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Alcoholic drinks have been consumed for thousands of years, and the problems that can accompany excess alcohol intake have undoubtedly been around just as long. In moderation, alcohol can be the oil that makes a social occasion go with a bit more flow or helps a shy person overcome his inhibitions. However, high levels of alcohol consumption can lead to physical illness and psychological and social distress. Alcohol, therefore, has always had an ambivalent position in society.

What is alcoholism?

Alcoholism or alcohol dependence is a medical term with a deliberately more precise meaning than the problems that can occur, sometimes as one-offs, through an uncharacteristic alcoholic binge. In alcohol dependence a number of features come together in the behavior of the person affected. These include - but are not limited to - the following:

  • Drinking begins to take priority over other activities. It becomes a compulsion.
  • Tolerance develops, so it takes more alcohol to produce drunkenness.
  • Withdrawal symptoms such as anxiety and tremor develop after a short period without a drink, and are reduced by taking more alcohol.
  • The alcoholic is unable to control his drinking in any given occasion.

Often alcohol dependence remains undetected for years. Both the availability of alcohol and the way it is used (the social patterns) appear to be major factors in influencing the likelihood of a person becoming alcohol dependent.

Alcoholism is a disease

One of the difficulties in recognizing alcoholism as a disease is it just plain doesn't seem like one. It doesn't look, sound, smell and act like a disease. To make matters worse, generally it denies it exists and resists treatment.

Alcoholism has been recognized for many years by professional medical organizations as a primary, chronic, progressive and sometimes fatal disease. The National Council on Alcoholism and Drug Dependence offers a detailed and complete definition of alcoholism, but probably the simplest way to describe it is as "a mental obsession that causes a physical compulsion to drink."

Mental obsession? Did you ever wake up in the morning with a song playing over and over in your head? It might have been a commercial jingle you heard on television or a song from the radio, but it kept playing... and playing… and playing.

That is an example of a simple mental obsession - a thought process over which you have no control. Such is the nature of the disease of alcoholism. When the drinking "song" starts playing in the mind of an alcoholic, he is powerless. He didn't put the song there and the only way to get it to stop is to take another drink.

The problem is the alcoholic's mental obsession with alcohol is much more subtle than a song playing in his mind. In fact, he may not even know it's there. All he knows is he suddenly has an urge to take a drink - a physical compulsion to drink.

Compounding the problem is the progressive nature of the disease. In its early stages, taking one or two drinks may be all it takes to get the "song" to stop. But soon it takes six or seven and later maybe ten or twelve. Somewhere down the road, the only time the song stops is when he passes out.

The progression of the disease is so subtle and usually takes place over such an extended period of time, that even the alcoholic himself failed to notice the point at which he lost control over - and alcohol took over - his life.

No wonder denial is an almost universal symptom of the disease. For those who have come to the realization that they do have a problem, help may be as close as their family physician. But for those who need help and do not want it, assertive outreach may be the only alternative.

Recognizing the illness...

There are many symptoms related to drinking problems. Alcoholism is considered a progressive disease, meaning that the symptoms and effects of drinking alcohol become increasingly more severe over time. Early signs of alcoholism include frequent intoxication, an established pattern of heavy drinking and drinking in dangerous situations, such as when driving. Other early signs of alcoholism include black-out drinking or a drastic change in demeanor while drinking, such as consistently becoming angry or violent.

The main symptom of alcohol abuse occurs when someone continues to drink after their drinking reaches a level that causes recurrent problems. Continuing to drink after alcohol causes someone to miss work, drive drunk, shirk responsibilities or get in trouble with the law is considered alcohol abuse.

The Diagnostic and Statistical Manual of the American Psychiatric Association defines alcohol abuse as drinking despite alcohol-related physical, social, psychological, or occupational problems, or drinking in dangerous situations, such as while driving.

When alcohol abuse reaches the alcohol dependence stage, the person also experiences at least three of seven other symptoms, including neglect of other activities, excessive use of alcohol, impaired control of alcohol consumption, persistence of alcohol use, large amounts of time spent in alcohol-related activities, withdrawal symptoms and tolerance of alcohol.

Are you an alcoholic?

How can you tell whether you, or someone close to you, may have a drinking problem? Answering the following four questions can help you find out. (To help remember these questions, note that the first letter of a key word in each of the four questions spells "CAGE".)

  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

One "yes" response suggests a possible alcohol problem. If you responded "yes" to more than one question, it is highly likely that a problem exists. In either case, it is important that you see your family doctor right away to discuss your responses to these questions. He or she can help you determine whether you have a drinking problem and, if so, recommend the best course of action for you.

Denial

One of the most frustrating factors in dealing with alcoholism, as a relative, friend or addiction professional, is it is almost always accompanied by a phenomenon known as "denial". In the long path the alcoholic takes toward emotional and physical decline, usually the first thing to go is honesty. He simply lies about his drinking. Little lies at first.

I only had two... I haven't had a drink in a week... I don't drink as much as he does...

As the alcoholic begins to drink more, and more often, he begins to hide this fact from those around him. Depending upon his circumstances he may drink openly, but usually he will conceal the amount he drinks, by not drinking around those who are closest to him.

If someone tries to discuss his drinking with him, he simply refuses to talk about it or dismisses it as not a real problem. After all, he's a big boy now and he can drink if he wants to, it's nobody else's business.

But these simple acts of denial, lying about his drinking or refusing to discuss it, are clues that the alcoholic himself deep down inside knows that he has a problem. If it's not a problem, why lie about it to anyone? The alcoholic covers up and denies his drinking out of his own feelings that there is something different or "wrong" about it. Somewhere inside he realizes that his drinking means more to him that he is willing to admit.

As the disease progresses and his drinking begins to cause real problems in his life, remarkably, the denial likewise increases. Even though his sprees have gotten him into some real trouble, he denies it has anything to do with his drinking. The drinking and the denial continue until he hits rock-bottom, at which point one of two things usually happen: either he admits there is a problem and seeks help, or the family decides to assertively intervene.

Treating the illness...

No available therapy, program, medication or surgical procedure can eliminate the recurrent desire or craving for alcohol. Eliminating the desire to drink is not a goal of treatment. A more reasonable expectation is that medication may reduce this urge and effective rehabilitation will teach a person what they must do to manage and contain their recurrent desires to consume alcohol, much in the same way as a person with diabetes or hypertension must learn to manage their lives to control their illness.

It is best to think of three stages of alcoholism treatment, each with a different function in the larger picture of care:

  1. Detoxification / stabilization
  2. Rehabilitation
  3. Continuing care

Detoxification / stabilization

Detoxification is not treatment - it is merely preparation for treatment, and must be followed by rehab and after-care for lasting improvement. Following cessation of heavy and sustained alcohol use, most individuals develop significant physical and emotional symptoms (the withdrawal syndrome). Detox is the medical management of these symptoms. It is almost always undertaken in an in-patient setting, in a hospital / deaddiction centre. It usually lasts for between one and two weeks, though, for severely dependent individuals, it can last much longer. Desired results include reduced physical and emotional instability caused by substance use and a patient who is motivated to recognize and accept that there is a problem that he needs to - and can - address.

Rehabilitation

Rehabilitation is appropriate for patients who are no longer suffering from the acute physical or emotional effects of recent alcohol use. It typically offers an array of treatment components to help address the many health and social problems associated with alcohol dependence.

Most rehabilitative care for addiction occurs in specialty "programs" that include

  • Medical management of craving
  • Individual, group and family therapy
  • Relapse prevention training
  • Developing a plan for an alcohol-free lifestyle
  • Familiarization with mutual-help groups (Alcoholics Anonymous, AA)

Continuing Care

The first 3-6 months following discharge from hospital are the period of greatest vulnerability to relapse. Consequently, continuing care services are designed to monitor the emotional health of recovering people, remind them of their commitment to lifestyle change and support their needs as they attempt the difficult job of living their former lives with a new perspective and resolve.

If the patient is on disulfiram, the family is encouraged to take responsibility for its administration. Individual, group and family therapy sessions continue, but typically occur less frequently than during the residential program. Some rehabilitation programs offer telephone counseling and support services for people to talk with their former counselors. The recovering addict is encouraged to continue association with mutual-help groups.

Are There Any Medications for Alcoholism?

Let me repeat: No available medicine can eliminate the recurrent desire or craving for alcohol. A more reasonable expectation is that medication may reduce this urge. However, three different types of medicines are used in the treatment of alcohol dependence, during various stages of the treatment process:

  1. The first are the benzodiazepines which are used during the first few weeks of treatment to help patients safely withdraw from alcohol.
  2. The second type of medication are the anti-craving drugs like naltrexone and baclofen. When used together with counseling, these medications lessen the craving for alcohol in many people and help maintain sobriety.
  3. Another medication, distinct in function from the previous two types, is disulfiram, which discourages drinking by causing nausea, vomiting and other unpleasant physical reactions when alcohol is concurrently used.

The Sinclair Method

Developed by Dr. David Sinclair, a psychologist and alcohol researcher, this method is based on the principle of pharmacological extinction. It involves the prescription of naltrexone, a drug approved by USFDA for reducing alcohol craving, even as the patient continues to drink. Many patients experience decreased craving over a period of three to six months.

Assertive Outreach

How can I get him to stop drinking? Usually, by the time family members ask this question, “he” has ceased to be a social drinker: “he” is now alcohol dependent. Unless he admits - or can be persuaded to admit - that he needs help, assertive outreach may well be the only alternative. Assertive outreach should be resorted to only when an individual requires intensive support or where it is no longer reasonable to step back and allow someone you care for continue to harm themselves through their addiction to alcohol. On behalf of the family, a team of professionals assertively intervenes in an individual’s addictive process. In addition to the other treatment modalities, programs which offer assertive outreach ensure round-the-clock supervision and entry and environmental control.

Relapse

To ordinary people, relapse is one of the most perplexing aspects of alcoholism. People recovering from alcohol dependence can experience a lack of control and return to their alcohol use at some point in their recovery process. This faltering, common among people with most chronic disorders, is called relapse. Relapse, when defined as return to excessive or problematic use, occurs in approximately 20-30% of those who have completed formal care in the previous 12 months. When defined as re-use of alcohol even in minimal quantities, relapse rates can be as high as 50%.

The road to recovery is usually long and hard. Few people with alcohol dependence travel it gracefully. There are many slips, trips and lapses. Those who eventually do recover, learn to pick themselves up when they fall, brush off the dust and keep going. By doing so, they keep temporary lapses from turning into full-blown relapses.

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