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Medical Treatment

A team of professionals is often needed to treat the alcoholic. The physician usually plays a key role in medical stabilization and facilitating treatment entry, but others are routinely needed beyond the initial management (for example, alcoholism counselors, social workers, family therapists, psychologists, and pastoral counselors).

Treatment of the alcoholic can be divided into 3 stages. Initially, the person has to be medically stabilized. Next, he or she must undergo a detoxification process, followed by long-term abstinence and rehabilitation.

• Stabilization: It is the treating doctor's responsibility to treat any medical conditions related or unrelated to alcoholism. Vast arrays of medical and surgical complications are associated with alcoholism, but only stabilization of alcohol withdrawal and alcoholic ketoacidosis are discussed here.
  • Alcohol withdrawal is treated by oral or IV hydration along with medications that reverse the symptoms of alcohol withdrawal. The most common medications used to treat alcohol withdrawal symptoms are benzodiazepines. Commonly used medications in this class are lorazepam (Ativan), diazepam (Valium), and chlordiazepoxide (Librium). They can be given by IV, orally, or by injection. Diazepam also comes as a rectal suppository. Chlordiazepoxide generally takes longer to have an effect than diazepam or lorazepam. Therefore, it is less commonly used in withdrawal emergencies. Pentobarbital is another medication occasionally used to treat alcohol withdrawal. It has an effect similar to benzodiazepines but is more likely to slow down breathing, making it less attractive for this use. Occasionally the agitated and confused person may have to be physically restrained until he or she becomes more calm and coherent.
  • Alcoholic ketoacidosis is treated with IV fluids and carbohydrates. This is usually done in the form of sugar-containing fluid given by IV until the person can resume drinking fluids and eating.
  • Any alcoholic treated by a doctor should receive thiamine (vitamin B1). Thiamine levels are often low in alcoholics, and deficiency of this important vitamin could lead to Wernicke's encephalopathy, a disorder characterized initially by the eyes looking in different directions from each other. If thiamine is given in a timely fashion, this potentially devastating disorder can be completely reversed. In the emergency setting, thiamine is customarily given as an injection. Folate (a vitamin) and magnesium are often given to alcoholics as well.
• Detoxification: This stage involves stopping alcohol consumption. This is very difficult for an alcoholic and requires extreme discipline. It is often performed in an inpatient setting. Alcohol is not available in this setting. The person is treated with the same medications discussed in the treatment of alcohol withdrawal, namely, benzodiazepines. During detoxification the medication is measured carefully to prevent withdrawal and is then gradually tapered off until no withdrawal symptoms are evident. This usually requires a few days to a week. Recently, physician-assisted, outpatient detoxification has become popular. In the current managed health care setting, it is increasingly difficult to obtain coverage for in-hospital detoxification.
• Rehabilitation: Short- and long-term residential programs aim to help people who are more severely dependent on alcohol develop skills not to drink, to build a recovery support system, and to work on ways to keep them from drinking again (relapsing).
  • Short-term programs last less than 4 weeks. Longer programs last for a month to a year or more. These are structured programs that provide therapy, education, skills training, and help develop a long-term plan to prevent relapsing.
  • Outpatient counseling (individually, in groups, or with families) can be used as a primary treatment or as a "step-down" for people as they come out of a residential or structured day program.
  • Outpatient counseling can provide education on alcoholism and recovery, can help the person learn skills not to drink, and spot early signs of potential relapse.
  • There are several very effective individual treatments delivered by professional counselors in outpatient treatment clinics. These treatments are Twelve-Step Facilitation Therapy, Motivational Enhancement Therapy, and Cognitive-Behavioral Coping Skills. A well-known self-help program is Alcoholics Anonymous (AA). Other self-help programs (for example, Women for Sobriety, Rational Recovery, and SMART Recovery) allow alcoholics to stop drinking and remain sober on their own.
  • People who deny or minimize their alcohol problem or who don't care about taking action benefit from brief interventions such as Motivational Enhancement Therapy or Motivational Interviewing.
• Several medications are available to assist the person in abstaining from alcohol consumption.
  • The classic medication is disulfiram (Antabuse). It interferes with alcohol metabolism resulting in a metabolite that makes the person very uncomfortable and nauseated when consuming alcohol. The greatest problem with disulfiram is that people will often stop taking the medication to drink alcohol. To overcome this problem, disulfiram is available as an implantable device that is inserted under the skin. Fatalities have been reported when people taking disulfiram have ingested large amounts of alcohol. Furthermore, disulfiram has been associated with several types of neurologic conditions, including optic neuritis, which can lead to visual disturbances and eye pain.
  • Other medications used in preventing relapse are naltrexone (ReVia), acamprosate (Campral), and a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). Some researchers suggest that naltrexone and acamprosate seem to be the most effective medications studied, although SSRIs are not as effective. Disulfiram seems to have a positive effect on maintaining an alcohol-free lifestyle, yet the magnitude of this effect seems to be rather limited. Therefore, naltrexone is being increasingly used. Studies suggest alcoholics who drink while on naltrexone drink less alcohol and have less severe relapses compared with those not on it. Acamprosate has recently been approved by the Food and Drug Administration in the United States. When compared to placebo (sugar pills), it was effective in helping people abstain from alcohol. It is generally recommended that these medications be used in conjunction with alcoholism counseling.

Next Steps

Follow-up

The alcoholic must first make the decision that he or she must stop using alcohol. Without such a resolve, achieving long-term sobriety is unlikely.

• To avoid an impulsive relapse, the person's home should be alcohol-free.
• The person should enroll in a social support group or counseling program. Also, social situations that encourage alcohol consumption should be avoided.
• If medication is prescribed to help maintain sobriety, the person must take the medication according to a strict schedule. Meeting with a counselor is mandatory. When the urge to relapse becomes strong, the person should immediately contact a member of his or her support group and discuss the urge.

Prevention

Prevention of alcoholism is best accomplished by abstinence. You must first have access to alcohol before becoming an alcoholic. A strong family history of alcoholism is a warning that you are at increased risk of becoming an alcoholic. Increased awareness of such a risk may help modify your attitude toward alcohol consumption. A strong social support system and early medical or psychiatric intervention may also help prevent the escalating consumption of alcohol so characteristic of alcoholism.

Outlook

Several studies have shown that about half of alcoholics who have successfully undergone detoxification will relapse within 6-12 months. Remaining alcohol-free is a very difficult task for most alcoholics.

• Alcoholism is a chronic disease not unlike diabetes or congestive heart failure. If alcoholism is considered a chronic disease, a treatment success rate of 50% does not differ much from the success rates in other chronic illnesses.
• If a person continues to drink excessively after numerous or ongoing treatments, their prognosis is very poor. Persistent heavy drinkers will often succumb to the effects of alcohol.

Reviewed: 01/2006

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