Basic Olicognograph: Alcoholism
(nfm - not from me: extracts from reference articles)
A variety of psychosocial interventions (including psychotherapy) has been found to be effective in alcohol treatment. Long-term abstinence rates following alcohol treatment rarely exceed 40%; many studies have shown less favourable treatment results. It is difficult to demonstrate the superiority of one active approach over another. Interventions that have been found to be effective include strategies aimed at the enhancement of motivation for recovery, CognitiveBehavioralTreatment, including broad spectrum treatment with a CBT focus and other related forms, 12-step treatment, various forms of family approach, social network, and marital therapy, or social competence training. The data for psychodynamically oriented treatments and others are less convincing.
Women with resolved Alcohol Use Disorder who had received treatment had high scores on the KarolinskaScorePersonality scales measuring psychic and somatic anxiety, tension, irritability, and feelings of guilt. This suggests that personality assessment might be a useful tool in tailoring individual treatment programs for women.
Pharmacotherapy can be used in conjunction with psychosocial treatment to increase abstinence rates or reduce relapse rates, treat other alcohol-related disorders or treat comorbid psychiatric disorders. In this context, psychotherapeutic or psychosocial interventions have been used to increase motivation for abstinence, improve motivation for medication compliance, and to enhance outcomes generally.
Acute alcohol intake has consistently been shown to enhance GABAergic neurotransmission. In alcowithdrawal, GABAergic dysfunction contributes to restlessness, seizures and other signs and symptoms. There also is cross-tolerance between alcohol and GABAergic drugs. The clinical picture of alcohol intoxication, which includes sedation, ataxia and drowsiness, can be explained by its effects on GABAergic neurotransmission; alcohol is metabolized by the alcohol dehydrogenases (ADHs) to acetaldehyde, which is rapidly converted by acetaldehyde dehydrogenases (ALDHs) to acetate. Acetaldehyde is a toxic compound that is responsible for many unpleasant effects of alcohol, especially the ‘flushing response’ seen among susceptible individuals.
The biological treatment of alcoholism includes therapies for alcohol intoxication, withdrawal symptoms,alcohol-related neuropsychiatric disorders,and for the initiation and maintenance of abstinence. Compounds that interact with the opioid, serotonergic, and gamma-aminobutyric acid (GABA)/glutamate systems are safe and efficacious medications for treating alcohol withdrawal, alcohol dependence, or both.
The alcohol withdrawal syndrome (AWS) occurs with some frequency among individuals with a diagnosis of alcohol dependence. The AWS develops within the first hours or days of abstinence or after a significant reduction of alcohol consumption in an individual with severe physical dependence. In many cases, this condition resolves without complications and does not require pharmacological treatment. However, in some cases it can progress to a more serious or even life-threatening condition.There are a number of rating scales to measure intensity of alcohol withdrawal symptoms.
The most frequently used scale is the Clinical Institute Withdrawal Assessment - Alcohol - Revised scale. The treatment of alcohol withdrawal focuses on the relief of immediate symptoms, prevention of complications, and the initiation of rehabilitation. Although outpatient detoxification is a safe treatment option for many patients with mild-to-moderate AWS
Supportive care and repletion of nutrient, fluid or mineral deficiencies plays a very important. Vitamin deficiencies are very common in patients with heavy alcoholic intake. Supplementation, especially of B vitamins including thiamine to prevent the development of Wernicke-Korsakoff. The major aims of pharmacotherapy are sedation of patients to control increased excitability as manifested by agitation, anxiety and related symptoms and prevention of cardiovascular complications due to high blood pressure and pulse rate. Results from placebo-controlled studies suggest that benzodiazepines (BZDs), b-adrenergic receptor antagonists, calcium channel blockers, anticonvulsants and clonidine reduce withdrawal symptoms.
After an alcoholic seizure, the patient should be observed in a hospital for at least 24 h. A number of studies demonstrating the efficacy and safety of anticonvulsants such as carbamazepine and valproate suggest that they provide safe alternatives to benzodiazepines for the treatment of alcohol withdrawal, free from abuse liability, and usually do not potentiate the psychomotor or cognitive effects of alcohol.
Chronic alcohol consumption can result in a psychotic disorder, most commonly with hallucinatory features. In the older psychiatric literature, this schizophrenia-like syndrome was called alcohol hallucinosis. Patients suffer from predominantly auditory but also visual hallucinations and delusions of persecution. In contrast to alcohol delirium, the sensorium in these patients is clear. Alcohol psychosis occurs rarely.
Alcohol dependence is primarily manifest as impaired control over drinking. Both naturalistic and clinical long-term studies have indicated that relapse to heavy drinking can occur even after decades of abstinence. Most clinicians and self-help organizations such as Alcoholics Anonymous consider alcohol dependence to be a chronic and disabling disorder for which they advocate long-term or lifelong abstinence. Although treatments that favour techniques aimed at regaining control over drinking (‘controlled drinking’) in alcohol-dependent patients have been advocated, the available data call into question whether this is an effective long-term strategy, at least for patients with moderate-to-severe alcohol dependence. Studies of the long-term course of alcoholism indicate that most individuals are unable to maintain controlled drinking.
Studies of effects of cognitive-behavioural therapy (CBT) - focused, selfcontrol training in patients with limited alcohol problems show some positive effects in comparison with no treatment, but the effect in alcohol-dependent individuals remains controversial. Following a harmreduction strategy for patients not motivated for abstinence-oriented interventions to promote a reduction in drinking is acceptable in such situations (Good Clinical Practice), but abstinence from alcohol remains the primary long-term goal for moderate-to-severe alcohol dependence.