Essays

Alcoholism has serious negative consequences not only for the affected individual but also for society at large. By using a public health approach that integrates medical, psychological, and social therapies, primary care physicians can educate at-risk patients to prevent alcohol abuse from starting and intervene to halt progression of the disease in patients with early or late alcoholism.

The signs of causes of alcoholism are unknown but strong evidence exists for a genetic origin. Given the inherited risk, a variety of psychological and environmental factors (e.g. depression, broken home, alcohol misuse by other family members) appear to influence the expression of that risk in the individual. Once begun, alcoholism typically progresses over 10 to 20 years. Because the progression is gradual, however, it is difficult to determine the exact time when a person becomes an alcoholic. People without a genetic risk for alcoholism or a previous history of alcohol abuse can also have an alcohol problem (e.g. a recently bereaved person) or experience negative consequences from drinking (e.g. a teenager who drinks and drives). Thus all patients, not just those with a diagnosis of alcoholism, are candidates for primary prevention efforts by the primary care physician in the office setting. These efforts can reinforce and support substance abuse education and interventions that take place within the home, at school or work and in the community.

The most effective way for the physician to reduce alcoholism (and Other substance abuse) is by taking a positive, public health approach combining medical, psychological and social interventions. When early alcoholism or risk factors for alcohol abuse are detected, the physician acts either to prevent alcohol abuse from beginning or to halt any further progression of the disease. Since alcohol problems and their solutions differ significantly according to the age, sex and ethnicity of the individual, it is important for physicians to be 'culturally sensitive' and avoid imposing their own personal norms upon their patients. Simply passing judgment usually proves to be counter-productive.

Primary-prevention: Before it starts

The goal of primary prevention is to identify those patients at risk for alcohol abuse and to educate them in order to stop the disease before it starts. Persons at risk for alcohol abuse often present to their doctor for routine healthcare.

To inform them of their increased vulnerability for addictions, the physician needs to take a thorough history to uncover risk factors for alcoholism. Sometimes drawing a genogram (medical family tree) helps uncover important information about family dynamics, major life events and other aspects of the environment that the patient may not otherwise volunteer.

Secondary prevention aims to identify patients with early disease and halt disease progression. In its early stages, alcoholism has few specific signs or symptoms but clinicians can prevent progression if they recognize alcoholism early and intervene.

Before they exhibit overt alcoholism, alcoholic patients typically present to healthcare facilities for a variety of difficulties over a 5- to 15-year period. Physicians with a high degree of suspicion can recognize combinations of certain conditions that are suggestive of alcoholism as the root cause.

The goal of tertiary prevention is to treat and rehabilitate patients with chronic alcoholism to prevent disease progression. Typically, 10 to 20 years of active drinking are needed to reach this stage, although in some persons alcoholism proceeds more rapidly. Patients often require hospitalization for an acute medical problem, related or unrelated to alcohol.

Since there is no cure for alcoholism, even sober alcoholics are said to be 'in recovery,' a lifelong process.

Abstinence—Total abstinence from alcohol and other sedatives (including prescription drugs) is the cornerstone of management. Relapses are so common that they should be expected and planned for. Discussion of temptations means of coping, support systems and nondrinking lifestyle (e.g. healthful diet, walking or other exercise) is often helpful.

Aftercare—This is a follow-up program to assist in maintaining sobriety. It may include group therapy, individual psychotherapy, employer-mandated or other monitoring programs and self-help groups.

Books for recovering alcoholics and their family members

are also valuable aids.

Medications—Medications have also been (used to help prevent a return to drinking.) Disulfiram (Antabuse) causes the patient to experience unpleasant sensations (occasionally fatal) when alcohol is ingested but it has not always proven to be clinically effective. It works best in patients who are motivated to take it every day. A typical maintenance dose is between 125 and 500 mg per day.

Naltrexone hydrochloride is a new medication that appears to prevent relapses by reducing the craving for alcohol. The dose must be individualized so, the product information should be carefully reviewed before this drug is prescribed. Indications are that this medication may be most effective when prescribed in the context of formal psychological and social therapies.

Predicting relapses—Patients who are 'in good recovery' do not drink or use drugs. They attend self-help meetings regularly, take care of their physical health (including not 'forgetting' or cancelling appointments), get along socially, function well at school or on the job and obey the law. If, at the time of a scheduled return visit, a patient reports failing At tine or more of these tasks, a relapse may be imminent. Consultation with an experienced substance abuse clinician may also be helpful, especially if the patient is experiencing overt psychiatric symptoms. Addictive medications should not be prescribed. It is helpful for patients in recovery to get some positive reinforcement; for example, the physician might say that he or she is proud of the patient's efforts and note the many rewards to living a healthful lifestyle.

Alcoholism is a common, chronic, often progressive disorder that has negative effects on a patient's health and severe consequences for society as well. A positive, public health approach that integrates medical, psychological and social therapies can lead to improved outcomes for patients who abuse alcohol.

Physicians can play an important role by educating patients to prevent alcohol abuse from starting, being alert to the risk factors, recognizing the signs of alcoholism (especially during its early stages) and initiating interventions designed to halt progression of this disease.

Doctors should maintain a therapeutic stance with patients who have continued to abuse alcohol, even after frequent relapses. Consultation with alcoholism experts may be helpful when treatment is difficult or there is the possibility of a dual diagnosis.