical forces cannot be ignored. During the1960s, one marijuana cigarette contained 10 mg of theactive ingredient tetrahydrocannabinol. Today, a mar-ijuana cigarette contains 150 to 200 mg. The higherdose may lead to a stronger addiction; a strongerchance of addiction most likely means that the cravingis worse, making it harder to stop using. Thus, your

Tetrahydro-cannabinol

the psychoactiveingredient to mari-juana that gives it itshallucinogenic andappetite effects. It isalso pharmaceuti-cally synthesized andreleased under thetrade name Marinoland is prescribed asan appetite stimulantfor cancer and AIDSpatients.


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daughter and her genetic, psychological, environmen-tal, and historical makeup are different from yours andare not to be discounted.

84. I am concerned that my teenager isdrinking. I have heard about parentshaving “key parties” in their homes toensure that the teens don’t drive homedrunk. What are they?A key party is a teenage drinking party that the teenshost with parental consent; the parents also closelysupervise the teens. For example, in 2004, a parent waspresented with a request from his child for permissionto celebrate his senior prom at an all-night beer blastwith his fellow classmates. The intended party was tobe at a beach, which was 40 minutes by car from theirhome in Rhode Island. The parents were alarmed, par-ticularly at the thought of a group of inebriated teensdriving home from the beach. The family carefullyweighed the options: to say no and alienate their son,to ignore the teen’s plans and jeopardize his safety andthat of the other teens, or to negotiate a compromise.The parents knew that drinking among teenagers intheir town was common. They also knew that if theyhad a party that allowed drinking they would bebreaking the law. In an effort to keep the teens safe,however, the parents developed a compromise that wasagainst the law but prevented the teens from drinkingand driving. The parent’s inherent dilemma was safetyversus legality.

The parents proposed the following: Their son couldhave the party at his home under specific circum-

A key party isa teenagedrinkingparty that theteens hostwith parentalconsent; theparents alsoclosely super-vise the teens.


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Special Populations

stances: (1) The son’s friends would agree to give uptheir car keys after entering the parent’s home (hencethe term, key party). (2) The guests would have toremain at the home all night with their parent’s per-mission. (3) During the entire night, the father wouldbe available to collect the keys from everyone whoattended the party, stand by the door to prevent anyone from leaving after the drinking began, and moni-tor the party so that no one did anything untoward ordangerous. The parents did not participate in buyingthe beer nor did they know how the teens obtained thebeer. A young person of drinking age brought the twokegs of beer. Tents were pitched in the backyard sothat the teens could spend the night. On the morningof the party, the father stopped by the local police sta-tion to warn the police about the party; however, theneighbors complained about the noise sometime aftermidnight. Consequently, the police went to the homeand noticed the two kegs. Of the roughly 35 teens whowere at the party, most were under 18 years old. Thefather was arrested for breaking the law because alco-hol was served to minors in his home.

According to researchers, many parents think thatdrinking among teenagers is unstoppable and thechoices they must make unbearable. Many teens seedrinking as a “rite of passage to adulthood.” The par-ents may or may not agree with this, but more impor-tantly, they want to keep their children safe. Do theyrisk losing their teen in a tragic motor vehicle accidentor risk violating the law? Consequently, parents makecompromises. The following results from a survey ofseveral thousand parents and teens illustrate thesecompromises. The parents often, but not always, sup-ply the alcohol to teens.


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Harris Interactive Survey of Parents• Forty-six percent of adults believed that teens

should not be allowed to drink under any circum-stances. Seven of 10 parents of children 12 to 20years old disapprove of underage drinking.

• Three of four parents think that teens obtain alco-hol with parental knowledge and/or permission.

• One of four parents with children 12 to 20 years oldhave thought that teens should be able to drink athome with a parent present.

• One parent of four indicated that they allow theirteens to drink under their supervision. One parentof every two has served his or her teenager’s friendsan alcoholic beverage in his or her home underparental supervision.

• One parent of 10 believes that it is acceptable tohave graduation or prom parties in high schoolwhere alcohol is served, if parents are present tosupervise the party.

Survey of Teens• Nearly half of all teens surveyed reported having

obtained alcohol somewhere at some point in time.• Two to three teens say it is easy to obtain alcohol

from their parents without their parents knowing it.• One third of the teens surveyed said that they can

get alcohol from their own parents. One of fiveteenagers reported that he or she could get alcoholfrom their friend’s parents.

Source: Adapted from Grand, L. (2004). Centre for Addic-tion and Mental Health, Ontario, Canada.

The downside of allowing the teen to drink at home orhosting a “key party” is that parents are sending a dan-


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gerous message that obeying the law is an option andnot a mandate. By allowing such parties, parents arerisking not only their own welfare but also their chil-dren’s by conveying the message that it is okay to drinkalcohol under the legal age.

If you are hosting a teen party, make your policiesabout no drugs and no alcohol clear to your childrenup front. Ask them to inform all potential guests.Invite an open discussion.

Help your teen plan the party. Develop an invitationlist and invite only a specific number of people. Avoid“open” parties, and turn away uninvited guests. Invita-tions should be personal and not sent by e-mail. Putyour phone number on the invitation, and invite otherparents to call you. Include directions about parking.Set the rules ahead of time: no alcohol, drugs, ortobacco. Establish a starting and an ending time. Pro-vide the refreshments; plan them with your teenager.Let guests know that if they leave the party, they maynot return. If they arrive at your house intoxicated orwith alcohol or drugs, inform them that you will calltheir parents or the police. Plan activities such asmusic, games, movies, and Karaoke in advance. Avoiddangerous activities, such as skateboarding. Let theneighbors know ahead of time that there will be aparty. Reassure them that you will be there to super-vise. Make regular and unobtrusive visits to the roomwhere the party is taking place. Invite other parents tohelp chaperone, especially when a large number ofteenagers will be present. Provide an atmosphere inwhich teens can have fun without alcohol or drugs. Ifyour child has been invited to a teen party, call the par-ents to find out about their plans for the party. Volun-teer to help chaperone the party. Share your concerns


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with the parents. Tell your teenager that you will beavailable so that if the party is not alcohol or drugfree, you are just a phone call away. Reassure teenagersthat you want them to have fun but that more impor-tantly your main concern is safety. Parents’ firstresponsibility is to ensure that their children are safe.

85. How are men and women differentin their responses to alcohol?Traditionally, men who were the breadwinners werealso the drinkers; women did not drink in polite soci-ety, which has kept female drinking and alcohol abuseaway from public discussion. Traditionally, convention-ality characterized female roles; however, throughoutthe ages, women have used alcohol for medicinal pur-poses. Alcohol was used during childbirth. Womenwere encouraged to drink beer to enhance breastfeed-ing. Hot toddies and various fruit tonics have been usedfor menstrual cramps. A rise of alcohol consumption inwomen accompanied the rise of feminism. Changes inwomen’s roles that involve exposure to traditionallymasculine environments have provided women withopportunities to drink more openly. Today, women rep-resent a growing number of drinkers who either havealcohol problems or are dependent on alcohol. Amongyounger women, the number of drinkers is approachingthe number of men who drink.

Despite the growing numbers of women drinkers, con-tinued differences remain between the two genders.Women prefer wine, whereas men prefer beer. Men pre-fer to drink in bars and ballparks, whereas women preferto drink in restaurants or lounges. Men have more social

Today, womenrepresent agrowingnumber ofdrinkers whoeither havealcoholproblems orare dependenton alcohol.


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Special Populations

problems than women due to drinking, such as havingtrouble with the law and DWIs, damaging property, andgetting into fights. Alternatively, women tend to useeither prescription drugs or over-the-counter drugs withalcohol. Women often take sedatives or tranquilizerswith alcohol, whereas more men use cannabis andtobacco with alcohol. Women who use alcohol and drugsare more often involved with a drug-dependent partnerand/or come from drug abusing and disorganized fami-lies than men. Men tend to become more aggressive withalcohol, whereas more women suffer more depressionand anxiety, which may partly explain their increased useof sedatives and hypnotics with alcohol. Despite thesedifferences, one alarming problem for both gendersequally is driving a car knowing that he or she has hadtoo much to drink.

Although men seem to have more social problems fromdrinking, women have more adverse physical effects as aconsequence of alcohol use. They are more susceptible toorgan damage than men. This is because women absorband metabolize alcohol differently. Men, pound perpound, contain more water than women, whereaswomen have a higher proportion of body fat than men.Alcohol is water but is not fat soluble. The more waterthat is available, the more diluted the alcohol becomesand thus the less toxic it is to the brain and other organsin the body. In summary, as a result of drinking, morenegative social responses occur in men, whereas womenexperience more physically toxic effects, possibly leadingto serious health problems, such as heart disease, osteo-porosis, high blood pressure, breast cancer, ulcers, andliver disease. Gender is a strong factor in understandingthe use and abuse of alcohol.


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86. My spouse just returned from theservice over seas. He refuses to talk aboutthe time over there. He says he needs todrink because he has nightmares andtrouble sleeping. I am worried that he isan alcoholic. What can I do?Many soldiers returning from overseas are reluctant totalk about their combat experiences, making it difficultfor wives to comfort or support them. Veterans oftenthink that their wives might not understand if they talkabout their experiences. Talking about it invokes badmemories and feelings of helplessness, severe anxiety, anddistress. Many veterans are afraid that they may lose con-trol of their feelings by talking about the injuries anddeaths of their buddies. When they do talk about it, manycry, and some fear not being able to stop crying.The mostfrequently diagnosed disorder among soldiers returningfrom active duty is PTSD. PTSD is a reaction to a trau-matic event, characterized by intense emotions that canexert a feeling of “going crazy.” Studies have demon-strated that individuals seeking treatment for PTSD haveconsistently had a high prevalence of drug and/or alcoholabuse, and the symptoms of the two disorders interface tothe point that they feed off one another.

PTSD is associated with a number of symptoms,including numbness, avoidance, and re-experiencing.The symptoms feed on each other so that one intensi-fies the other. Numbness often occurs immediatelyafter the trauma and may persist. Some returning veter-ans feel numb, and if they do not feel numb, they wantto suppress whatever feelings they might have bydrinking alcohol or using other substances. Most veter-ans suffering from PTSD have few friends. Some fan-

Posttraumatic Stress Disorder (PTSD)

a mental/emotionaldisorder that is char-acterized by persist-ent distressingsymptoms lastinglonger than 1 monthafter exposure to anextremely traumaticevent.

Studies havedemonstratedthat individu-als seekingtreatment forPTSD haveconsistentlyhad a highprevalence ofdrug and/oralcohol abuse,and the symp-toms of thetwo disordersinterface to thepoint that theyfeed off oneanother.


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Special Populations

tasize living the life of a hermit in which they do nothave to be around people. To avoid their feelings, manyfurther retreat from close relationships, and normalmarital relationships, which are often the closest, sufferthe most. Consequently, there is a clinically significantdisturbance in family relationships. Re-experiencingtraumatic memories can be triggered by everyday seem-ingly trivial stimuli, such as helicopters flying overhead,the smell of urine, the smell of diesel, or the poppingsound of popcorn. These stimuli provoke anxiety, stressreactions, depression, and anger. Thoughts about theircombat experiences may intrude at any moment, makingit difficult to concentrate. They are always on the alert.Consequently, they can rarely relax and enjoy themselvesin a crowd. Very few who suffer from PTSD fall asleepeasily, and then once asleep, they have recurrent dreamsor nightmares that are related to their combat experi-ences, startling them awake.

People suffering from PTSD suffer from periods ofanxiety and chronic depression. Frequently, many vet-erans self-medicate their symptoms using drugs oralcohol. Data from a 1988 study demonstrated thatbetween 60% to 80% of treatment-seeking Vietnamcombat veterans with PTSD also met the criteria foralcohol and or drug abuse. The assumption is thatPTSD patients use alcohol and drugs to self-medicatetheir distressing symptoms. In a 1996 study, alcohol,marijuana, heroin, and benzodiazepines did help tocontrol the severity of the symptoms, but cocainemade the symptoms worse; however, over time, as thedrinking and drug using continues and tolerancedevelops, the symptoms not only increase but alsoreturn with the additional problems associated withchronic substance abuse.


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Both conditions need to be addressed, or the chance oftreatment success is minimal. Medication can assist incoping with the uncomfortable symptoms. The med-ication used most often is an antidepressant medica-tion. Occasionally, it may be one of the medicationsused in the treatment of alcohol dependence to detercompulsive drinking. Benzodiazepines are rarely, ifever, used because of their addictive qualities. Othertreatments include cognitive behavior therapy (assistspatients to reframe stressful experiences and negativethoughts into more positive thinking), hypnotherapy(hypnosis) and behavior therapy (interventions thatreinforce more desirable behaviors), desensitization(incremental exposure to stressful events as tolerated),relaxation therapy and guided imagery (both tech-niques to handle anxiety), and counseling (individual,group, and family therapy). Couples therapy is espe-cially important for PTSD veterans and their wives inorder to reverse the effects of the strained marital rela-tionship. A wife’s support and understanding of herhusband is very effective in helping him to cope betterwith the debilitating symptoms of PTSD.

The Veterans Administration (VA) has treated thou-sands of veterans and has studied and published numer-ous articles related to PTSD and substance abuse. TheVA provides specialized treatment for veterans sufferingfrom PTSD with co-occurring substance abuse disorderand has done so since the 1960s. Besides providing thetraditional approaches to substance abuse and mentalillness, they also provide outpatient groups for veteransand support groups for wives. Seek help with your hus-band at the closest VA hospital or outpatient center or


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Special Populations

look up services that might be available at a local mentalhealth center. The earlier you seek treatment the betterthe prognosis.

87. Does alcohol affect older personsdifferently?The aging process alters a person’s response to drugs ofall kinds. Metabolism is slower because of the reducedsize of the liver. Declining kidney function delays theelimination of drugs. Vulnerabilities to drug sensitivi-ties and drug interactions are due to the decline in theaging body’s water content, increased fat content,decreased lean body mass, and a diminished hepaticblood flow. There is a greater sensitivity to lower druglevels and a greater vulnerability for drug–drug inter-actions and toxicity in older adults. Consequently, astandard dose of alcohol in an older person will resultin a higher blood alcohol level because the alcoholclears the body more slowly in a 60 year old than itdoes in a 20 year old. The aging brain is also more sus-ceptible to the effects of alcohol. Concurrent use ofdrugs and alcohol can significantly change a drug’sactions that may lead to toxicity. The greater variety ofdrugs, both prescription and over-the-counter, that areused with alcohol, the greater potential there is foradverse reactions. Table 18 reflects some age relatedchanges in response to drugs and alcohol.

Statistically, alcohol and drug abuse among older personshas reached epidemic proportions and remains under-reported, undiagnosed, or ignored.The prevalence of older

Consequently,a standarddose of alcoholin an olderperson willresult in ahigher bloodalcohol levelbecause thealcohol clearsthe body moreslowly in a 60year old thanit does in a 20year old.


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Table 18 Age-Related Changes in Response to Drugs and Alcohol

Physiological Changes Response to Drugs

Less total body fluid

Increased adipose tissue

Decreased secretions in the gastrointesti-nal tract and lower gastric pHReduced liver size and decreased hepaticmetabolismReduced kidney functionsDrier oral mucosa

Higher blood levels of water-solubledrugsGreater accumulation of fat-soluble drugs(diazepam, barbiturates)Reduction in absorption

Slower metabolism results in a longerhalf-life of some drugsSlower elimination of drugsDifficulty swallowing tablets and capsules

people who have a problem with alcohol ranges frombetween 2% and 10%. Studies of older hospitalizedpatients have demonstrated much higher rates of alco-holism, ranging from 8% to 70%. Nearly half of theolder persons who are hospitalized for a medical problemare abusing alcohol, which has compromised theirhealth. Older men outnumber older women alcoholicsby 4 to 1, although women are more likely to start drink-ing heavily in mid to late life. Few are dependent onillicit drugs, although they are more likely to misuse oreven abuse over-the-counter and prescription medica-tions. The epidemiological literature examining the riskfactors as predictors for late-onset alcohol problems isextremely limited. Several studies reported that late-onset alcoholics are not likely to have family histories ofalcohol abuse, and only a few have legal or social prob-lems as compared with early-onset alcoholics. Evidenceshows that late-onset alcoholism is more likely to be theresult of maladaptive responses to stressors that are com-


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Special Populations

mon during the aging process, including social, psycho-logical, and physical changes.

Factors Associated With Drinking andOlder Persons• Social factors: social isolation, poor housing or resi-

dential changes, reduced finances, loneliness, loss ofsocial support systems

• Psychological factors: depression, grief and loss of aspouse and close friends, loss of self-esteem associ-ated with unemployment, anxiety, fears either war-ranted or unwarranted, fear of crime

• Physical factors: loss of youth, loss of mobility andstrength, decreased acuity of the senses, loss ofhealth because of either chronic or acute illnesses,such as heart disease, hypertension, diabetes, lungdisease, or arthritis

Suicide among older persons is a big problem. Twenty-five percent of those who commit suicide are older than65 years. The rate of suicide for older adults is five timesthe general population. Alcohol use is involved in onethird of older-persons’ suicides. No age group isimmune to the problems associated with the misuse ofdrugs, alcohol, over-the-counter drugs, and prescriptiondrugs, but older people have problems that are unique totheir age group.

No age groupis immune tothe problemsassociatedwith the mis-use of drugs,alcohol, over-the-counterdrugs, andprescriptiondrugs, butolder peoplehave problemsthat areunique to theirage group.


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88. We are thinking about moving to arural area to avoid the drug anddrinking problems that our children areexposed to in the city. Do ruralAmericans, especially teens, have similarproblems with alcohol or drugs?A move to a rural area will not insure that teenagers willescape the influences of alcohol and drugs. Higher ratesof substance abuse, including alcohol, tobacco, andother drugs, actually exist among rural teens. There arealso higher rates of traffic violations, such as DWIs, inrural areas. There is speculation as to whether the highernumbers of DWIs in rural areas have to do with the dis-tances traveled or the number of intoxicated drivers.Certain rural areas in the northeast, such as NewHampshire and Vermont, and the west (Nevada andCalifornia) have higher rates of alcohol and substanceabuse among teenagers than in the south. It is specu-lated that the number of individuals in the south withstrong Christian values has kept the incidence of alco-holism low. Here are some surprising statistics: Eighthgraders living in rural America are more likely to do anyone of the following than their urban counterparts:

• Smoke marijuana (34.5%)• Drink alcohol (29.9%)• Use tobacco (chewing and smoking) (50%)

Factors that may contribute to the higher rates of sub-stance abuse among rural teens are as follows:

Higher rates ofsubstanceabuse, includ-ing alcohol,tobacco, andother drugs,actually existamong ruralteens.


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Special Populations

• Higher rates of unemployment• Limited after-school activities because of distance,

weather events, and so forth• More uneducated families living below the poverty

line

Not only is the rate of alcoholism and drug abusehigher, but there are barriers to accessing health careresources for a number of reasons, including culturalbeliefs and attitudes. Stigma is associated with seekinghelp for mental illness and substance abuse. RuralAmericans believe that individuals should take care ofthemselves. A “pull-yourself-up-by-the-bootstraps”mentality exists. Maintaining confidentiality in asmall town is also difficult because there are nosecrets. There is fear that everyone will know, result-ing in shame for the entire family. Other barriers toaccessing care include a lack of qualified health careand substance-abuse professionals, fewer AA meet-ings and other substance-abuse treatment programsper square mile, long distances to get to health andmental health programs, and a lack of transportationto those services.

If you are concerned about the influence of the drugculture at your child’s school in the city, discuss yourconcerns with the teachers, the principal, other par-ents, and your child. Insist that your children attenddrug-education programs. Moving to a rural area maybe peaceful and quiet and may be beneficial for yourfamily, but it will not make your children any saferfrom alcohol and drugs. No such thing as a “geograph-ical cure” exists. Where and when you move, troubleswill be packed in your luggage along with your clothesand other belongings.


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89. I have heard the term “impairedprofessional.” Do professionals havesimilar problems with alcohol or drugs asothers? If I suspect that a professional isimpaired, what should I do?During the past few years, a body of literature has beengrowing on the impaired physician, as well as otherhealth care professionals, because of alcohol or drugabuse; however, the impaired professional may includecollege professors, lawyers, and even congressmen,besides doctors and nurses. The impaired health careprofessionals are used as a model for this discussionbecause physicians and nurses have easier access todrugs and are thus at a greater risk for being impaired. Afrequently mentioned rate of alcoholism and drug abuseamong physicians is that physicians have a greater riskof addiction by 30 to 100 times that of the general pop-ulation. Some authors dispute that figure, however,claiming that no sound data are available. Other authorsspeculate that the rate of addiction among health careprofessionals is equal to the general population. What issimilar to the general population is that men outnumberwomen in terms of excessive drinking or drugging.Some of the risk factors are the same as the risk factorsfor the general public, as are the therapeutic interven-tions. One factor other than an easy access to drugs isthe stress that is associated with the work of caring forothers, which increases the risk of professional impair-ment; however, each professional role has its uniquestressors associated with the job. All professionals have agreater sense of being invulnerable because of their abil-ity to control their own destinies. Precisely because pro-fessionals are independent, however, they are also more


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Special Populations

vulnerable because of the lack of formal controls orsupervision to monitor their job performance.

Since the late 1970s, programs have been developed toassist professionals in becoming drug and/or alcoholfree. The American Medical Association has publisheda number of articles about impaired professionals,including doctors, nurses, social workers, and lawyers.AA has developed groups that specifically target pro-fessionals. Both the American Medical Associationand the American Nurses Association have establishedprograms that are based on AA principles for theimpaired health care professional. The NationalNurses Society on Addictions has two goals: advocacyand education. During the 1980s and 1990s and today,many corporations, including hospitals, have estab-lished employee assistance programs to promote earlyidentification and intervention for employees, enablingthem to receive rehabilitation and still maintain theirjob status in the future after completion of a substanceabuse program.

Impaired professional programs serve as follows:

• Liaisons with hospitals, professional organizations,and licensing boards

• Educators about impairment among professionals• A registry of programs for recovering professionals• Investigators related to reports of impairment• Advisors regarding financial aid during treatment,

while away from the job

State licensing boards are available to the general pub-lic to respond to concerns of the possibility of animpaired professional. They will conduct an inquiry,


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and if the concern is valid, they will initiate measuresfor rehabilitation. The only down side of the investiga-tions that state professional licensing boards conduct isthat some boards have become overly zealous, actinglike tribunals that accuse a suspect of being impairedand presuming guilt without due process. State boards,however, see their mission as protecting the public andthey take that mission very seriously.

The prognosis for recovery of professionals is good,especially if the intervention is started early in the dis-ease process. Treatment entails close monitoring by apeer in the work situation, usually designated by thetreatment team or the licensing board, maintenance ofhealth promoting activities by the professional, ran-dom urine screens, regular checkups with a designatedsubstance-abuse professional, and attendance at a 12-step program. Finally, nurses may not work nightswhere there is less supervision, nor can they pass outnarcotic medications or have access to the medicinekeys, at least during the first year of recovery. Supportfrom fellow employees, family, and a 12-step programis essential for a successful recovery.

The prognosisfor recovery ofprofessionals isgood, especiallyif the inter-vention isstarted earlyin the diseaseprocess.


SurvivingAlcoholism

Will I ever be able to drink again?

I was arrested for a DUI. What should I do?

What are my rights to privacy?

More . . .

PART VII


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Moderation Man-agement (MM)

founded in 1993 asan alternative alco-holic treatment pro-gram to thetraditional AA 12-step program.

90. Will I ever be able to drink again?This will forever be the most controversial issue, par-ticularly with the growth of Moderation Manage-ment (MM) and its founder’s eventual jump to AA,followed by her causing the deaths of two people whiledriving intoxicated. MM’s primary book, ModerateDrinking, shares some important points in commonwith AA’s Big Book. Notably, it makes clear distinc-tions between problem drinkers and alcoholics: Prob-lem drinkers may be able to control their drinking,whereas alcoholics need to maintain abstinence (seeQuestion 44). This is exactly the claim that the BigBook makes. Where the two organizations differ is onwho makes the determination that someone is a prob-lem drinker versus an alcoholic. Because AA focuseson denial as a major problem with alcoholics, thenclearly an alcoholic is incapable of deciding for himselfor herself whether he or she is a problem drinker or analcoholic. Only an outside observer can determinethat. MM, on the other hand, allows its own membersto make the determination. Thus, according to AA,MM’s members are merely alcoholics in denial. AA’sgoal is absolute abstinence over the remainder of a per-son’s lifetime, and any drink constitutes either a “slip”or relapse. MM, alternatively, allows the individual todecide whether to drink or maintain abstinence.

MM members are more likely than AA members to befemale, younger, and employed. Additionally, mostMM members have never sought treatment for theiralcohol problem. They reported animosity toward AAand had no desire to participate in such a program. Anumber of individuals in MM still have evidence ofalcohol dependency, and many of those who are unable

AA’s goal isabsolute absti-nence over theremainder of aperson’s life-time, and anydrink consti-tutes either a“slip” orrelapse. MM,alternatively,allows theindividual todecide whetherto drink ormaintainabstinence.


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Surviving Alcoholism

to moderate their drinking do move toward a goal ofabstinence with some measure of success. One of thecriticisms is that, aside from inappropriately promot-ing continued alcohol use among alcoholics, morbidityand mortality will rise as a result of this type of pro-gram. Despite this criticism, the continued morbidityand mortality among AA members remains an ever-present issue, as slips and relapses are high in thisgroup as well. Remember that the founder of MM leftMM for AA in order to achieve abstinence the monthbefore her tragic accident.

Moving away from the controversial rhetoric that vari-ous groups engage in hinges on one simple question: Isalcohol reeking havoc in your life in any way? Are youusing alcohol despite all evidence that it is destroyingyour personal and professional relationships and/oryour health? If the answer is yes, then you are an alco-holic. If you are an alcoholic you need to stop drink-ing, period; otherwise, your life and/or someone else’slife are in jeopardy. Whether you can moderate youralcohol use will quickly become apparent to you and allwho you affect. You may be able to deny the obvious,but the obvious will not deny you!

91. I was arrested for a DUI. Whatshould I do?Everyone agrees that traffic-related fatalities resultingfrom alcohol intoxication are terrible tragedies thatevoke a great deal of anger, rage, and a need for retri-bution. In 2005, as a result of active lobbying efforts ofMothers Against Drunk Driving (MADD), the U.S.Congress passed a federal law requiring all states to

Mothers Against Drunk Driving (MADD)

an advocacy group ofwomen who havelost someone, usuallya child, because of adrunk driver.


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enforce a legal limit for blood alcohol level of 0.08.Overall, this has been a success in reducing the inci-dence of traffic related fatalities. The penalties for sucha violation are left up to the state. They can includesanctions such as jail, detention, and/or probation,impounding of the vehicle, license suspension, licenseplate confiscation, enforced use of ignition interlockmechanisms that require one to blow into a breatha-lyzer for the key to function, and rehabilitation pro-grams ranging from education classes to inpatientrehabilitation programs. States often modify their lawsto change behavior. For example, Minnesota foundthat 80% of drivers who lost their licenses as a result ofa DWI continued to drive. This law obviously did notachieve its goal. Thus, they began impounding theirvehicular license plates with much greater success ingetting alcoholics off the roads. Eighteen states havemandatory jail time for first-time offenders. Addition-ally, some states have the leeway of charging someonefor driving under the influence with any amount ofalcohol in their system, even if the blood alcohol levelis less than 0.08, if they fail a field test and/or are onother prescription or nonprescription medications thatmight influence their driving ability.

What should you do? First, get yourself a good lawyerin the state where the incident occurred. Because eachstate’s laws are different, you must find a crediblelawyer who knows the laws specific to your state. Sec-ond, stop drinking, and join a recovery program imme-diately. If you can show the court that you admit toneeding rehabilitation, the sentence might be lighterthan if you deny that you are having problems withalcohol or drugs.

In 2005, as aresult of activelobbyingefforts ofMothersAgainstDrunkDriving, theU.S. Congresspassed a fed-eral lawrequiring allstates toenforce a legallimit for bloodalcohol level of0.08.


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American Hospital Association

founded in 1898 torepresent and serveall types of hospitals,health care networks,and their patientsand communities.

92. What are my rights to privacy?Every patient has the right to privacy, which is 1 of 12patients’ rights that the American Hospital Associa-tion adopted in 1973 and revised in 1992. A corollaryof the patient’s right to privacy is the professional’sobligation to protect that right, which is confidential-ity. Health care professionals have always honored theethical principle of confidentiality; therefore, thepatient may disclose personal information to his or herhealth care professional without fear of it beingrevealed to others, including to family members andother professionals. Traditionally, mental health careproviders, as well as those involved with the care of thealcoholic or drug addict, have been extremely protec-tive of their patients’ rights to privacy. Maintaining anindividual’s privacy is both an ethical and legal obliga-tion.

Long-standing laws in all states and at the federal levelprotect a patient’s right to privacy and the health careprovider’s obligation to maintain confidentiality. Shar-ing information about a patient’s health and healthcare without his or her permission involves legal sanc-tions against those who have breached confidentiality.During the 1980s, the President’s Commission onMental Health recommended to Congress that thereshould be a federal law that protects a patient’s right toprivacy, especially patients who are extremely vulnera-ble, such as the mentally ill, substance abusers, and thementally retarded. Public Law 99-319 legally guaran-tees a patient’s right to privacy. No information can bereleased without the written authorization of thepatient. The patient must knowingly and specifically

Health careprofessionalshave alwayshonored theethical princi-ple of confi-dentiality;therefore, thepatient maydisclose per-sonal infor-mation to hisor her healthcare profes-sional withoutfear of it beingrevealed toothers, includ-ing to familymembers andother profes-sionals.


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Health Insurance Portability and Accountability Act (HIPAA)

the American HealthInsurance Portabilityand AccountabilityAct (HIPAA) waspassed by the U.S.Congress in 1996 andwas put into effect onApril 14, 2003.

request psychiatric and/or drug and alcohol informa-tion to be released before it can be.

In 1997, professionals from nine organizations whoserve the mentally ill worked together to develop aMental Health Bill of Rights, which further addresseda patient’s right to privacy and patient confidentiality.A patient’s right to privacy includes not only his or herpersonal information, but it also includes the relation-ship with his or her mental health and/or substanceabuse provider, except as laws dictate. Exceptions whereprivate information may be disclosed include (1) athreat to harm others; (2) issues involving mandatoryreporting, such as communicable diseases, impaireddriving, child abuse or neglect, or any other require-ment that is mandated by a particular jurisdiction; (3)in some states, a court-ordered or court-subpoenaedrecord that may be released to the court without thepatient’s written permission; (4) hospitals and medicaloffices that may release minimally necessary healthcare information without the patient’s written permis-sion for the purposes of diagnosis, prognosis, type oftreatment, time, length of treatment, and cost, particu-larly in emergency situations. An additional exceptionhas been mandated under the recent Patriot Act,whereby health care providers may disclose informa-tion without the patient’s permission to authorizedofficials conducting security investigations.

A recent law that governs the right to privacy is theHealth Insurance Portability and Accountability Act(HIPAA). This went into effect April 14, 2003, andprovides stringent legal penalties for health care insti-tutions or professionals breaching confidentiality. Theinitial intent of HIPAA was to allow people to main-

A recent lawthat governsthe right toprivacy is theHealthInsurancePortabilityandAccountabil-ity Act(HIPAA).


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tain their healthcare insurance after termination ofemployment and to decrease the exclusions for pre-existing conditions. HIPAA also mandated thatpatients have the right to make informed decisionsabout their health care, which is another ethical princi-ple called informed consent. The law provided furthercontrols over Medicare fraud and abuse and standard-ized the electronic claims system between providersand third-party payers. Patients also have the right toview and amend their healthcare information by sub-mitting a written request. Patients not only have theright to access their medical records, but they also havethe right to know who else has access to them. Inaddition, over time, HIPAA has become known forprotecting patient’s privacy. Before being seen eachtime by the health care provider, the patient is issued anotice of privacy that must be read and signed.

If your right to privacy may have been violated, youcan contact the privacy officer of the institution whereyou believed the violation occurred. You can also con-tact the Center for Mental Health Services, who canprovide information about the protection and advocacyagency in your state.

93. I am worried about my employerfinding out about my treatment. Howcan I prevent his or her finding out?All employees need to know that they are under noobligation to disclose medical information, whetherthey are seeking employment or are currently em-ployed. Many job application forms request informa-tion about mental illness. The employers may requestinformation about a gap in employment, and because


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many employers pay the medical bills, employers fre-quently feel that they have a right to know an em-ployee’s medical history. If treatment requires timeaway from work, some medical information may needto be released in order to justify the time off.

The information given to an employer is strictly at theemployee’s discretion. If a health care professional orhealth care institution shares information with theemployer without permission, legal sanctions may beinvoked that will penalize the provider. The threat oflegal sanctions should prevent the employer from find-ing out about your health status. The legal sanctionsare described Question 92.

Many patients fear that they will be fired if anemployer finds out about their history of alcoholism ordrug addiction. The American Disabilities Act is afederal law that was passed to protect patients withdisabilities from being fired because of a specific dis-ability. The American Disabilities Act of 1990 makesit unlawful to discriminate against an employee if he orshe is a qualified individual with a disability. A disabil-ity is defined as “a person who has a physical or mentalimpairment that substantially limits one or more majorlife activities, has a record of such impairment or isregarded as having such impairment” (U.S. EqualEmployment Opportunity Commission, 1991). Thislaw also applies to people with mental disorders,including addictions. If the disabled person is the mostqualified person among all of the applicants, thenaccommodations must be made, such as job restructur-ing, modifying work schedules, and acquiring or modi-

American Disabili-ties Act

title I of the Ameri-cans with DisabilitiesAct of 1990 tookeffect July 26, 1992.It prohibits privateemployers, state andlocal governments,employment agen-cies, and labor unionsfrom discriminatingagainst people whohave physical ormental disabilities injob application pro-cedures, hiring, fir-ing, advancement,compensation, jobtraining, and otherterms, conditions,and privileges ofemployment.


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Family Medical Leave Act (FMLA)

the U.S. Congresspassed this act in1993 with the goal ofproviding employeeswith a balanced lifebetween family andwork.

fying equipment. According to the American Disabil-ities Act, employers cannot discriminate in their hir-ing and firing practices based on medical information.The law specifically prohibits an employer from ask-ing questions about a person’s disability during anemployee’s job interview unless the questions aredirectly related to job requirements. The same princi-ple remains true after the prospective employee ishired.

Current laws protect employees from unwanted disclo-sures to employers, which should prevent the employerfrom finding out about your alcoholism or drug addic-tion. In this case, the law prevents your employer fromfinding out about your medical status.

94. My employer ordered me intotreatment or risk getting fired? What aremy rights?Employees need to know that disciplinary actions mayoccur, including dismissal, if the employee’s job per-formance has been compromised as a result of alcoholor drug abuse. Employers may offer time off to seektreatment and a return-to-work agreement. The Fam-ily Medical Leave Act (FMLA) may also cover theemployee’s ability to take a temporary leave of absenceto seek treatment for alcohol and drug addiction. Youare eligible to take time off without pay to get treat-ment under these circumstances:

1. Your employer has 50 or more employees.2. You have been employed at least 12 months or

worked in excess of 1,250 hours.

The FamilyMedicalLeave Act(FMLA) mayalso cover theemployee’sability to takea temporaryleave ofabsence to seektreatment foralcohol anddrug addic-tion.


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3. Your employer must continue your health insur-ance coverage, but you must pay your share of thepremium.

4. You may or may not return to the same job, but itshould be an equivalent position.

5. You must give notice 30 days in advance of yourintention to go on medical leave.

6. You do not have to reveal a great deal of confiden-tial information, but the employer has the right toknow enough of the facts in order to discern thatyour reason is covered by FMLA.

7. The health condition must be serious enough towarrant inpatient care in a hospital, hospice, or res-idential medical facility or continuous treatment bya health care provider.

8. You may be required to provide a physician’s certifi-cation that you are in need of continuous treatment,with the date on which the condition began, itsprobable duration, and the pertinent medical facts.

If written notification has been given to the employee,the employer also has the right to require a fitness-for-duty exam before the employee returns to work.

If your employer ordered you to get treatment or befired, you have the following rights:

• The right to not be unfairly dismissed• The right to refuse treatment• The right to privacy• The right to be absent from your job, while seeking

treatment, under the FMLA guidelines, if you andyour employer qualify


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It is also your right not to tell your employer whetheryou are receiving treatment and still remain on the job.Your job performance, however, must meet the requiredstandards.

If your addiction is interfering with your job per-formance, take your employer’s offer to seek treat-ment rather than be fired. Employers have the rightto take disciplinary action based on job performanceproblems that result from an employee’s alcohol ordrug abuse. Negotiate with the employer on theamount of time away that you will need to get therequired treatment. Determine what you must changein order to meet his or her expectations regardingyour job performance. Take the offer: Save your job,and save your life!

95. What is co-dependency? How do Iknow if I am co-dependent, and whatcan I do about it?Co-dependence is a concept that developed after thedisease model of alcoholism took hold in the 1960s.Until then, the focus of treatment was on the alcoholicpatient and excluded the family. At that time, thespouse was labeled as the chief enabler, which includedtrying to control the alcoholic’s behaviors, picking upthe pieces from the adverse consequences of the alco-holic’s behaviors, or rescuing the alcoholic from theadverse consequences. It was discovered in addictiontreatment centers that not only did the individual suf-fering from the addiction need treatment, but his orher family members needed treatment as well. In treat-ing the alcoholic or drug addict, the clinicians noticed

Co-dependence

a maladaptive copingpattern in familymembers who areclosely related to asubstance abuser orexperience a pro-longed exposure tothe behaviors of thealcoholic- or drug-dependent person(s).


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that the family members had specific characteristicsand behaviors in common.

The co-dependent is not sick because of the alcoholic’sbehaviors but because he or she is attracted to thealcoholic. The attraction is because of the co-dependent’s own defense mechanisms that were devel-oped during childhood. These behaviors may be eitherpassive or aggressive and are reactions to childhoodtrauma. The characteristics of co-dependency includelow self-esteem, self-defeating behaviors, distortedthinking, problems in expressing feelings, difficultieswith relationships, and the disowning of one’s ownneeds in order to respond to external demands (being amartyr). People who are at risk for co-dependencyinclude spouses of addicts, recovering addicts, adultchildren and grandchildren of addicts, professionals incaretaker roles, such as nurses, families with a secret,and people raised in a co-dependent family. Co-dependent families have unwritten rules that encour-age self-deception and manipulation. The rules includethe following:

• Don’t feel—just smile.• Always be perfect.• Don’t embarrass the family.• Loyalty is everything.• Don’t have fun.• Don’t ask for help.• Don’t tell family secrets.

If you are a spouse of an addict, come from an alco-holic family, are a professional caretaker, or come froma family who has a secret that family members hide

The character-istics of co-dependencyinclude lowself-esteem,self-defeatingbehaviors, dis-torted think-ing, problemsin expressingfeelings, diffi-culties withrelationships,and the dis-owning ofone’s ownneeds in orderto respond toexternaldemands(being a mar-tyr).


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from themselves and each other but everyone knowsabout, you may be at risk for being a co-dependent.Treatment for codependency includes helping the co-dependent do the following:

• Express your feelings and own up to your own real-ity.

• Acknowledge your needs and wants.• Grieve the past and accept your family’s dysfunc-

tional behaviors, while seeing their assets.• Identify your strengths and build on them to

enhance your self-esteem.• Develop healthy relationships.• Refrain from rescuing other people, especially at

one’s own expense.• Learn to communicate clearly and directly.

Many programs for co-dependents also follow theAA’s 12 steps. Many books about co-dependency areavailable to the general public. Recovery from co-dependency involves an increased self-awareness, aswell as more open and honest expression of feelings,recognizing one’s own needs with a focus on self-careand self-nurturing. Individual psychotherapy and/orcounseling may help the codependent accomplish this.Joining a 12-step program is also beneficial. Develop-ing healthy relationships with others and with a higherpower, as in all of the 12-step programs, can provide agreater sense of self during the recovery process. If youthink you may be a co-dependent and you tend to res-cue others at your own expense, deny your ownthoughts and feelings, and feel that your life hasbecome unmanageable because of the unhealthy rela-tionships that you are involved in, seek out a support


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group. Support groups include Al-Anon, Alateen, Co-Dependents Anonymous (CoDA), and Adult Childrenof Alcoholics Organization (ACoA), which are 12-stepprograms in the tradition of AA but are designed forthe family and friends of alcoholics. They offer the nec-essary support for these individuals regardless ofwhether their loved one is recognizing their problemand is in treatment. In fact, these programs are espe-cially beneficial to those whose family member remainsin denial, as they are especially in need of support andguidance during these initial stages of intervention.There are obvious overlaps between AA, CoDA,ACoA, Alateen, and Al-Anon. Try them all out beforedeciding which group has the strongest fellowship andthe most frequent meetings in your community.

96. My family member is an alcoholicand refuses to get help. What should Ido?Aside from joining a support group, you may wish totake several steps to help your loved one. The realchallenge will be to broach the subject of the use ofalcohol or drugs in a nonthreatening and nonjudg-mental way. First, you may wish to consider alternativeways of discussing the problem. Second, discuss withyour family member his or her experiences with alco-hol during the past, including childhood. What werehis or her parents drinking habits? Describe variousstrategies for coping with stressful situations, both inthe past and now. Talk about alcohol as a way of cop-ing, which may have worked initially but is currentlyleading to unacceptable behaviors. When linking hisor her alcohol use with negative coping behaviors, use


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open-ended questions so that you do not seem accusa-tory or threatening. These allow for discussion and donot end with yes or no answers. If he or she acknowl-edges that alcohol use may be a means of dealing withan emotional problem, such as depression, then sug-gest that your spouse seek counseling or the care of apsychiatrist. Third, if your spouse does not acknowl-edge a problem, you may leave pamphlets from variousalcohol treatment organizations around the house forhis or her information. Next, if he or she still refuses toget help, you may need to suggest a separation or pro-pose some other drastic measure, which may be inter-preted as coercion. It is not coercion in so far as youare giving that person a choice, albeit with specificconsequences that impact on both of you.

The issue is you and your loved one’s health and safetyor chronic illness and potential death. Do not threaten!Be prepared to set up a set of consequences and thenfollow through with them. When you lay out the con-sequences, be sure to use “I” messages, which conveyless blame. The following is an example of an “I” mes-sage: When you become verbally abusive after you havehad a couple of drinks (the behavior), I feel helpless,and my feelings are hurt; then I get depressed (yourfeelings). If you continue to verbally abuse me and donot stop drinking or get help for yourself, then I willhave to leave for the sake of my own mental health (theconsequences). The formula for “I” messages:

When you _____ (describe the behavior).

Then I feel ______ (describe how you feel).

Consequences ___ (describe what the conse-quences will be).


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If repeated attempts to talk to one’s family memberabout the problem have failed, it is then time for action.Remember that ultimately one individual has little con-trol over the behavior of others. Someone sufferingfrom alcoholism cannot be coerced into treatment. Inthat context, separation is a legitimate measure to pro-tect yourself from the dangers of continued heavydrinking. It is critically important to stop bailing theperson out from alcohol-related problems. This onlystrengthens the denial and perpetuates the problem, asthe person never fully appreciates what dangers his orher alcohol or drug use is causing.

Many clinicians think that addiction is a family illnessbecause it affects each and every member of a family;therefore, individual and family therapy are essentialingredients to recovery as well as attending supportgroups. Recovery takes a lifelong commitment on thepart of the individual and the family. The prognosis isbetter if family members also participate in treatment.Finally, consider doing an intervention. Many of theseorganizations have resources that can help you conducta group intervention. It is best to use a professionalintervention specialist to guide the process and supportyour family in confronting the alcoholic’s denial. In aprivate meeting with family members, friends, employ-ers, and coworkers, along with an intervention special-ist, confront the abuser about the problem that drinkingand/or drugging are causing him or her personally athome and at work, as well as the effects on his or herbody. The facts and the objective evidence are pre-sented in a calm nonemotional manner. During theintervention, the family and others also identify theconsequences that will occur if the behavior continues

Many clini-cians thinkthat addictionis a family ill-ness because itaffects eachand everymember of afamily; there-fore, individ-ual and familytherapy areessentialingredients torecovery aswell asattending sup-port groups.


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and the addicted family member refuses to get help(see Question 46 for further information).

97. What is the impact of alcoholism onchildren?Most co-dependents are children of alcoholics, but notall come from alcoholic families. Some may havegrown up in dysfunctional families who had otherproblems, such as poverty or a mental or physical ill-ness. Adult children of alcoholics grow up physically—but emotionally, psychologically, and spiritually, manystill function on a developmental level that is appropri-ate for a young child. ACoAs have never learned a“normal” way of thinking, feeling, or reacting. Theirparents never grew up to be responsible, integratedadults. Consequently, ACoAs have never had appropri-ate role models to emulate. Frequently, childhood traumahas compromised their adult relationships, career tra-jectories, and marriages. For example, because theyhave never seen a functional parental partnership inaction, they tend to have poor parenting skills, andoften the cycle of alcoholism continues from generationto generation unless it is broken by an intervention.

Characteristics of Alcoholic Families• Low levels of cohesion• Lack of the expression of love and caring for each

other• Poor communication• High degree of conflict• Inconsistent parenting• Lack of routine, such as meal and bed times

Adult childrenof alcoholicsgrow up physically—but emotion-ally,psychologi-cally, andspiritually,many stillfunction on adevelopmentallevel that isappropriatefor a youngchild.


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• Lack of traditions and rituals, such as celebratingEaster or 4th of July

• Chaotic family systems with loose boundariesbetween family members, often with role reversalssuch as a child parenting the alcoholic parent

• Rigid boundaries between the family and the com-munity to hide the alcoholism and maintain afaçade of normalcy

Young Children of AlcoholicsYoung children have a tendency to blame themselvesand feel guilty for their parents drinking. They worryabout their parents, fearing that they might get sick orinjured and get anxious when their parents fight. Theymay perpetuate the lie that their family life is normaland are ashamed of their parents, thus avoiding havingfriends play at their homes. Because of the manypromises that are broken by inconsistent parenting,they do not trust other people. Other characteristicsmay include the following:

• Failure in school or truancy and poor high schoolgradation rates

• Lack of friends and withdrawal from classmates• Difficulty having fun• Judging one’s self mercilessly, resulting in poor self-

esteem• Delinquent behavior, such as stealing or violence• Frequent physical complaints, such as headaches or

stomachaches• Abuse of drugs or alcohol• Anger and aggression toward other children• Impulsivity, risky behaviors, and a lack of self-

discipline• Mistrusting adults and authority figures


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• Being super responsible or very irresponsible• Depression, suicidal thoughts, or attempts

Adult Children of AlcoholicsThe roles that children assume are sometimes func-tional within an alcoholic family system, but the dangeris that ACoAs will continue these same behavior pat-terns, enacting roles that are no longer functional asadults. ACoAs often stay in abusive relationshipsbecause of their own lack of self-esteem, their comfortwith chaos, their fear of abandonment, and/or theirsense of unfailing loyalty. They frequently remain loyaleven in the face of evidence that the loyalty is unde-served. Because of their past experiences with their par-ents who disappointed, hurt, or abused them, ACoAsoften perceive themselves as victims and may continueto play the roles of martyr or victim as adults. ACoAslearn other roles in order to adapt to chaotic family pat-terns. The following are some of the roles that are iden-tified in the literature on alcoholism. The behaviorsassociated with each role may persist into adulthood.Table 19 provides a list of roles that children adopt inorder to cope within alcoholic families.

Each family member plays a role in order to keep thefamily system in balance, which is true in all families.The difference between a “normal” family and an alco-holic family is that the roles in the dysfunctional fam-ily tend to be rigid and not interchangeable. Therefore,dysfunctional behavior problems persist into adult-hood; thus, the enabler continues to rescue others. Thehero continues to excel at all costs to himself or her-self. The scapegoat continues to set himself or herselfup as the victim of abuse or follows in his or her par-ents’ footsteps by drinking or drugging. The mascot


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Table 19 Adopted Roles to Cope Within Alcoholic Families

• The Enabler. The family member who helps, supports, and allowsthe substance abuse to continue by “saving” the abuser from the con-sequences of his or her behavior and then covering up the mistakes.The enabler may deny the alcoholism, but the child or spouse mayfeel angry and helpless to control the situation. He or she makesexcuses for the alcoholic’s behaviors. The enabler has learned to be a rescuer.

• The Hero. The sibling who excels in academics and sports in order tocompensate for feelings of inadequacy and guilt and to create the illu-sion of a successful family. The hero may also be the super responsiblefamily member who takes care of both the parent(s) and the otherchildren in the family, thus assuming the adult parental role.

• The Scapegoat. The sibling who acts out his or her anger by display-ing unacceptable behaviors. The behaviors may include delinquencyor substance abuse. This person allows the rest of the family tobelieve that the family problems are because of his or her acting outbehaviors. The scapegoat may be the child who brings attention tothe family so that family may be required by the school or lawenforcement to seek help for this child. They are inadvertently discovered to be an alcoholic family.

• The Mascot. This child is the comedian who diverts the attentionaway from the alcoholic and the family to himself. His or her diver-sionary tactics defuse the anger that everyone in the family feels byproviding comic relief.

• The Lost Child. This child is the family member who never causes a problem and is relatively invisible. The lost child has also beenlabeled the placater because he or she is sensitive to the needs of oth-ers and is often sympathetic to the alcoholic parent. The lost childmay not only be a placater, but also an adjuster who easily followsdirections and doesn’t draw attention to him or herself. This child is protected from the family’s anger and blame because the lost child is the unnoticed child who avoids the family’s hostility.

plays the comedian as an adult, and the lost child tendsto remain isolated as an adult, under everyone’s radar.The impact of having an alcoholic parent has lastingeffects on children, as they continue to play out theirassigned family roles. The good news is that if you area child of an alcoholic, a number of self-help groupsare available, as mentioned in the previous question.Sometimes depression hampers progress. If that is the


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case, psychotherapy and/or antidepressant medicationsmay give the ACoA the boost in energy to work on hisor her lifelong problems.

98. What resources are available forwomen whose spouses are alcoholic andabusive?Spousal abuse as well as child abuse is highly corre-lated with alcoholism. Domestic violence occurs in allcultures, races and ethnicities, religious, and socioeco-nomic groups. Many clinicians and researchers believethat violence is a learned behavior, role modeled by theparents and perpetuated in the next generation. Achild raised in a home with physical abuse is muchmore likely to be abusive as an adult or to tolerate anabusive spouse. Women are more likely to be the vic-tims than men and when attacked by men, theirinjuries are more severe. Men, however, can also bevictims of spousal abuse, but are less likely to reportabuse or to seek help. Another alarming fact is that50% of men who assaulted their wives also abusedtheir children. Seventy-five percent of spousal abusereports stated that the offender had been drinking. Astudy of spousal abuse by male U.S. army soldiersfound that domestic violence was more prevalent infamilies where the soldier drank heavily. A large per-centage of women who abuse alcohol or drugs arereported to have been abused either physically or sexu-ally as children. The result of early childhood abuse ispoor and inadequate coping skills and severe psycho-logical problems such as chronic anxiety, depression, orPTSD.


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There is no one explanation as to why women staywith their abusers. Usually these relationships start outloving and down the road the first incidence of vio-lence occurs, leaving the woman stunned and the manapologetic; however, the cycle frequently is repeated,and the spouse is ashamed, begins to blame himself orherself, and feels trapped. There are some things youcan do if you find yourself in a cycle of violence. Planahead when you may or may not need an escape route.Pack a bag and hide it from your spouse. Include inthe bag a change of clothes, a set of car and housekeys, bank account numbers, birth certificates, insur-ance policies and numbers, marriage license, valuablejewelry, important telephone numbers, and money. Tryto contact resources ahead of time. Seek support from12-step programs for wives of alcoholics. Get supportfrom multiple sources, Al-Anon, Crises Centers, theclergy, and other community organizations. This willempower you to do what is best for you and your chil-dren.

99. What are my rights to refusetreatment?Treatment for alcoholism and drug abuse is most oftendone in the community, except for detoxification froma substance, which usually takes place in a hospital.Hospitalizations occur when either the patient’s life isthreatened during the withdrawal period or because ofsome other threat to safety, such as threatening vio-lence, as in child abuse or spouse abuse. Unlike mosthospitalizations where the issues of safety trumpautonomy (the right to self determination), the rightto refuse treatment is sacrosanct in all of health care.

Treatment foralcoholism anddrug abuse ismost oftendone in thecommunity,except fordetoxificationfrom a sub-stance, whichusually takesplace in a hos-pital.


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In general, patients have the right to refuse medical orpsychiatric treatment, short of emergency hospitaliza-tions for reasons of safety.

Informed ConsentWhen a patient agrees to treatment, he or she must beable to sign a form regarding informed consent thatstates that he or she understands the proposed treat-ment plan and the reasons for it. The process ofobtaining informed consent includes the following:

• Assessment of the patient’s capacity to make med-ical decisions

• The absence of coercion• The patient who has been fully informed of the

diagnosis, prognosis, risks, and benefits of the treat-ment and who has been informed of alternativetreatments as well as the risks versus benefits of notreatment

The health care provider should test the patient’sunderstanding of the explanation in order to be certainthat he or she clearly understands it. All relevant fac-tors, including what was disclosed, the patient’s com-petency, and the agreement to treatment, plus theactual consent form, should be stored in the patient’smedical record. Exceptions to informed consent doexist, however.

• Emergencies, such as alcohol withdrawal syndromeor impending DTs

• Court-ordered evaluations• Therapeutic privilege waiver


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• A patient who is unconscious and in need of life-saving treatment

• A patient who is incompetent• Child abuse proceedings

Therapeutic privilege occurs when the physician with-holds information from the patient because he or shebelieves that informing the patient will cause moreharm than good. Occasionally, patients waive the rightto know. It is a good idea for the health care provider toenlist the aid of a family member to make decisionswhen the patient refuses to participate in his or herhealth care decisions. Consent is implied when he orshe actively participates in the treatment; for example,the patient offers his or her arm to have blood drawn(Albrecht & Herrick, 2006). When refusing medicationor treatment, it is important that the patient under-stands the potential consequences.

The Elements Necessary to Refuse TreatmentIf you are refusing a lifesaving treatment, your physi-cian is responsible for ascertaining that you clearlyunderstand the refusal. He or she may request a capac-ity determination. This entails a psychiatrist’s formalevaluation of your capacity to make such a decision.The capacity to refuse treatment requires four ele-ments:

• The ability to express a choice• The ability to understand the treatment options and

their consequences• The ability to appreciate the information as it

applies to one’s specific situation• The ability to make reasonable judgments regarding

the information


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These four elements must be met for a patient to havethe capacity to decide on medical or psychiatric treat-ment or to refuse it. It is important for the health careprovider to sort out each of these elements. An emer-gency conservatorship may be required to help makethe necessary decisions to save the patient’s life if it hasbeen determined that the patient lacks capacity tomake decisions regarding his or her health and/orfinances. Usually a family member is appointed as theconservator.

Life-Threatening ConditionsA few life-threatening situations occur in the treat-ment of alcohol and drug abuse. Severe symptomsfrom the sudden and untreated withdrawal of a drugor alcohol, and DTs can be life threatening. Anotherlife-threatening situation may be when someone’sbehavior is out of control and he or she is threateningviolence—the patient is a danger to self or others. Ifsafety is at stake—to the patient, someone else, orsociety—then hospitalization or treatment may berequired without the patient’s permission.

At this point, the patient may not be capable of makingan informed decision, particularly if he or she is still indenial that there is a problem and is threatening harm toself or others, is intoxicated, or has the DTs. Under thesecircumstances, the decision to treat or hospitalize thesubstance abuser will be made in the best interests of thepatient, the family, and society. If safety remains a con-cern even after a patient is no longer intoxicated or inactive alcohol withdrawal, the health care provider orphysician may turn to the courts for guidance. The courtcan order treatment for an unwilling patient to be admit-ted to a hospital and/or to be treated. The legal proce-dures for this vary from state to state. In most states,


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treatment can be provided without a patient’s consentonly if the patient remains an immanent threat to self orothers. After this threat has resolved, then only a courtcan intervene to order a patient into a rehabilitation cen-ter and generally only after the patient has broken thelaw and the matter involves an alternative to sentencing.Otherwise, no state allows a patient to be civilly commit-ted to a drug or alcohol rehabilitation program.

In summary, you have the every right to refuse treat-ment. The right to refuse treatment is a valued ethicalprinciple that all of the health professions honor. It isone of many of the rights that the American HospitalAssociation’s Patient’s Bill of Rights lists. The rights ofpsychiatric and substance abuse patients are posted inmost treatment settings. If you refuse treatment, youmust consider the consequences to you and to yourfamily. Study the risk/benefit ratio carefully beforemaking the decision. Also, be aware that if your behav-ior or medical condition is life threatening, physicianshave an obligation to admit you to the hospital forobservation and treatment, especially if the treatmentis life saving.

100. Where can I get more information?Many resources are available through organizations,websites, and publications. A partial list is included inthe appendix.


AppendixOrganizationshttp://alcoholism.about.com/www.nlm.nih.gov/medlineplus/alcoholism.htmlwww.aca-usa.org/www.alcoholismtreatment.org/www.naadac.org/www.medicouncilalcol.demon.co.uk/www.collegedrinkingprevention.gov/www.soberrecovery.com/www.substancereview.com/www.mentalhealth.com/dis/p20-sb01.htmlwww.ModerateDrinkingPrograms.comwww.aarecovery.com/alcoholism.htmlwww.recoverymd.com/www.drunkdrivingdefense.com/alcoholism.htmwww.aa.org/www.ncemi.org/cgi-ncemi/edecision.plhttp://www.whitehousedrugpolicy.gov/http://www.streetdrugs.org/http://www.drugsense.org/html/http://www.alcoholpolicymd.com/alcoholpolicymd/index.htmhttp://www.mentalhealthchannel.net/alcohol/diagnosis.shtmlhttp://www.alcoholconcern.org.ukhttp://www.nida.nih.gov/http://www.codependents.org/

APPENDIX

39189_APPx_Herrick.qxd 11/29/06 9:54 AM Page 257

http://www.projectmainstream.net/http://historyofalcoholanddrugs.typepad.com/

alcohol_and_drugs_history/www.asam.org/http://www.aahistory.com/http://www.pamf.org/teen/parents/risk/alcohol.htmlhttp://www.madd.org/under21/4254http://parents.berkeley.edu/advice/teens/marijuana.htmlwww.theantidrug.com/

Organizations and HelplinesThe National Center for Victims of Crime: 1-800-FYI CALL

(394-2255)National Domestic Violence Hotline: 1-800-799-7233 or SAFE

(1-800-787-3224)National Organization for Victim Assistance: 1-800-TRY

NOVA (1-800-879-6682)

Al-Anon, Alateen, and Other ResourcesAl-AnonP.O. Box 862Midtown StationNew York City, NY 10018Phone: 1-800-344-2666

Alateen(For teens who are worried about someone else’s drinking)P.O. Box 862Midtown StationNew York City, NY, 10018Phone: 1-800-344-2666

Alcoholics Anonymous (AA)General Service OfficeP.O. Box 459Grand Central StationNew York City, NY 10163Phone: 1-212-870-3400

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Families AnonymousP.O. Box 528Van Nuys, CA 91408Phone: 1-800-736-9805 or 1-818-989-7841

Hazelden Center for Youth and Families11505 36th Avenue NorthPlymouth, MN 55441-2398Phone: 1-800-257-7800

Narcotics Anonymous (NA)World Service OfficeP.O. Box 9999Van Nuys, CA 91409Phone: 1-818-780-3951

National Council on Alcoholism and Drug Dependence, Inc.12 West 21st Street, 8th floorNew York, NY 10010Phone: 1-212-206-6770

ReferencesAlbrecht, A. T., Herrick, C. 100 Questions and Answers About

Depression. Sudbury: Jones and Bartlett, 2006.D’Alesandro, D., Huth, L. (April 2002). Kids and Alcohol: Com-

mon Question and Quick Answers. Virtual Pediatric Hospital.Retrieved February 20, 2006. Available from: http://www. virtualpediatrichospital.org/patients/cqqa/alcohol.html

Hazelden Foundation. Parents Can Help Kids Stay Alcohol-Free:Parents Can Take Advantage of “Teachable Moments.” RetrievedFebruary 20, 2006. Available from: www.hazelden.org/ servlet/hazelden/cms/ptt/hazl_alive_and_free.html

Higher Education Center. (n.d.). Eight Points for Parents.Retrieved February 20, 2006. Available from:www.edc.org/hec/parents/8points.html

Homeier, B. P. (March 2005). Kids and Alcohol: Kids Health forParents. Retrieved February 20, 2006. Available from:http://kidshealth.org/parent/emotions/behavior/alcohol.html

Homeier, B. P. (May 2005). Talking to Your Child About Drugs.Kids Health for Parents. Retrieved February 20, 2006. Availablefrom: http://kidshealth.org/parent/positive/tlk/talk_about_ drugs.html

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Appendix


How to Talk to Children About Alcohol and Drugs. (n.d.). RetrievedFebruary 20, 2006. Available from: www.tcda.state.tx.us/ issues/straigttalk/hml

Kuhn, C. (2002). A Scientific Approach to Talking With Kids Alco-hol. Contact source: [email protected]. Retrieved February 20,2006. Available from: dukemednews.duke.edu/av/medminute. php?id=5332

Leadership to Keep Children Alcohol Free. (n.d.). Retrieved Febru-ary 20, 2006. Available from: www.alcoholfreechildren.org/gs/pubs/html/Prev.htm

Palo Alto Medical Foundation. (2004). Teens and Alcohol.Retrieved February 20, 2006. Available from: http://www. pamf.org/teen/parents/risk/alcohol.html

Set Rules: How Strict Should Parents and Caregivers Be? Talking toYour Children About the Dangers of Alcohol, Tobacco and IllegalDrugs. (n.d.). Retrieved February 20, 2006. Available from:family.smhsa.gov/set/moreArticles.aspx

Stephens, D., Dudley, R. (December 2004/January 2005). “TheDrunken Monkey Hypothesis.” Natural History.

Talk to Your Kids as Families Watch TV Together. Tips for Parents.(n.d.). Retrieved February 20, 2006. Available from: www.texasdwi.org/kids.html

Talking to Your Kids About Alcohol. (n.d.). Retrieved February 20,2006. Available from: www.adhl.org/clearinghouse

Teach Your Children Well. (n.d.). Retrieved February 20, 2006.Available from: http://www.madd.org/under21/4254

What Can Parents Do to Help Their Children Be Drug Free? (Feb-ruary 20, 2006). Retrieved February 20, 2006. Available from:http://www.yic.gv/drugfree/whatparent.html

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GLOSSARY

Glossary

Acetylcholine: The first neurotrans-mitter discovered. It is found in boththe peripheral nervous system and thecentral nervous system. In the periph-eral nervous system, it is involved inboth muscle contraction as well as thatpart of the involuntary nervous systeminvolved with “rest and restoration.” Inthe central nervous system, it is in-volved with memory function.ACTH: Adrenocorticotropic Hor-mone. A hormone released by the pi-tuitary gland, which stimulates theadrenal glands to release adrenalin.Adrenalin is a stress response hor-mone that has a multitude of meta-bolic effects including alterations inblood pressure, heart rate, and musclemetabolism involved in the “fight orflight” response in the involuntary orautonomic nervous system. It also re-verses inflammatory reactions.

Agonist: A drug capable of combin-ing with a receptor on a cell and initi-

ating a reaction or activity. The drugmay produce the same biological ef-fect as the neurotransmitter itself.

Alcohol: an organic chemical thatconsists of carbon, oxygen, and hy-drogen.

Alcohol dehydrogenase: An enzymethat is a biological catalyst that accel-erates the breakdown of alcohol intoaldehyde, responsible for many of thenegative effects of alcohol.

Alcohol-related neurodevelopmen-tal disorder (ARND): A disorder inthe development of the nervous sys-tem in a fetus. It is related to the ex-posure of the fetus to alcohol.

Alcohol withdrawal delirium: Asyndrome that occurs after theamount of alcohol that is usually con-sumed has decreased, or upon absti-nence, after prolonged and heavy useof alcohol which leads to the follow-ing: changes in the individual’s vital

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signs and adverse gastrointestinal andcentral nervous system symptoms.Aldehyde dehydrogenase: An en-zyme that accelerates the breakdownof aldehyde into acetic acid, a non-toxic chemical that is easily eliminat-ed from the body.ALT (Alanine Aminotransferase):See AST. The ratio of AST to ALT(AST:ALT) can sometimes help todetermine whether the liver or anoth-er organ has been damaged. BothALT and AST levels are reliable in-dicators of liver damage.American Board of Psychiatry andNeurology: The governing body thatoversees clinical standards for bothpsychiatrists and neurologists and thevarious subspecialty fellowships suchas child and adolescent psychiatry andaddiction psychiatry.American Disabilities Act: Title I ofthe Americans with Disabilities Act of1990 took effect July 26, 1992. It pro-hibits private employers, state and localgovernments, employment agencies,and labor unions from discriminatingagainst people who have physical ormental disabilities in job applicationprocedures, hiring, firing, advance-ment, compensation, job training, andother terms, conditions, and privilegesof employment. Although alcoholismis included as a disability, the law doesnot shield employees who drink on thejob or employees who cannot performthe job up to the required standards.American Hospital Association:Founded in 1898 to represent and

serve all types of hospitals, health carenetworks, and their patients and com-munities. The American Hospital As-sociation provides education for healthcare leaders and is a source of informa-tion on health care issues and trends.Close to 5,000 hospitals, health caresystems, networks, and other providersof care and 37,000 individual healthcare professionals form the AmericanHospital Association, which is locatedin Chicago.

American Nurses Association: TheAmerican Nurses Association is aprofessional organization of nurses toadvance the profession of nursing. Itsmission includes public education, es-tablishing standards for nursing prac-tice and guidelines for ethical healthcare practices, lobbying state and fed-eral lawmakers to advance the prac-tice of nursing. The American NursesAssociation keeps their members in-formed of current issues regardinghealth care economics and the generalpublic’s health.

American Society of AddictionMedicine (ASAM): Established in1989 and was the first Americanmedical society to focus on drugs andalcohol. Its mission is to train medicalstudents, faculty, and residents toprovide better treatment and rehabili-tation and to develop strategies forprevention of alcoholism. The organ-ization has established a uniform cre-dentialing process for psychiatristsand other physicians who demon-strate their expertise by examination


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Glossary

in substance-use disorders and otherbehavioral health issues.

Amygdala: Attached to the tail of thecaudate structure of the brain that isconsidered a part of the limbic system.

Anemia: A deficiency of red bloodcells.

Antabuse: A drug given to alcoholicsthat produces nausea, vomiting, dizzi-ness, flushing, and tachycardia (a fastheart rate) if alcohol is consumed, thusit is a deterrent to drinking and acts asa negative reinforcer.

Antagonism: The mechanism thatcauses the blocking of the biologicalresponses at a given receptor site, dueto a drug or other chemical.

Anterograde amnesia: Loss of memo-ry where new events are unable tobe transferred to long-term memory.Amnesia refers generically to memoryloss and usually refers to memory lossfor previously remembered events.

Antibodies: Occur in response to anantigen as larger numbers of proteinsthat have high molecular weights.Antibodies are a normal immune re-sponse to fight infection.

Anticonvulsant: A drug that pre-vents seizures from occurring.

Antiemetic: A drug known for its anti-nausea and antivomiting qualities.

Antisocial personality disorder(ASPD): An enduring pattern of innerexperience and behavior that deviatesmarkedly from the expectations of the

culture is pervasive, inflexible, and mostoften has an onset in late adolescence.It may be preceded by the diagnosis ofa childhood conduct disorder. The an-tisocial person exhibits a disregard forand violates the rights of others, lacksempathy for others, is unremorsefulwhen hurting others, fails to conformto social norms, including participatingin criminal and other high risk behav-iors, lies or is deceitful, impulsive, andaggressive. The disorder is more preva-lent in adolescents whose parents alsohave the disorder.

Aqua vitae: Latin for “the water oflife.”

AST (Aspartate Aminotransferase):See ALT. A liver enzyme present inliver cells but also in red blood cells,cardiac tissue, and pancreatic tissue.When there is acute liver disease, thisenzyme is released into the bloodstream leading to its elevation on lab-oratory testing. AST can help deter-mine the cause of the liver damage.An AST:ALT ratio > 2.0, a value rare-ly seen in other liver diseases.

Atrophy: A decrease in the size of anorgan or muscle, or a wasting away ofa body part or tissue.

Attention deficit hyperactivity disor-der (ADHD): A persistent pattern ofinattention and/or hyperactivity andimpulsivity that is seen more fre-quently in children with ADHD thanin children at comparable develop-mental levels. Other features associat-ed with ADHD are low frustration


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tolerance, temper outbursts, stub-bornness, excessive and frequent insis-tence on their own requests, labilemood swings, dysphoria, rejection bypeers, and poor self-esteem. Academ-ic achievement is often impaired be-cause the children are distractible.Conflicts with authority figures, bothparents, and school personnel arecommon. Many of these children alsohave oppositional defiant disorders.These children may have been ex-posed to drugs or alcohol in utero.Many ADHD children exhibited lowbirth weights as newborns. Someteenagers who have ADHD self-medicate with drugs or alcohol.

Aura: A subjective sensation of voicesor colors prior to a seizure.

Axon: That part of the neuron ornerve cell that is a long tube conduct-ing signals away from the cell body.

Barbiturates: A class of drugs that ef-fect GABA to prevent seizures fromoccurring. They were used for anxietydisorders until the discovery of benzo-diazepines, which were found to bemuch safer.

Beriberi: From Sri Lankan for “I can-not, I cannot.” A condition caused bythiamine deficiency, leading to dam-age to the central nervous system andcausing memory and emotional dis-turbances (Wernicke’s encephalopa-thy), weakness and pain in the limbs,and periods of irregular heart beats.Swelling of bodily tissues is common.In advanced cases, the disease maycause heart failure and death.

Bipolar disorder: A mental illness de-fined by cyclic episodes of mania or hy-pomania, classically alternating withepisodes of depression; however, thecondition can take various forms, suchas repeated episodes of mania only oronly one episode of mania and repeatedepisodes of depression or rapid cyclingbetween mania and severe depression.

Bupropion: Generic for Wellbutrin,marketed as an antidepressant, andZyban, marketed as a smoking cessa-tion medication.

Campral: A drug used to maintainalcohol abstinence. Its mechanism isnot well understood but it is be-lieved to restore the normal balancebetween neuronal excitement andinhibition.

Carbohydrate-deficient transferrin:A protein found in blood involved intransferring iron to cell tissues. It is ele-vated with heavy alcohol consumption.The performance of carbohydrate-deficient transferrin as a screen for al-coholic liver disease has a sensitivity of80% and a specificity of 92%; however,carbohydrate-deficient transferrin isnot routinely tested, is expensive, andis not reimbursed by Medicare.

Centers for Disease Control: A fed-erally mandated program that was es-tablished in 1973 to monitor the na-tion’s health. The overarching goal isto protect the health and safety ofU.S. citizens.

Central pontine myelinolysis: Disin-tegration of the myelin sheath in thepons that is associated with rapid re-


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Glossary

placement of low sodium, most oftendue to alcoholism.

Cerebellar system: The part of thenervous system that has to do withcoordination of muscles and themaintenance of equilibrium.

Cerebral edema: Swelling of thebrain because of an abnormal accu-mulation of fluid.

Cirrhosis: A liver disease where thereis widespread disruption of normalliver functions. It is a chronic pro-gressive condition that may eventual-ly leads to death.

Classical conditioning: A type oflearning that results when a condi-tioned and unconditioned stimulus arepaired together, resulting in a similarresponse to both stimuli. Pavlov, whopaired a bell tone with the delivery offood to dogs, developed this learningmodel. The salivation in response tothe food (unconditioned stimulus) be-came associated with the bell (condi-tioned stimulus) over time, such thatthe food was no long needed to causesalivation in the presence of the belltone.

Clotting factors: A group of proteinsspecifically designed to interact to-gether to cause blood to clot and stopbleeding.

Cocaethylene: A chemical producedby the liver when processing cocaineand alcohol (ethanol) simultaneouslythat has many pharmacological prop-erties similar to cocaine except that itstays in the body longer and is poten-

tially more toxic to the nervous andcardiac systems.

Co-dependence: A maladaptive cop-ing pattern in family members who areclosely related to a substance abuser orexperience a prolonged exposure tothe behaviors of the alcoholic- ordrug-dependent person(s). It may alsorefer to people who are not associatedwith an alcoholic family but may comefrom families that are dysfunctionalfor whatever reason, including povertyor mental illness.

Cognitive behavior therapy: A ther-apeutic intervention that reinforces“positive thinking” and extinguishes“negative thinking” (i.e., changing un-desirable cognitive functioning).

Concordance rates: The rate atwhich genetically related individualsshare with one another a particulartrait. For example, identical twinshave 100% of their genes in common,whereas fraternal twins have only50% of their genes in common.

Confabulation: Filling in the memorygaps through fabrication (i.e., makingup stories to cover the loss of memo-ry). This is opposed to lying, which isdeliberate story telling to hide real (re-membered) events from someone toachieve some other gain other thanmerely filling in memory gaps.

Congestive heart failure: The heart isunable to maintain adequate circula-tion of blood to the body’s tissues andis unable to pump out blood via thecirculation system.


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Coronary artery disease: The buildup of plaque in the coronary arteriesconstricting blood flow to the heartmuscle, leading to chest pain (angina)and the potential for muscle death(myocardial infarction).

Cortisol: Also called hydrocortisone.It is derived from cortisone and isalso used to treat inflammatory con-ditions, including arthritis.

Cystic fibrosis: An inherited diseasefound in Caucasians that appears earlyin childhood. It involves a function-al disorder of the endocrine system.Symptoms include faulty digestionbecause of a lack of pancreatic en-zymes, difficulty breathing because ofthe accumulation of mucus in thelungs, and excessive salt in the sweat.At one time, these children only livedto be 4 or 5 years old. Now they liveto be adults.

Delirium tremens (DTs): An acutewithdrawal syndrome from alcoholthat frequently occurs in alcoholicswho have a 10-year (or more) historyof heavy drinking. Tachycardia, sweat-ing, hypertension, tremors, and delu-sions characterize it. Vivid hallu-cinations that are usually visual innature and wild agitated behavior,however, define it.

Dexedrine: A psychostimulant that isprescribed to treat ADHD.

Dipsomania: An uncontrollable urgeor craving for alcohol. This is an oldexpression for an alcoholic.

Disulfiram: Generic name forAntabuse, which is the most widelyused medication for alcoholism inthis country. It inhibits aldehyde de-hydrogenase, thereby preventing themetabolism of alcohol, which leads toa variety of unpleasant side effects ifthe person takes a drink. These ef-fects include nausea, vomiting, flush-ing, palpitations, and overactivity ofthe sympathetic nerves; however, it isonly effective if the person is motivat-ed to stop drinking and continues totake the drug as a support for notdrinking.

Dopamine: One of the brain’s majorneurotransmitters, it is responsible forattention, alertness, decision making,reward, pleasure, and mood.

Double-blind study: A drug studythat consists of an experimental groupof patients/volunteers who receive theexperimental drug, medical device, ortreatment and a control group whoreceives a placebo or the current andstandard drug, medical device, ortreatment. Neither the investigatornor the patient/volunteer knows whois getting the experimental drug,treatment, medical device, or placebo.

Downregulation: The process bywhich a cell decreases the number ofreceptors to a given hormone or neu-rotransmitter to decrease its sensitivityto this molecule. An increase of re-ceptors is called upregulation.

Down’s syndrome: A person withDown’s syndrome is mentally delayed


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Glossary

and has characteristic facial features.The risk factors for having Down’ssyndrome include family history ofAlzheimer’s disease, a family historyof Down’s syndrome, and advancedmaternal age at the time of the preg-nancy.

Drosophila: A type of fruit fly that iscommonly used to test genetic influ-ences to various physical and behav-ioral traits.

Drunken monkey hypothesis: Anevolutionary theory as to why havinga taste for alcohol may convey somesurvival advantage by allowing ani-mals to choose fruit that is the ripest.

DWI: A legal acronym for drivingwhile intoxicated. Some states use theterm to mean driving while impaired.it is also known as driving under theinfluence or DUI. Some states defineDUI as referring to drugs other thanalcohol, whereas DWI refers specifi-cally to alcohol and typically involves amoving violation. Other states defineDUI as driving under the influence ofany substance even when not intoxi-cated and not having made a movingviolation. For example, a minor iscaught behind the wheel of a car withalcohol on his breath, but his blood al-cohol level is under the legal limit.States define these terms based on is-sues of burden of proof. For example,some states regard driving while intox-icated as requiring a greater burden ofproof on the part of the state thandriving under the influence or driving

while impaired. Refer to your ownstate definitions for further informa-tion.

Dysphasia: The loss of the ability touse or understand language as a resultof an injury to the brain or a disease.

Electrochemical: The means by whicha nerve conducts signals through thebody and axon. This causes a release ofchemicals.

Eliciting stimuli: Plural for elicitingstimulus. It is a trigger that elicitsan involuntary or automatic response.Traditionally, in Pavlovian condition-ing, pairing a bell with the presence offood stimulated the dog to salivate.After repeated pairings, the bell alonewould elicit salivation from the dog.The bell became the eliciting stimulus.Such repeated pairings occur frequent-ly in an addict’s pursuit and use of adrug. Therefore, a bar, a friend, evenan innocent but frequently used wordcan act as an eliciting stimulus toprompt intense craving or even feel-ings of withdrawal.

Endogenously: Functional causesoccur from internal factors in themind or the body. An example maybe depression if there was no externalevent that might have precipitatedthe depression.

Endogenous opiates: Opioids thatdevelop or originate within the body.

Endorphins: Short for endogenousmorphine. See enkephalin or endo-genous opiate.


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Enkephalins: Greek for cerebrum. Anendogenous opioid made up of aminoacids, the building blocks of proteinsalso known as peptides, which are pro-duced in the brain that have an affinityfor opiate receptor sites and act simi-larly to analgesics and opiates, provid-ing pain relief and a feeling of well-being.

Enzyme: A biological molecule thatcatalyzes or accelerates a chemical re-action. Most enzymes are proteins.

Epidemiological: The basic science ofpublic health, having to do with epi-demiology, which is the study of pat-terns of disease distribution in time andspace that focuses on the health statusof population groups or aggregates,rather than on individuals, and involvesquantitative analysis of the occurrenceof diseases in population groups.

Epileptogenic: Causing epileptic at-tacks or seizures.

Epistemological: The study of thenature and grounds of knowledge es-pecially with reference to its limitsand validity.

Euphoric: A happy and elated mood.

Excitotoxicity: The pathological pro-cess by which neurons are damagedand killed by the overactivation ofreceptors for the excitatory neuro-transmitter glutamate, such as theNMDA receptor. Excitotoxins, such asNMDA, which bind to these recep-tors, as well as pathologically high lev-els of glutamate, can cause excitotoxici-ty by allowing high levels of calciumions to enter the cell. These calcium

ions lead to neuronal cell death alsoknown as apoptosis.

Executive functions: Brain functionsinvolving planning and decision mak-ing. Such functions require thinkingand postponing of more immediatewants or needs thus suppressing impul-sive action. Executive functions are lo-cated in the frontal lobes of the brain.

Extinction: Elimination of a classicallyconditioned response by the repeatedpresentation of the conditioned stimu-lus without the unconditioned stimu-lus. It is also the elimination of an op-erantly conditioned response by nolonger presenting the reward immedi-ately after the response.

Family Medical Leave Act (FMLA):The U.S. Congress passed this act in1993 with the goal of providing em-ployees with a balanced life betweenfamily and work. The law only per-tains to companies with 50 or moreemployees. The employee must haveworked with the company for at least1 year. The law mandates up to 12weeks of leave for various medicalemergencies, such as birth or adop-tion of a child or the illness of a fami-ly member. The old job or an equiva-lent position must be provided whenthe person returns to work.

Fetal alcohol syndrome disorder(FASD): A disorder that is found ininfants whose mothers ingested alco-hol during pregnancy, resulting inthe infant being mentally retardedalong with having other distinguish-ing features.


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Glossary

Flumazenil (Romazicon): A ben-zodiazepine antagonist that is usedto reverse the sedative effects ofbenzodiazepines in the managementof an overdose.

Fluoxetine: The generic name forProzac, which is an SSRI. It is alsoeffective with obsessive compulsivedisorder, posttraumatic stress disorderand other anxiety disorders.

GABA: Gamma-amino butyric acid,the brains major inhibitory neuro-transmitter. This neurotransmitterdampens all brain activity, essentiallycalming the brain down at every level.

Gabapentin (Neurontin): An anti-convulsant medication that may beused as an adjunct treatment withother drugs for seizures for adults andchildren over 12 years old. Themechanism of action is unclear.

Gene: A specific sequence of nu-cleotides in the DNA and RNA,which is a unit of inheritance thatcontrols the transmission and expres-sion of specific traits in people andother living organisms. Scientists andclinicians believe that alcohol de-pendence and abuse is influenced bygenetic factors.

GGT (Gamma Glutamyl Trans-peptidase): A liver enzyme thatwhen elevated is associated with al-coholic liver disease (among otherdiseases).

Glial: Cells that support and nourishthe brain’s neurons.

Glutamate: The brain’s major excita-tory neurotransmitter. This neuro-

transmitter activates all brain activity,essentially stimulating the brain and“lifting” it up at every level.

Gray matter: The part of the brain thatcontains the nerve cell bodies, includ-ing the cell nucleus and its metabolicmachinery, as opposed to the axons,which are essentially the “transmissionwires” of the nerve cell. The cerebralcortex contains the gray matter.

Growth hormone: Secreted by thepituitary gland and regulates growth.

Half-life: The time it takes for half ofthe blood concentration of a medica-tion to be eliminated from the body.The half-life determines the time toachieve equilibrium of a drug in theblood and determines the frequency ofdosing to maintain that equilibrium.

Hallucinogen: A classification ofdrugs that produces hallucinations,euphoria, an altered body image, dis-torted or sharpened visual and audi-tory perceptions, confusion, loss ofmotor coordination, and impairedjudgment and memory.

Health Insurance Portability andAccountability Act (HIPAA): TheAmerican Health Insurance Portabil-ity and Accountability Act (HIPAA)was passed by the U.S. Congress in1996 and was put into effect on April14, 2003.

Hematocrit: Measures of the propor-tion of blood volume that is occupiedby red blood cells—a measure of theamount of blood one has. When thisis low, one is known to have anemia.


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Hepatitis: A liver disease due to aviral infection. Drug users are at highrisk for developing infectious dis-eases, such as hepatitis, because drugusers share injection equipment withother users, are immunosuppressed,and have poor hygiene. There areseveral types of hepatitis viruses: A isusually transmitted by fecal-oral con-tact; B is often acquired through sex-ual contact, frequently among drugusers; C is transmitted among drugusers by injection; and D also isspread by drug users and their sexualcontacts.

Hypertension: High blood pressure,which can appear without an appar-ent cause. Hypertension can damageother organs in the body and is fre-quently the cause of strokes.

Hypocalcemia: Low blood calcium.

Hypokalemia: Low blood potassium.

Hypomagnesemia: Low blood mag-nesium.

Hyponatremia: Low blood sodium.

Hypophosphatemia: Low bloodphosphorous.

ICD (International Classification ofDiseases): This is the World HealthOrganization’s manual for classifyingall diseases, including mental illnessand substance abuse. It is very similarto DSM.

Immunosuppression: Involves an actthat reduces the activation or effective-ness of the immune system. A personwho is immunosuppressed is said to be

immunocompromised—more suscep-tible to infections and cancer.

Intensive outpatient treatment pro-gram (IOP): A program usually runby inpatient personnel, as part of thedischarge plan for continuing follow-up treatment for their inpatients, upondischarge. It may be at a hospital or ina community setting. It frequently in-cludes any of the common treatmentmodalities, including cognitive behav-ioral therapy, motivational enhance-ment therapy, and the 12-step AAprogram. The interventions are usual-ly group rather than individually ori-ented.

Intermittent reinforcement: The re-inforcement of a behavior (the re-ward) that occurs some of the time asopposed to continuous reinforcementthat occurs every time after the be-havior occurs. The behavior tends toreoccur when followed by a positivereinforcer (e.g., a good grade for awritten paper) or by eliminating thenegative reinforcer (e.g., a spanking).

Kindling: An effect on the brainwhereby repeated electrical or chemi-cal stimulation of the brain eventuallyinduces seizures. This may explainwhy cocaine and alcohol previouslydid not lead to seizures but after re-peated use now do.

Kudzu (Pueraria lobata): A plantused in alternative medicine to reducealcohol cravings.

Lamotrigine: Generic name forLamictal, an anticonvulsant also ap-proved for the treatment of bipolar


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Glossary

depression, particularly with respectto relapse prevention.

Learning theories: Theories that haveto do with the acquisition of knowl-edge and skills and modifying behaviorto learn new behaviors through behav-ior modification interventions (positiveand negative reinforcement, extinc-tion) and cognitive behavior interven-tions.

Leukopenia: A condition in whichthe number of leukocytes (white bloodcells) circulating in the blood stream islow, commonly due to a decrease inthe production of new cells in con-junction with various infectious dis-eases, drug reactions, other chemicalreactions, or radiation therapy.

Macrocytic: From “macro” for largeand “cytic” for cell. Primarily in refer-ence to large red blood cells from thi-amine deficiency (pernicious anemia)that is common in chronic alcoholicswhose nutrition is poor.

Malabsorption: Faulty absorption ofnutrients from the alimentary canal.

Marchiafava-Bignami Syndrome:Named after the two Italian patholo-gists who first discovered the condi-tion. A syndrome first identified inalcoholics of Italian origin who diedafter suffering from seizures resultingin a coma. Autopsy results demon-strated degeneration of the area of thebrain known as the corpus callosum,the major pathway connecting the leftand right hemispheres of the brain. Itnow appears that this very rare condi-

tion is not exclusive to alcoholics ofItalian origin.

Mean corpuscular volume: A meas-ure of the size of the red blood cells.When this number is high and thehematocrit is low, this is known amacrocytic anemia.

Mellanby effect: Impairment fromalcohol is greater at a given blood al-cohol level when the amount of alco-hol in the blood is increasing as op-posed to decreasing. This alsoexplains the differences in feeling“hung over” as opposed to “buzzed” atthe same alcohol level depending on afalling or rising level. This is why tak-ing “the hair-of-the-dog” or anotherdrink “cures” a hangover.

Mendelian: The central tenets of ge-netics developed by Gregor Mendel.They relate to the transmission ofhereditary characteristics from parentorganisms to their children; they un-derlie much of genetics.

Metaphysical: Relating to a realitynot investigated by the natural sciencesor perceptible to the normal senses.

Metronidazole: Generic name forFlagyl, an antibiotic medication thatrarely can have an Antabuse-like ef-fect for patients taking it and drink-ing alcohol.

Microcephaly: An abnormally smallhead with associated mental retarda-tion.

Microvascular: The part of the cir-culatory system made up of minutevessels or capillaries measuring lessthan 0.3 millimeters in diameter.


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Mitigate: To soften or become lessharsh.

Modeling: Learning through perva-sive imitation. One person tries to belike another person, who is a rolemodel, who is admired. The secondperson identifies with the role modelin order to imitate what they observedthe role model doing. Modeling is astrategy used to form new behaviors,learn new skills, or enhance existingskills. The theory of modeling was alsonamed by Bandura as “Social LearningTheory.”

Moderation Management (MM):Founded in 1993 as an alternative al-coholic treatment program to the tra-ditional AA 12-step program. MMrequires each person to plan to limittheir drinking rather than requiringcomplete abstinence. MM includesnine steps, which does include absti-nence for the first 30 days. Theremust be the desire to moderate one’sdrinking behavior and to accept re-sponsibility for one’s own behavior.Attendance at MM meetings is alsorequired. Its goal is prevention and itshopes to support persons at the onsetof the disease of alcoholism.

Monoamine oxidase inhibitors: Anantidepressant that is not used asfrequently as other antidepressants,namely because of the side effects,which include anticholinergic effects,such as a dry mouth. Additional sideeffects are adverse reactions, includ-ing a hypertensive (high blood pres-sure) crisis when eating certain foods,

such as aged cheeses, casseroles madewith cheese, pizza, dry sausage, pep-peroni, and alcoholic beverages (espe-cially beer, including nonalcoholicbeer and wine, especially red wine).Patients must adhere to low tyraminediets, which are sometimes difficultto follow. This diet should be ad-hered to even after the drug has beenstopped for a period of 2 weeks.

Mothers Against Drunk Driving(MADD): An advocacy group ofwomen who have lost someone, usual-ly a child, because of a drunk driver.The purpose of the group is to educatethe public about the dangers of alcoholand driving while under the influenceof an intoxicating substance and tolobby legislators at the federal, state,and local levels to pass laws that willget intoxicated drivers off the road.

Motivational enhancement therapy:Cognitive interventions are usedto enhance the substance abuser’s de-sire to stop using. The therapy inte-grates a combination of humanistictreatment and enhanced cognitive– behavioral strategies. Motivationalenhancement therapy was designedfor the specific purpose of treatingthe substance abuser, particularly theopiate addict who uses euphoric en-hancing drugs. The focus is on thenegative implications of substanceabuse, for each individual, encourag-ing the client to articulate his or herown need for change. It has beenused with alcoholics but less effec-tively. Often, motivational enhance-ment therapy has been combined


273


Glossary

with biological interventions such amethadone. The underlying messageis that drug misuse is a choice and itis the individual’s choice to changehis or her own behavior. It is an indi-vidually-oriented program conductedby a skilled therapist rather than agroup program. Consequently, it isexpensive.

Motivational interviewing: A brieftreatment approach designed to pro-duce rapid internally motivated changein addictive behavior and other prob-lem behaviors. The core principles are(1) to express empathy, (2) develop dis-crepancy, (3) avoid augmentation, (4)roll with resistance, and (5) supportself-efficacy. Motivational interviewingassumes that ambivalence and fluctuat-ing motivation occur during substanceabuse recovery. Motivational enhance-ment therapy and motivational inter-viewing are based on similar assump-tions, especially the belief that changewill not occur unless the individual ismotivated to change.

Motor cortex: An area on the outerpart of the brain that is responsiblefor voluntary motor control.

Muscular dystrophy: A group ofheritable diseases characterized by theprogressive wasting of muscles.

Myopathy: A disorder of the mus-cle tissue, typically causing wastingand weakness.

Naloxone: Generic for Narcan. It isan opioid antagonist and competeswith opioids at the opiate receptorsites. It is used as an antidote when

there is respiratory depression in-duced by opiate intoxication.

Naltrexone: Generic for ReVia. It isan opioid antagonist that competeswith narcotics at opiate receptor sites,blocking the opioid analgesics. It isused primarily to treat various addic-tions.

Narcan: See Naloxone.

Narcotic analgesic: An opioid usedto control pain.

National Organization of Fetal Alco-hol Syndrome: An organization to ed-ucate young women about the dangersof drinking while pregnant, hopefullyto prevent the incidence and prevalenceof fetal alcohol syndrome.

Neurochemical: A broader name forneurotransmitter. Any chemical thathas effects on nerve cells.

Neuron: A nerve cell made up of acell body with extensions called den-drites and the axon.

Neuroprotective: A protection of thenervous system against toxic sub-stances.

Neurotoxic: Toxic or lethal to thenerve and/or nervous tissue.

Neurotransmitters: Chemicals re-leased by nerves that communicatewith other nerves causing electro-chemical changes in those nerves tocontinue to propagate a signal.

NMDA (N-methyl-D-aspartic acid):An amino acid derivative acting as aspecific agonist at the NMDA recep-tor and therefore mimics the action ofglutamate at that receptor. In contrast


274


to glutamate, NMDA binds to andopens the above receptor only, butnot other glutamate receptors.

Nonsteroidal anti-inflammatorydrugs (NSAIDs): An extremely di-verse group of anti-inflammatory andanalgesic drugs that inhibit the en-zyme cyclooxygenase and reduce thesynthesis of prostaglandins. Aspirinand ibuprofen are examples.

Norepinephrine: A neurotransmit-ter in the brain as well as a stresshormone released by the adrenalglands, also known as noradrenalineor adrenaline. As a stress hormone,this compound affects the “fight orflight response,” activating that partof the involuntary nervous systemknown as the sympathetic nervoussystem to increase heart rate, releaseenergy from fat, and increase mus-cle readiness. As a neurotransmitter,it increases alertness and helps inelevating mood, but it can also in-crease anxiety and cause tremors.

Off-label: Prescribing of a medica-tion for indications other than thoseindicated by the Food and Drug Ad-ministration.

Ondansetron: Generic name forZofran, an antiemetic drug that actson specific serotonin receptors.

Open-label: A term used to describethe type of study where both the re-searcher and the volunteer/subjectsknow the drug or treatment that thesubjects are receiving. An open-labelstudy is the opposite of the double-blind study. In the double-blind study,

neither the researcher nor the partici-pant know whether the subject is re-ceiving the experimental drug, deviceor treatment, or a placebo.

Operant conditioning: A type oflearning that is concerned with the re-lationship between voluntary behaviorand the environment. If behavior isfollowed by a reward, it will reoccur.It was developed by B. F. Skinner.

Opiate: A type of opioid. An opioid isany agent that binds to opioid recep-tors. Found principally in the centralnervous system and gastrointestinaltract. There are four broad classes ofopioids: endogenous opioid peptides,produced in the body; opium alka-loids, such as morphine (the prototyp-ical opioid) and codeine; semisyntheticopioids such as heroin and oxycodone;and fully synthetic opioids such aspethidine and methadone that havestructures unrelated to the opium alka-loids. Although the term “opiate” isoften used as a synonym for opioid, itis more properly limited to the naturalopium alkaloids and the semisyn-thetics derived from them. Opioids/Opiates have addictive qualities.

Parathyroid hormone: A hormoneproduced by the parathyroid gland thatis next to the thyroid. This hormoneregulates calcium and phosphorus.

Partial agonist: A chemical (e.g.,drug) that can both block and stimu-late a receptor depending on the rela-tive amount of neurotransmitter pres-ent in the synaptic cleft. If the amountof neurotransmitter is great, the chem-


275


Glossary

ical acts as an antagonist; if the amountof neurotransmitter is low, the chemi-cal acts as an agonist.

Partial hospital program (PHP): Aprogram usually run as part of the dis-charge plan for their inpatients. Pa-tients attend 2 to 3 days per week.Partial hospital programs for alco-holics frequently include AA meetingsand are based on the 12 steps of AA.The interventions are focused ongroup work rather than individual psy-chotherapy. It provides an opportunityto monitor the patient’s progress andserves as a therapeutic bridge betweenthe hospital and the community.

Peripheral neuropathy: Peripheralrefers to the nerves outside of thecentral nervous system. Neuropathy isthe degeneration of the nervous sys-tem. Peripheral neuropathy is the de-generation of the peripheral nerves.

Phenobarbital: A barbiturate cur-rently used as an anticonvulsant.

Phenylketonuria: An inheritedmetabolic disease that causes mentalretardation because of the inability tooxidize the metabolic product ofphenylalanine.

Physician’s Desk Reference: A com-pendium of all of the drugs available tolegal prescribers (MDs, DOs, andNPs) in the United States and Cana-da, along with guidelines about theiractions, how each drug is generallyused, the drug interactions, side ef-fects, and contraindications.

Placebo: A drug, medical device, ortreatment that looks similar to the

experimental drug, medical device,or treatment, but it is in fact an inac-tive drug, liquid, device, or treatmentand will not affect the volunteer’shealth or illness.

Platelets: Also known as thrombo-cytes. A type of blood cell involved inthe cellular mechanisms of the forma-tion of blood clots. Low levels or dys-function predisposes for bleeding,whereas high levels, although usuallyasymptomatic, may increase the riskof the development of a thrombus orclot.

Posttraumatic Stress Disorder(PTSD): A mental/emotional dis-order that is characterized by per-sistent distressing symptoms lastinglonger than 1 month after exposureto an extremely traumatic event.

Potable: Drinkable.

Potentiates: To make more activeor effective, to augment, and tomake more potent.

Prolactin: A hormone found in theanterior lobe of the pituitary that in-duces and maintains lactation duringthe postpartum period in a female.

Prophylaxis: Preventing the occur-rence of something.

Proximate cause: In evolutionary the-ory, the initial cause that changes thebehavior of a biological system. Pullingone’s hand from a fire is caused by areflex arc in the nervous system andwould be an example of a proximatecause.

Prozac: See fluoxetine.


276


Pseudobulbar: A condition that simu-lates paralysis of certain cranial nervescaused by lesions in the medulla oblon-gata, a part of the brain.

Pseudobulbar palsy: Condition causedby damage to the cranial nerve path-ways that can lead to unprovoked out-bursts of laughing or crying along withother neurological deficits.

Psychosis: A state in which an indi-vidual experiences hallucinations, de-lusions, and disorganized thoughts,speech, and/or behaviors. An inabilityto distinguish reality from fantasy.

Psychosocial theory: A theoreticviewpoint that developed in the early1900s that the cause of mental illnesspertains to environmental circum-stances that impact on one’s psycho-logical well-being. Mental disordersresult from environmental and socialfactors, including social and environ-mental deprivation.

Psychostimulant: “Psycho” pertains tothe brain and its cognitive functions. Itis an agent or drug that increases thefunctional activity or efficiency of anorgan. A psychostimulant enhances thefunctional capacity and efficiency ofthe brain and its cognitive functionstemporarily during a brief span of time.

Psychotropic: A drug that has an ef-fect on the psychic functions of thebrain, behavior, or experience.

Rapid eye movement (REM): Rapideye movements that occur during astage of sleep that appears on EEG asif the subject is awake. During this

time the subject is actively dreaming.Also known as dream sleep.

Receptors: Specific areas of proteinon a neuron that are configured to re-spond only to specific neurotransmit-ters. Receptors act like locks, whichcan only be opened by specific keysthat are the neurotransmitters.

Reinforcers: The stimuli that arecoupled with a behavior in operantconditioning so that the reward is ei-ther applied or removed to elicit thedesired response.

Reliability: The ability to repro-duce the same outcomes upon re-peated testing.

Reuptake: The process by whichneurotransmitters return to the presy-naptic cells after being released intothe synaptic cleft and attaching re-ceptors on the postsynaptic cells.

Reverse agonism: A chemical (drug)that has reverse activity on the recep-tor rather than just merely blockingthe receptor.

ReVia: Trade name for naltrexone. Amedication used for narcotic and al-cohol addictions thought to controlcraving. It is an antagonist and blocksthe effects of opioids.

Ritalin: The trade name for methyl-phenidate. It is used to treat ADHD.

Selective serotonin reuptake in-hibitors (SSRI): A class of antidepressant/antianxiety medicationsthat works by blocking the serotonintransporter, thereby increasing theamount of serotonin in the synaptic


277


Glossary

cleft. These medications include flu-oxetine (Prozac), sertraline (Zoloft),paroxetine (Paxil), fluvoxamine(Luvox), citalopram (Celexa), and es-citalopram (Lexapro).

Self-medication: Taking medicationsthat are not prescribed by a physicianor nurse practitioner, including alco-hol or other drugs, to cope with emo-tional distress (e.g., drinking alcoholor smoking marijuana to calm downwhen one is feeling anxious).

Sensitivity: Probability of a positivetest among patients with a particulardisease. The more sensitive the testthe better it is at detecting the pres-ence of disease.

Sensory cortex: An area on the outerpart of the brain that is responsiblefor organizing sensory input into acoherent perception at the level ofconsciousness.

Serotonin: One of the brains majorneurotransmitters. It is responsiblefor “vegetative functions,” that issleep, appetite, sex drive (libido), anx-iety, and mood.

Sleep architecture: A predictable pat-tern during a night’s sleep that includesthe timing, amount, and distribution ofrapid eye movement (REM) sleep andnon REM. REM and NREM occurapproximately in 90 to 110 minute cy-cles over the course of an 8-hour periodduring a person’s night sleep. There arefour stages in sleep architecture.

Slow-wave sleep: A state of deep sleepthat occurs regularly during a normalperiod of sleep with intervening peri-

ods of rapid eye movement (REM)sleep. At this stage, there is a low rateof autonomic physiological activity.

Specificity: Probability of a negativetest among patients without disease.A very specific test rules out disease.

Status epilepticus: A state in a personwhereby seizures occur in rapid succes-sion without recovery of consciousness.

St. John’s Wort (Hypericum perfora-tum): A plant used in alternativemedicine as an alternative to antide-pressant medications.

Synaptic cleft: The gap betweennerves where neurotransmitters arereleased that allow nerves to commu-nicate with one another.

Teratogen: An agent, such as a virus,drugs or alcohol, or radiation, thatcauses malformations in a fetus orembryo.

Tetrahydrocannabinol: The psy-choactive ingredient to marijuanathat gives it its hallucinogenic andappetite effects. It is also pharmaceu-tically synthesized and released underthe trade name Marinol and is pre-scribed as an appetite stimulant forcancer and AIDS patients.

Tetrahydroisoquinolone (THIQ):A chemical compound that can beformed by combining acetaldehyde(the toxic breakdown product of alco-hol) and dopamine (the neurotrans-mitter). It is thought to be specific foralcoholics and has opioid-like activi-ties causing euphoria, thereby ex-plaining their increased propensity


278


toward addiction when compared tothe normal population.

Therapeutic communities: The en-vironment on an inpatient unit that isdeveloped to be a healthy milieu forstaff and patients and that facilitatesthe development and implementationof treatment. A therapeutic commu-nity is described as a group of pa-tients and professionals that adhere tocultural norms for behavior, value theindividual, and provide activities forpatients to teach them skills forhealthy interpersonal relationships, aswell as activities for daily living.

Thiamine: Vitamin B1. It plays animportant role in converting carbo-hydrates and fat into energy. Defi-ciency can lead to conditionsknown as Beriberi and Wernicke/Korsakoff’s syndrome.

Thrombi: Plural for thrombus orblood clot. If the clot detaches andmoves, it is known as an embolus.

Thrombocytopenia: The presence ofrelatively few platelets in blood.

Topamax: The trade name for topira-mate. An anticonvulsant.

Topiramate: Off label, it may beused as an adjunctive mood stabilizer,especially in bipolar disorders.

Trade name: The name given todrugs by the company that has thepatent rights to the drug, eitherthrough purchasing the patent rightsfrom another company, or havingdiscovered or designed them. Thetrade name is the company name.

Transporter: Also known as atransport pump. Transporters aremade up of proteins that act as “vac-uum cleaners,” taking up leftoverneurotransmitters from the synapticcleft and transporting them backinto the nerve cell that originally re-leased them.

Transport pump: See transporter.

Ultimate cause: In evolutionary theory,the ultimate cause for why a particularbehavior evolves to serve an evolution-ary purpose that has survival value. Areflex arc is a more efficient system forconferring survival value than havingthe signal go to the level of conscious-ness before one pulls one’s hand out ofthe fire would, as with the ultimatecause. Ultimate causes are often theo-retical in nature because they are diffi-cult to prove.

Upregulation: The process by whicha cell increases the number of recep-tors to a given hormone or neuro-transmitter to improve its sensitivityto this molecule. A decrease of recep-tors is called downregulation.

Valerian (Valeriana officinalis): Analternative medicine that is used inplace of sedative drugs.

Validity: The accuracy of the out-come of a test or instrument (i.e., theextent to which a test or instrumentmeasures what it intends to measure).

Valproic acid: An anticonvulsantmedication that acts on GABA and isFDA approved for use in bipolar dis-order (manic depression) and seizuredisorders.


279


Glossary

Vascular dementia: A cognitive dis-ease with mental and emotional im-pairments, plus neurological signsand symptoms. The disease is the re-sult of multiple vascular lesions. Vas-cular dementia may be seen with orwithout delirium, delusions, and de-pression and may be with or withoutbehavioral disturbances. As in mostdementias, there is memory loss andother cognitive impairments.Vertigo: Dizziness, as in the room isspinning around. This is a brain ef-fect as opposed to lightheadedness orfeeling faint, which is often also de-scribed as dizziness but is due to lowblood pressure.Vivitrol: An injectable, long actingform of naltrexone.

White matter: Tracts in the brainthat consist of sheaths (called myelin)covering long nerve fibers.

Zofran: Trade name for ondansetron.It is an antiemetic that prevents nau-sea and vomiting by blocking sero-tonin peripherally, centrally, and inthe small intestine.

Zolpidem (Ambien), zaleplon (Son-ata), and eszopiclone (Lunesta):These are all sleep-enhancing orsleep-inducing medications that arenot benzodiazepines but do act onone of the GABA receptors in amanner similar to benzodiazepines.

Zyban: See bupropion.




Index

IndexAAA. See Alcoholics Anonymous (AA)Abilify, 144Abstinence

Acamprosate and, 127alcohol-related dementia and, 165defined, 113internal struggles and, 20–21as key to treatment, 24loss stage, 86

Abuse, of alcohol, 47–48, 64. See also Alco-holism

Acamprosate, 126–128, 128tAcamprosate calcium, 115Acetaminophen, 181–182Acetylcholine, 15Addiction, 43–46, 207t

addictive behaviors, 21addictive qualities of alcohol, 26–30defined, 20–22as family illness, 246genetic predisposition to, 213historical forces, 213–214learning theory, 27pattern of use associated with specific

environments, 29–30social factors for, 213

Addiction counselors, 94–95Addiction treatment specialization, 94Adolescents. See also Children; Teenagers

alcohol treatment for, 115–116communication with, 199–200

Adoption studies, 68–70Adult Children of Alcoholics Organization

(ACoA), 244Advil, 182African Americans, alcoholism risk and, 72, 75Aggression, 81–82

Agingbrain atrophy and, 164effect of alcohol in, 223–225factors associated with drinking, 225physiological changes, 224tsuicidal tendencies and, 225

Agonism, 121Agonist, 122Al-Anon, 244, 258Alaskans, 76Alateen, 244, 258Alcohol

addictive nature of, 26–30defined, 2discovery of, 4–6evolution of human use of, 6–9health benefits of, 7–8religious/spiritual associations, 9safe level of consumption of, 84–85, 84t

Alcohol abuse, 47–48, 64. See also Alco-holism

Alcohol amnestic disorder, 164Alcohol dehydrogenase, 7, 59Alcohol dependency, 43–46Alcoholic cirrhosis, 177–178Alcoholic families, 247–251

adopted roles to cope within, 250adult children of alcoholics, 249characteristics of, 247–248young children of alcoholics, 248–249

Alcoholic(s). See also Alcoholismdetermining if individual/self fits criteria

of, 48–50family members who refuse to get help,

244–247offspring of, 68and problem drinkers compared, 232type I vs. type II, 58–59

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Alcoholics Anonymous (AA), 98–101, 258dry drunk concept, 85–87and rehabilitation compared, 104–105sponsors, 9912-step approach, 99, 100t12 traditions, 101t

Alcoholismalternative treatments/herbal remedies,

152–154biological effects of, 59–62cause of, 37–40costs of, 65debate over nature of, 34–37defined as a disease, 22–26link to mood disorders, 173–174medications, 117–119phases of (Jellinek), 58prevalence of, 64–65quantitative vs. qualitative differences,

48–49risk of inheriting, 65–70screening tools, 51–58violence and, 80–82voluntary and involuntary aspects of,

30–34Alcohol-related dementia, 163–166Alcohol-related neurodevelopmental disor-

der (ARND), 191Alcohol-related psychosis, 172Alcohol withdrawal delirium, 136Aldehyde dehydrogenase, 7, 119ALT (alanine aminotransferase), 61Altered states, of consciousness, 8–9Alternative treatments, 152–154, 210Alzheimer’s disease, 165Ambien, 151American Board of Psychiatry and Neurol-

ogy, 94American Disabilities Act, 238–239American Hospital Association, 235American Hospital Association Patient’s

Bill of Rights lists, 256American Medical Association, 229American Nurses Association

Credentialing Center, 97impaired health professional program,

229American Society of Addiction Medicine

(ASAM), 20, 43, 101–104Patient Placement Criteria, 101–102specialty certification, 94

use of Dilantin in alcohol withdrawal,169–170

Amsterdam, 203Amygdala, 70Analgesic properties, of alcohol, 8Anemia, 61, 62, 153Anglo-Americans, 81Anhedonia, 133Antabuse, 115, 119–120, 120tAntagonism, 122Anterograde amnesia, 164Antibodies, 154–155Anticonvulsant medications, 14, 45, 140,

169–170off-label use, for anxiety, 145

Antidepressant medications, 16, 45–46, 175Antiemetic, 16, 17Antihypertensive medications, 45Antisocial personality disorder (ASPD),

80–81Anxiety

alternatives to benzodiazepines, 144–145benzodiazepines and, 143–144disorders, 114following detox, 141medications, 146–147tposttraumatic stress and, 221

Aqua vitae, 8Aripiprazole, 144, 147tASAM. See American Society of Addiction

Medicine (ASAM)Asian Americans, alcoholism risk and, 72,

77Asian societies, 81AST (aspartate aminotransferase), 60–61Ativan, 138, 139–140Atrophy, of brain, 164–165Attention deficit hyperactivity disorder

(ADHD), 114–115, 191Atypical antipsychotics, 144AUDIT (Alcohol Use Disorders Identifica-

tion Test and shorter versions of),51–53, 56

Auditory hallucinations, 171–172Aura, 169Axon, 11f

BBarbiturates, 14Beer, 4–5


283


Index

Behavior modification, medication and,117–118, 119–120

Benadryl, 150Benzodiazepines, 139–141, 142–144, 168,

169, 222Berkeley Parents Network, 206Beta-blockers, 140Betaendorphin, 17Bible, 74–75, 75Big Book, 99, 232Binge drinking, 79–80, 176, 203Biological effects, of alcoholism, 59–62Biopsychosocial model, 38–39Bipolar disorder, 118, 134–135, 145, 172,

174–175, 191Bipolar II disorder, 175Birth defects, 188, 190–192Black Death, 5Blackout, 163Blacks, alcoholism risk and, 75–77Blood alcohol levels, 18, 234Blood pressure, 183Brain, 9–13, 10f

effect of alcohol on, 13–19gray and white matter, 10injury, 79limbic areas involved with mood/reward,

17fneurons, 10neurons and neurotransmitters, 11–13,

11fstudies, 70

Breast cancer, 79“Brewers droop,” 183Britain, 65Brühl-Cramer, 34–35Bupropion, 27B vitamins, 61, 153, 164

CCAGE screening tool, 53, 56Calcium, 62Campral, 115, 126–128Cancer/cancer treatment, 16, 78Capacity determination, 254Carbamazepine, 140, 145, 147tCarbohydrate-deficient transferrin, 61Carcinogen exposure, 78Cardiovascular disease, 78Cardiovascular system, 159–160Catholicism, alcohol use and, 75

Caucasians, 72Celebrities, 28–29Centers for Disease Control, FASD criteria,

192, 193tCentral pontine myelinolysis, 163, 166Cerebellar system, 166Cerebral edema, 163Chief enabler, 241Children

abuse of, 80, 252–252abuse of alcohol/drugs by, 82–83,

192–196age 5-7, 198age 8-12, 198–199age 13-17, 199–200alcohol discussions with, 194–201of alcoholics, 65–70binge drinking/drug use, 203birth defects/fetal alcohol syndrome and,

189–192cultural differences in alcohol consump-

tion, 201–202giving alcohol to minors, 202impact of alcoholism on, 247–251marijuana use by, 205preschoolers, 197–198rationales for noncompliance, 210traveling to country where drinking is

permitted, 203–204Chinese traditional medicine, 153Chlordiazepoxide, 138, 142Cholesterol, 183Christian temperance movements, 98Chronic insomnia, 150Chronic phase, 58Cirrhosis, 79, 177–178CIWA-A, 137, 138tClassical conditioning, 27, 32Clinical Institute Withdrawal Assessment

for Alcohol (CIWA-A), 137Clinical trials, 134–135, 155Clotting factors, of liver, 61Cocaethylene, 186Cocaine, 75, 76, 82, 186Co-dependency, 241–244

characteristics, 242children of alcoholics, 247treatment for, 243

Co-Dependents Anonymous (CoDA), 244Cognitive behavior therapy, 109Cognitive deformities, 188Communication, 195


284


Co-morbid substance abuse, 87Concordance rates, 68Confabulation, 164Confidentiality, 235–237Controlled drinking therapy, 112–114Coronary calcification, 79Costs, of alcoholism, 65Couples therapy, 222Court-ordered treatment, 255–256Crisis plan, 90Cross-tolerance, 184Crucial phase, 58Cubans, in South Florida, 76Cultural differences, in alcohol consump-

tion, 201–202Cystic fibrosis, 66

DDelirium, 171–172Delirium Tremens (DTs), 34, 136, 167–169Dementia, alcoholism-related, 153,

163–166Demographics, of alcohol use, 64Depakote, 145Dependence, on alcohol, 43–46, 64–65Dependence syndrome, 43–44Depression, 87–89, 191

in alcoholics, 173following detox, 141–142posttraumatic stress and, 221sobriety and, 110

Desyrel, 151Detoxification, 102, 136–137, 252

alcohol withdrawal syndrome, 137–139,138t

anxiety/insomnia/depression and,141–149

benzodiazepines, 139–141levels of care, 103

Dexedrine, 115Diagnosis, 42–62

clinician requirements for, 94–98DSM-IV, 42–43dual diagnosis, and treatment, 110–111of mood disorders, 173–174

Diagnostic and Statistical Manual of MentalDisorders, 42–43

alcohol abuse criteria, 47alcohol dependence criteria, 44

Diazepam, 142Diet, 78Dilantin, 141, 169–170

Diphenhydramine, 147t, 150Dipsomania, 34–35Disabled employees, 238Discontinuation syndromes, 145–149

medication-specific, 148withdrawal, 145, 148

Discrimination, based on medical informa-tion, 239

Diseasealcoholism seen as, 22–26germ theory of, 24related to alcohol abuse, 78–80

Distilled spirits, 2, 5Disulfiram, 115, 119–120, 120tDomestic violence, 251Dopamine, 13, 14, 17–18, 19t, 26–27, 89Dose titration, 83Double-blind, placebo-controlled studies,

134Downregulation, 168Down’s syndrome, 66Doxepine, 146t, 151Drosophila, 7Drug, alcohol viewed as, 2–4Drug-induced hepatotoxicity, 180Drug research and development, 131–132Drunken monkey hypothesis, 6–7, 26Dry drunk concept, 85–87DSM-IV, 42–43, 44DUI (driving under the influence), 219,

233–234DWI (driving while intoxicated), 50Dysfunctional families, 249Dysphasia, 166

EElectrochemical, defined, 11, 12Electrolyte deficiencies, 169Eliciting stimuli, 32, 34Emergency conservatorship, 255Emergency room visits, alcohol-related, 64Emotion, extremes of, and relapse, 90Employee assistance programs, 229Employment

compromised job performance, 239–241medical disclosure, 237–239

Enabler role, 250Endocrine system, 162Endogenously available neurotransmitter,

122Endogenous opiates, 13, 14Endorphins, 17, 18


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Index

Enkephalins, 16–17, 18Environmental exposure, to carcinogens, 78Environmental factors, in alcoholism, 66–67Enzymes, 7–8Epidemiological studies, 80Epileptogenic, 170Epistemological, 9Esophageal cancer, 79Eszopiclone, 151Euphoric aspects, of alcohol, 8Euphoric feelings, 90Europe, children’s alcohol consumption in,

202Excitotoxicity, 15Executive functions, 81Experimentation with drugs/alcohol,

212–214Extinction, 28

FFaith-based programs, 99, 107–108Families Anonymous, 259Family Medical Leave Act (FMLA),

239–241Federal Drug Administration (FDA), 118,

131–132Federal law, against DUI, 234Female-male alcohol response compared,

218–219Fetal alcohol syndrome disorder (FASD),

188–192Five-shot screening tool, 53–55, 54t, 56Flumazenil, 134Fluoxetine, 16, 18, 129, 146tFolate, 61, 141Foreign countries, lenient drinking/drug

laws, 203–204France, 65Fruit, alcohol content of, 7

GGABA (gamma-aminobutyric acid), 13,

127, 142, 168Gabapentin, 15, 134, 145, 147t, 151Gabatril, 145Gamma-aminobutyric acid. See GABA

(gamma-aminobutyric acid)Gastrointestinal system, 159Gateway drug concept, 82–83, 208tGender differences, in alcohol response,

218–219Genes, 65–66

Gene Theory, 66Genetic tendency, for alcoholism, 65–70Genetic variation, in taste for alcohol, 7–8Genitourinary system, 162Geodon, 144Germ theory, 5–6, 24GGT (gamma-glutamyl transpeptidase), 60Glial cells, 165Glutamate, 13, 14–15, 168Glutamate receptor blocker, 126–127Grief and loss stages, 86Group treatment, 111–112Growth retardation, 193t

HHaldol, 141, 175Half-life, 139Hallucinations, 171–172Hallucinogens, 15, 211Haloperidol, 141Hazelden Center for Youth and Families,

259Health benefits, 7–8, 83–84Health care providers, substance abuse by,

228Health Insurance Portability and Account-

ability Act (HIPAA), 236–237Heart attack risk, 165Heart defects, 188Helplines, 258Hematocrit, 61Hematologic system, 61, 160–161Hemorrhagic stroke, 79Hepatitis, 60, 177

medications to avoid, 180–182types of, 178

Herbal remedies, 152–154Heroin, 89Hero role, 25HIPAA, 236–237Hispanics, alcoholism risk and, 72, 76Homicide, 79, 80, 81Hypericum perforatum, 154

IICD (International Classification of Dis-

eases), 44“I” messages, 245Immune system, 160–161Immuno-suppression, 61, 62Impaired professionals, 228–230Inderal, 140


286


Individual treatment, 111–112Information, 256–260

helplines, 258organizations, 257support groups, 258–259

Informed consent, 237, 253–254Inhalant use, 76Inheritance, 65–70

environmental factors, 66–67Gene Theory, 66nature vs. nurture, 67–68twin and adoption studies, 68–70

Inpatient program, 102, 108–109Inquiry into the Effects of Ardent Spirits on the

Human Mind and Body, An (Rush),35

Insomniachronic, 150following abstinence, 149–152medications, 146–147tsleep architecture, 149–50treatment, 150–152

Institutional review boards, 135Insulin sensitivity, 162–163Insurance plans, 106Intensive outpatient treatment, 102, 104Intermittent reinforcement, 28Interventions, 116–117, 246Intoxication, at cellular level, 13Involuntary deliberation, 30–34Irritability, 86–87Islam, use of alcohol in, 74Italians, and Marchiafava-Bignami Syn-

drome, 166Italy, 65

JJaundice, 177Jellinek, E.M., 35, 58Judaism, use of alcohol in, 74

KKey parties, 214–216Kindling, 172Koran, 74Korean-Americans, 77Korsakoff’s dementia, 164Kubler-Ross, Elizabeth, 85, 86Kudzu, 153–154

LLamictal, 145Lamotrigine, 14, 15, 145, 147tLearning theory, 27–29Libido, 182–183Librium, 138, 139–140, 142Lifestyle issues, 37–38, 78Lippich, Franz, 35Lithium, 175Liver

alcohol effect on, 60–61cancer, 79disease, 153transplant, 178–180

Lorazepam, 138, 146tLost Child role, 250Low birthweight, 188Lunesta, 151Lung cancer, 38–39Lyrica, 145

MMacrocytic, 61Magnesium, 62Malabsorption, intestinal, 164Manic depression, 172, 174–175Mantle, Mickey, 178Marchiafava-Bignami Syndrome, 166Marijuana, 13, 82, 205–209

and alcohol issues compared, 207–208effects of, 205–206, 209rationales for, 210

Mascot role, 250MAST (Michigan Alcohol Screening Test),

55Mead, 4–5Mean corpuscular volume, 61, 62Medical consequences, of alcoholism,

158–163Medically managed intensive inpatient

treatment, 103Medical records, access to, 237Medicare, 237Medications, for alcoholism, 117–155

Antabuse (disulfiram), 119–120benzodiazepines, 143–144Campral (acamprosate), 126–128, 128tdetoxification meds, 137–141drug research/development, 131–132off-label treatment, 128, 131–134ondansetron, 129–130Prozac (fluoxetine), 129


287


Index

ReVia (naltrexone), 121–125Topamax (topiramate), 129, 130Vivitrol (naltrexone), 125–126Zofran (ondansetron), 129

Medications, vs. drugs, 2–3Medication-specific discontinuation syn-

dromes, 148Mediterranean societies, 81Melatonin, 152, 154Mellanby effect, 18–19, 20Mendel, Gregor, 66Mendelian (Gene) Theory, 66Mendelian patterns of inheritance, 66Mental disorder(s), 42–43. See also Mental

illnessMental Health Bill of Rights, 236Mental health specialists, 94Mental illness

dual treatment of, with alcoholism,110–111

stigma, 227Metabolism, 162Metaphysical, 9Metronidazole, 120Mexican Americans, 76Microcephaly, 190Microvascular changes, 165Middle Ages, 5Military service, and PTSD, 220–223Milk thistle extract, 153Mind altering, 3Mirtazepine, 146t, 151Modeling, 28–29Moderate Drinking, 232Moderate drinking therapy, 112–114Moderation Management (MM), 232–233Monamine oxidase, 132Mood disorders, 87–88, 172–174Mood swings, 174–177Morbidity and mortality, 78–80Mothers Against Drunk Driving (MADD),

233–234Motivational enhancement therapy, 109Motivational interviewing, 113Motor cortex, 10, 11Motor vehicle accidents, 18, 20, 81, 202Motrin, 182Mouth cancer, 79Multivitamins, 141Muscular Dystrophy, 66Musculoskeletal system, 161–162Muslims, alcohol use and, 74

NNaloxone, 122Naltrexone, 115, 122–126, 123tNarcan, 122Narcotic analgesics, 16, 18Narcotics Anonymous (NA), 259National Council on Alcoholism and Drug

Dependence, Inc., 259National Institute on Alcohol Abuse and

Alcoholism, 47National Nurses Society on Addictions, 229National Organization of Fetal Alcohol

Syndrome, 191Native Americans, alcoholism risk and, 72,

76–77Natural recovery, 65“Natural” substances, 210–211Nature vs. nurture, 67–68Neurochemical effects, 83. See also Demen-

tia, alcoholism-relatedNeurodevelopmental disorders, 193Neurological efffects, of alcoholism,

166–167Neurontin, 15, 134, 145, 151Neuroprotective effect, 127Neurotoxic effects, 164Nicotine, 184–186NMDA, 15NMDA glutamate system, 19tNon-steroidal anti-inflammatory drugs

(NSAIDs), 182Norepinephrine, 15NSAIDs, 182Nurse practitioners, 96–97Nurses, substance abuse impairment and,

228–230

OOff-label treatment, 128, 131–134Olanzapine, 144, 146tOndansetron, 16, 17, 129–130One-stepper. See Dry drunk conceptOpen-label studies, 134Operant conditioning, 28, 32Opiate antagonist, 122Opiate receptors, 89Opiates, 13, 16–17, 18, 45, 121, 211Opioid peptide system, 19tOrganizations, 257Oropharyngeal cancer, 79Outpatient treatment, 102


288


PPain medications, prescribed, 16, 45Pancreatic disease, 153Parental guidelines, for alcohol discussions,

194–195Partial agonist, 122Partial hospital programs (PHPs), 105–107Pathogenic phase, 58Patient’s Bill of Rights, 256Patriot Act, 236Pavlov, 27PAWS (post acute withdrawal syndrome),

141Per capita alcohol consumption, 64Peripheral neuropathy, 167, 184Personality disorder, 175Personality types, and alcoholic tendencies,

39“Pharmakos,” 4Phenobarbital, 14Phenylketonuria, 66Phenytoin, 141Phosphate, 62Physical assault, 183Physical deformities, 188Physicians, drug/alcohol abuse by, 228Physician’s Desk Reference, 132Placater, 250Platelets, 62Polygenic diseases, 67Post Acute Withdrawal Syndrome

(PAWS), 141Posttraumatic Stress Disorder (PTSD), 39,

114, 220–223symptoms, 220–221treatment of, 222

Potassium, 62Potentiate, 15, 16Pregabalin, 145, 147tPregnancy, 188–189Premature birth, 188Prepathogenic period, 58Preschoolers, alcohol discussions with,

197–198President’s Commission on Mental Health,

235Prevalence, of alcohol use/alcoholism,

64–65Prison population

cocaine and, 75violent offenders, 81

Privacy, rights to, 235–237

Problem drinkers, and alcoholics compared,232

Prodromal phase, 58Prohibition, 35Prometa treatment protocol, 134–135Propanolol, 140Prophylaxis, 170Proteins, 65Protestantism, alcohol use and, 75Proximate cause, 26Prozac, 129Pseudobulbar palsy, 166Psychiatric clinical nurse specialists, 96Psychiatric disorders, 42–43Psychiatrists, 97–98Psychological dependence, 58Psychologists, 94, 96Psychosis, 172Psychosocial theory, 27Psychostimulant medications, 115Psychotherapy, 142Psychotropic effects, of alcohol, 8–9Psychotropic substances, 3–4PTSD. See Posttraumatic Stress DisorderPublic Law 99-319, 235Pueraria lobata, 153Puerto Ricans, 76

QQuetiapine, 144, 146t, 151

RRamelteon, 146t, 152Rapid eye movement (REM) sleep, 149Rebound, 148Receptors, 11, 12Recovery

abstinance required for liver transplant,179

detox and rehab settings/levels of serv-ices, 102–103

dry drunk concept, 85–87family commitment to, 246impaired professionals and, 230support and persistence, 88–8912 steps, 86, 99, 100t

Recurrence, 148Rehabilitation, 102Reinforcers, 20Relapse, 90–91, 112–113Remeron, 151


289


Index

Research Council on Problems of Alcohol, 35Residential program, 102Respiratory system, 158–159Reuptake, 12, 13Reverse agonism, 121–122ReVia, 115, 121–125Reward, immediacy of, 30Risk, alcoholism and

aging, 73–74genetic variations in ADH2, 72–73inheritance of alcoholic tendencies,

65–70knowledge of, 71lifestyle choices and, 37–38males vs. females, 73modifiable, 72for other addictions when addicted to

alcohol, 89–90poverty/lack of education, 72race, 72–73, 73t, 75–77religious and cultural differences, 74–75

Risperdal, 144Risperidone, 144, 146tRitalin, 115Role models, 28–29, 99, 195Romazicon, 134Rozerem, 152Rural areas, alcohol/drug use and, 226–228Rush, Benjamin, 35

SSt. John’s Wort, 154Scandinavians, 81Scapegoat role, 250Schizophrenia, 72, 145, 174–175Screening tools, 51–58

AUDIT, 51–53, 56CAGE, 53, 56difficulty in incorporating, 55Five-shot screening tool, 53–55, 54t, 56influence on patient behavior, 57–56MAST, 55sensitivity and specificity of, 51validity and reliability of, 51

Seizures, withdrawal, 169–170Selective serotonin reuptake inhibitors

(SSRI), 16, 17, 144Self-medication, 173–174

posttraumatic stress and, 221teenagers and, 212

Sensory cortex, 10, 11Seroquel, 144, 151

Serotonin, 13, 14, 15–16, 19tSexual assault, 80, 81, 82, 183Sexual problems, 182–184Shakespeare, 36Shame, 227Sinequan, 151Sleep architecture, 149–150Slow-wave sleep, 149Smoking, 38, 78, 82–83, 85, 184–186Sobriety. See RecoverySocial factors, for addiction, 213Social support networks, 99Social workers, 94, 95Sociopathy, 58, 80Sonata, 151Sponsors, 99Spousal abuse, 252–252SSRIs. See Selective serotonin reuptake

inhibitorsStatus epilepticus, 169Steroids, 45Stigma, 24–25, 227Stress hormones, 19tStroke risk, 165Suicide, 79, 81, 225Support groups, 244, 252, 258–259Synaptic cleft, 11, 12, 13f

TTea drinking, 8Teenagers, 199–200. See also Adolescents;

Children; Underage drinkingalcohol use by, 207tdrinking seen as “rite of passage,” 215key parties and, 214–216marijuana use by, 206peer pressure and, 213rationales for noncompliance, 210rebellion and, 212substance abuse in rural areas, 226

Tegretol, 140, 145Teratogen, 190Tertiary syphilis, 24Testosterone, 183Tetrahydrocannabinol, 213Tetrahydroisoquinolone (THIQ), 89Therapeutic communities, 108Therapeutic privilege, 254Therapy, individual and family, 246. See also

Recovery; TreatmentThiamine, 61, 141, 153, 164Thrombi, 165


290


Thrombocytopenia, 61–62Tiagabine, 145, 147tTobacco, 78, 82–83, 85, 184–186Tolerance syndrome, 44–45, 184Topamax, 129Topiramate, 129, 130Trade name, 129Traffic fatalities, alcohol-related, 64Transporter/transport pump, 12Trauma, alcohol-related, 55–56Traumatic brain injury, 166Trazadone, 146t, 151Treatment

of adolescents, 114–116alternative/herbal remedies, 152–154benzodiazepines and, 143–144clinician requirements for, 94–98court-ordered, 255–256detoxification, 102–103, 136–137of DTs, 168for dual diagnosis, 110–111elements necessary to refuse, 254–256faith-based programs, 107–108individual vs. group, 111–112interventions, 116–117life-threatening conditions, 255–256medications, 117–119moderate drinking programs, 112–114Moderation Management, 232–233partial hospital programs, 105–107post-detox, 142–143Prometa treatment protocol, 134–135rehabilitation, 104–105rights to refuse, 252–254success of types of options, 109–110thiamine, 164of withdrawal symptoms, 169–170

Triggers, 90Trotter, Thomas, 3412-step approach, 99, 24412 traditions, 101tTwin studies, 68–70Tylenol, 181–182Type I/Type II alcoholics compared, 58–59

UUltimate cause, 26Underage drinking

Harris Interactive Survey of Parents, 216key parties, 214–216planning a non-alcohol party, 217–218

teen survey, 216Upregulation, 15, 168

VVaccines, 154–155Valerian, 154Valeriana officinalis, 154Valium, 142Valliant, George, 72, 113Valproate, 147tValproic acid, 14, 15, 145Vascular dementia, 165–166Vertigo, 18Veterans Administration (VA), 222–223Vietnamese-Americans, 77Violence, 80–82, 208t, 252

patient a danger to self/others, 255Viral hepatitis, 178Visual hallucinations, 171–172Vitamin deficiencies, 61, 141, 153, 164Vivitrol, 125–126Voluntary deliberation, 30–34

WWater, potable, 8Wellbutrin, 186Wernicke’s encephalopathy, 164WHO, 35, 43, 65Wine, 5Withdrawal seizures, 136, 169–170Withdrawal syndrome, 44–45, 117Women

with alcoholic/abuse spouses, 251–252vs. male response to alcohol, 218–219

World Health Organization (WHO), 35

ZZaleplon, 151Ziprasidone, 144, 147tZofran, 129Zolpidem, 146t, 151Zyban, 27, 186Zyprexa, 144


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100 Questions and Answers About Alcoholism