Medical Treatment of Alcohol Dependance
Medical treatment involves the use of medications under the care of a physician for the treatment of alcohol dependence to ensure that the transition from active addiction to active recovery is achieved without harm or unnecessary discomfort. At its earliest stage, medical treatment deals with withdrawal. Alcohol is a drug that produces both tolerance, the need for increasing quantities to achieve desired results, and withdrawal symptoms when use is discontinued. Withdrawal symptoms for any drug are usually the opposite of the desired effects. With alcohol, a hangover can be seen as a type of mild withdrawal. For the individual suffering from alcohol dependence or addiction, the symptoms can be much, much worse and may require supervised medical care. The greatest danger in alcohol withdrawal is the potential for life-threatening seizures, accompanied by delirium. In the worst cases, physicians can utilize what is called a "taper" to help the withdrawing person through the worst of the symptoms and protect him or her from seizures.
A taper is usually accomplished by substituting a long-acting sedative-hypnotic drug, such as phenobarbital, for the alcohol. Alcohol is in the same family as such sedative drugs as barbiturates and benzodiazepines, so these can act to mediate the alcohol withdrawal symptoms. Dosages of the substitute drug are gradually reduced until there is no further danger of seizure and the patient is drug free.Medication monitoringis very important at this stage as each patient needs a personalized drug plan designed for their unique body If it is to be effective, medical treatment for withdrawal is accomplished along with psychosocial treatment including counseling, therapy, education on the nature of addiction and recovery, and entry into abstinence and a program of recovery.
As with all forms of addiction, alcohol dependence is a chronic problem with the ever present threat of relapse. Alcohol dependence is incurable in that the user can never return to non-addicted use. However, alcohol dependence can be brought into long-term, even permanent remission through abstinence from all psychoactive drugs and adoption of a program of supportive recovery, such as that found in the Alcoholics Anonymous fellowship. These may not be enough, however, and so there are medications that will reduce alcohol craving and help guard against relapse into active addiction.
At present, there are three medications that are approved for the treatment of alcoholism. They are disulfiram, naltrexone and acamprosate .These medications are, according to a recent research, much underused in the treatment of alcohol abuse, especially as recent changes to the Affordable Care Act make it compulsory for all insurance sold through Health Insurance Exchanges to provide services for substance abuse. More education is needed on the benefits of these medications, now that their cost will likely be covered by the ACA.
Disulfiram also known as Antabuse is the oldest and undoubtedly the most severe.It reduces desire for alcohol by nullifying the desired reward payoff. It works by blocking the metabolization of an alcohol metabolite, acetaldehyde, in the liver. Acetaldehyde is particularly toxic, and its buildup causes acute discomfort for anyone who drinks alcohol while they are being maintained on disulfiram. The experience is highly unpleasant, and if it does occur, serves as a strong deterrent to drinking.
In contrast, Naltrexone has no overtly negative physiological effect. What it does is occupy certain receptor sites in the brain that are also used by alcohol-activated neurotransmitters in the process of intoxication. Originally used to block the effects of heroin for recovering opioid addicts, naltrexone was found to also reduce craving for recovering alcoholics and dramatically decrease the incidence of slips and relapses. To be effective, medications need to be used on an on-going basis usually for several months, to promote abstinence long enough for the brain of the person with alcoholism to return to normal neurochemical functions.
Acamprosate is a post withdrawal medication given to help reduce the cravings for alcohol.It commonly has little or minor side effects.Other post-withdrawal medications are currently in development, either to improve medication compliance or modify other neurochemical pathways, and in the future should serve as a supplement to psychosocial treatment and supported recovery.
Inpatient vs. Outpatient Treatment
Every day, more than 700,000 people in the United States receive treatment for alcoholism. Treatment settings fall into two main categories: inpatient and outpatient. Several treatment methods exist under each category. No specific method or category is held to be the absolute best treatment; rather, several methods have equal success rates. The majority of people receiving treatment do so in an outpatient setting. According to a Department of Health and Human Services report, of those participating in alcohol treatment in 1991, 88% were enrolled as outpatients and 12% were inpatients. However, the outpatient setting, while having a comparable success rate, has a higher dropout rate than inpatient settings.
Inpatient vs. Outpatient Settings
Often substance abusers are a product of their environment; therefore, inpatient treatment may provide a much needed change of scenary for the alcoholic patient. Inpatient alcohol treatment is usually recommended for patients who...
- Have psychiatric disorders
- Have accompanying medical problems
- Are dangerous to themselves or others
- Have a non-supportive home environment
- Have not responded to traditional treatments
Inpatient settings consist of very intense treatment. These programs usually last around 28 days, but the lengths of stay are becoming shorter. Inpatient programs include detoxification, therapy (group and individual) and education for recovering alcoholics. The main benefit of the inpatient setting is the round-the-clock assistance for each patient. Examples of inpatient settings include hospitals, rehabilitation centers, and halfway houses or other residential programs.
Outpatient settings vary in intensity. The format of outpatient treatment can be Day Hospital programs that last several hours per day a few days per week or weekly counseling sessions. Outpatient treatment is generally reserved for patients who are mildly alcohol dependent and whose goal may be to simply cut down their drinking rather than complete abstinence.The main benefit of outpatient settings is that patients can maintain their home lives and get support directly from family members and friends on a daily basis.
The key to a successful therapy is to match a person's characteristics with the type of treatment that would be most beneficial to that set of characteristics. The goal of therapy is always to help the alcoholic achieve and maintain sobriety for the years to come, since over 50% will relapse in the first three months of the completion of treatment.
About 13.5% of people receiving alcoholism treatment do so in a hospital or residential setting. Hospital stays can be low or high intensity, but both options provide full-time medically directed treatment programs within a general or psychiatric hospital. Care usually starts out intensively and then filters down to outpatient care once the patient has made significant progress. Hospitalization is usually for the most urgent effects of alcoholism.
Centers can be a part of a hospital program or be completely independent. Centers usually provide 24-hour care and programs that aggressively address treatment and recovery. Most programs admit patients for extensive weeks of stay, while other programs offer day treatment. Rehabilitation facilities often have educational, vocational, or spiritual components to the program.
Halfway Houses and other Residential Programs
Halfway houses are not usually affiliated with hospitals and allow patients to be in a stable, structured environment while learning how to make lifestyle changes during the recovery period. Halfway houses combine outpatient psychiatric or medical programs with high-intensity structured living program. Halfway houses offer around five hours or more of professional services per week for residents.
In recent years, escalating health care costs have propelled a shift from inpatient to outpatient treatment for most patients for all stages of recovery. Eighty-six percent of alcoholics receive outpatient treatment. Despite this fact, inpatient care remains more appropriate for patients with serious occurring conditions who do not have supportive social environments. Outpatient therapy consists of reporting to a program once a day or a few times a week for therapy sessions. The range of therapy options is wide in outpatient programs, consisting of motivational and cognitive-behavioral therapies. The physician and the patient can schedule meetings with social workers or other therapists, providing for the patient a sense of belonging and encouragement. Many psychiatrists work on a part-time basis at clinics, hospitals, and mental health centers, making the psychiatrist available a few days a week and the patient's regular physician available the alternate days.
Phase One of Treatment
Whether in an inpatient or outpatient setting, the first phase of treatment focuses on detoxification, the gradual withdrawal of alcohol from the body. The doctor will first assess the severity of the withdrawal symptoms with a questionnaire. The questionnaire will determine whether the symptoms are mild, moderate or severe. For patients with moderate to severe symptoms, detoxification is usually handled in an inpatient setting with medications because the symptoms can be critical or even fatal. A popular medication used is benzodiazepines. For 90 to 95% of alcoholics, the withdrawal symptoms are only mild to moderate. These patients are usually treated on an outpatient basis.
Symptoms of detoxification
- Rapid pulse
- Elevated blood pressure
- Hand tremors
- Nausea or vomiting
- Depressed mood or irritability
- Temporary hallucinations or delusions
Phase Two of Treatment - Behavioral Methods vs. Drug Therapy
Behavioral treatmentsfocus on changing behavior to prevent relapse of alcohol consumption. There are 3 primary methods of behavioral treatment. Cognitive-Behavioral Therapy helps the alcoholic identify and deal with situations and circumstances that lead to alcohol consumption. Motivational Enhancement Therapy helps the alcoholic use his/her own motivation and resources to alter their behavior in positive ways. Finally, 12 Step Programs identify 12 steps an alcoholic needs to achieve during recovery.
Pharmacotherapy, or drug therapy, uses medication to curb desire to drink alcohol.
Mostly used with people who abuse alcohol and are not classified as alcoholics, brief intervention can have a small positive effect on the treatment of alcoholics. Brief intervention consists of a counseling session that lasts 5-20 minutes long and may or may not include follow-up sessions. Brief interventions have been found to be successful in clinical research settings, family practices, college campuses, hospitals, and urgent care settings for abusers of alcohol. Research is being conducted to see the effect of brief intervention on alcoholics.
Research is being conducted on an age old Asian remedy for hangovers and alcohol intoxication. The "drunken dispeller" is a simple Chinese herbal tea that has many ingredients including one compound: NPI-028. This may sound complicated, but is found in a common plant found in most south-eastern US states. It grows up to a few feet a day and virtually overtakes any available land in its growth path. So what is this plant? KUDZU. Oddly enough, the Chinese and other Asian populations have been drinking an herbal tea with kudzu components to combat alcohol intoxication and hangovers. There hasn't been any use of the chemical in trying to decrease or prevent alcohol consumption.
At the UNC Bowles Center for Alcohol Studies, Dr. Overstreet with Dr. Rezvani and Dr. Lee have shown that when rats were injected with purified extracts of NPI-028, they reduced their alcohol intake. These rats were genetically bred to prefer alcohol rather than water. So in essence, these rats were alcoholics. The doses used by the researchers were not significant enough to affect heart rate, body temperature, cause behavioral depression, nor decrease water/food intake. The mechanism by which the chemical works is still under investigation. However, these researchers have shown that NPI-028 doesn't affect the metabolism of alcohol because alcohol blood levels were the same after administration of this chemical and a control chemical. It is theorized that it affects the serotonin system thus affecting the craving for alcohol.
There have been similar results in African green monkeys. Dr. Overstreet and colleagues found that there was a decrease in alcohol consumption when NPI-028 was administered either orally or by injection.
In combination with other therapies, acupuncture could be a considerable advantage to the treatment of alcoholism and other drug dependencies. Some research that has been conducted on acupuncture suggested that some of its analgesics effects are due in part to the release of opioid peptides. Opioids help in pain relief or pain perception. There is also evidence to suggest that the hypothalamus and pituitary gland are also stimulated, thus producing a wide range of effects. Despite these evidences, the results of the therapy is subjected to influences from the person's expectations and environment. "Sham" acupuncture points have also shown similar effects as regular acupuncture.
The procedure consists of five small needles being placed in each ear to release certain chemicals within the body. These five needles corresponds to specific organs including the lungs, liver, kidneys and nervous system and one for relaxation. The client then rests for about 45 mins.
Despite not knowing everything about the mechanisms of acupuncture and how it mediates its effects, this therapy is often used in combination with other treatment plans to combat substance abuse. The effects of acupuncture during detoxification is reduction of withdrawal symptoms. Specifically, the physical symptoms of withdrawal, depression, anxiety, insomnia, cravings, nausea and body aches, just to name a few.
Physician Barriers to Treatment
Physician Barriers to Treatment Studies have shown that patients are responsive to physician alcohol interventions. Many patients have indicated that they would like their physician to recognize and participate in treating substance abuse problems.