Medical Rounds

ALCOHOLISM THEODORE W. WASSERMAN, M .D.

From the Dep artm ent of Psychiatry. Albert Ein stein M edica l Center. Oaroff Division, and Thomas Jefferson University, Philadelphia , Penn sylvania

Physi c i;rns have for years been confronted with the treatment of physical conditions related to alcohol abuse, but have traditionally had a " hand s off" policy as to wh ether their patients should drink or not. Today, there are many forces working to lead us toward s the co nsideration of alcoholism as a disease, the provi sion of spec ial treatment for thi s di sease and ded ica tion toward s finding better treatment through resea rch and educa tion .

the phy sical, the psychological and the sociocultural aspects and integrate them for the purpose of diagnosis and treatment of the individual patient. Major diagnostic criteria can be divided within two tracks. The first, physiological and clinical, is further broken down to physiological dependence and is manifested by withdrawal syndromes, i.e. , gross tremor, hallucinosis, rum fits or delirium tremens. Further physiological criteria include evidence of tolerance, i.e., blood alcohol level of more than 1SOmg/1 OOml without gross evidence of intoxication and presence of alcoholic "black outs" or periods of amnesia. Presence of any of these physiological criteria is diagnostic of alcoholism . In like manner, presence of any of the major alcoholassociated illnesses such as Laennec's cirrhosis, Wernicke Korsakov's syndrome, peripheral neuritis, etc., supports a diagnosis of alcoholism. The second track of criteria includes behavioral, psyc hological and attitudinal elements, such as drinking despite strong medical contraindication known to the patient, drinking despite strong identified social contraindication such as job loss or marriagedi sruption and lastly, the patient's subjec-

Physicians' Attitude Th e attitud e of phy sician s toward alcoho li sm and treatment of the alcoholic pati ent has, in the last 10 years, showed a positive c han ge. It is difficult to spec ify the exact cause of this change. Certainl y, the usual soc ial stati sti ca l criteria have had an impact, impli ca ting alcoholism in striking fashion in mortality rates, homi cides, suicides, divorce, highway death s and in indu strial accidents and time lost from work . In the United States, governmental co nce rn with these indicators of pub I ic disease has resulted in increased appropri ation s for resea rch and education. Program s have been funded for career teachers in alco holi sm and courses of stud y in the di sease have been initi ated in many medical sc hool s. In stud yin g the di sease, one must consider Addn% for rL•print s: ThPodore W. Wasse rm an. M.D .. Albert Ein,rc in Med ical Cl'nter, Daroff Di vision, 5th and Rcl'd Street,, PhilJdelphia, PA 19 14 7.

00 11-9059-78-0600-0411 -0060 © Internati onal Society of Tropi ca l D erm atology, Inc.

411

412

INTERNATIONAL JOURNAL OF DERMATOLOGY

tive complaint of loss of control of alcohol consumption. Research in the past 10 years has also contributed towards better treatment of the alcoholic patient. Many old and false beliefs have been cast off. Cirrhosis can be induced in primates, given high doses of alcohol, even in the presence of a fully nutritious diet. Pharmacological dependence and tolerance to alcohol has been demonstrated experimentally. Brain damage has developed in individuals who take alcohol in high doses over long tim e periods without regard to nutrition. No beneficial pharmacological effects can be attributed to alcohol. Use of alcohol by pregnant women has been shown to cause a high inciden ce of fetal anomalies; subsequent research has lead to nationwide educational programs for physicians on the fetal alcohol syndrome. Early diagnosis is as important in the trea tment of alcoholism as it is in most med ica l disorders. The major diagnostic criteria mentioned before may not be seen frequently in many types of medical subspecialties, such as dermatology. In the latter, specialty certain of the minor diagnostic criteria may be encountered, including odor of alcohol on the breath at the time of a medical appointment, alcoholic facies, vascular engorgment of the face; increased incidence of infections, complaint of nocturnal diaphoresis, ecchymoses on lower extremeties, arms or chest, cigarette or other burns on hands or chest. Dermatological patients after frequent followup visits, offer other "soft" clues of alcoholism such as morning drinking, surreptitious drinking, repeated unsuccessful attempts at abstinence, med ical excuses from work for a variety of reasons, inappropriate use of the telephone to relieve anxiety, "telephonitis," unexplained changes in family, social and business relation ships and complaints about spouse, job and friends. Recognition

Middle and late signs and symptom s of alcoholism can be recognized by most physicians. Unfortunately, the "hands-off" policy

Jun e 1978

Vol. 17

too often prevails and both physician and patient deny the condition. When one ha s seen many recovering alco holic patients, it becomes apparent that motivation begins with confrontation, and that physicians can often play a major role in this important first step. It is important to neither moralize nor threa ten the patient. "You o ught to be as hamed of your drinking" or " take another drink and you're sure to die within th e year" are all-toocommon themes. They fall on deaf ears. Alternative confrontation may be introduced by questions. "Have you had somethin g to drink thi s morning?" "How much do you consume?" "How often do you become intoxicated?" "Have you ever felt you drink too mu c h? " "Have you ever tri ed to stop?" "How do people describe your beh;ivior when you're intoxicated?" Answers to th ese questions combined with observation of major o r minor c riteri a lead to an impress ion, which should be verbalized. "I think you have a drinking problem ." "Have you given it any thought?" "Ca n I refer you for help? " Recommendations

Making the diagnosis and con frontin g the patient will usually lead to refe rral for trea tment which ca n be medi ca l or non-medical or both. In the abse nce of se riou s med ica l or psychiatric complications and some degree of denial on the part of the patient, a ca ll to Alcoholics Anonymous and requ est for a sponsor to talk to the pat ient may be th e most efficacious route. AA is a non profit, large ly free, self help organization whose primary thrust is group-oriented structured programs which teach and support sobri ety. The m ajority of tod ay's treatment ap proaches whether medical or non -med ica l, are abstinence oriented and highly didactic. The patient rap idly becomes well informed about his di sease and all the methods available to lead an alcohol-free life. The disease is viewed as a chroni c relapsing cond ition for which there is no cu re. Patients are sa id to be recove ring, not recovPred. The tre;itment is

No. 5

ALCO HO LI SM

lifelo ng and the goa l is return of max imum fun ction both physica l and men tal as we ll as co ntinu ed personal growth . More recentl y, there have been no n-abstinence approac hes to alco ho li sm th ro ugh controll ed d rinkin g and beh;:ivio r mod ific;:i ti u n. These programs have been large ly med ica l, uni ve rsity-based and resea rc h o ri ented. Ec lecti cism preva il s in med ica l, abstinence o ri e n ted- trea tm e nt progr;:i m s. Ta l k in g th e rapies in c l ude in div idu a l and gro up th erapy, psyc hud r;:i m a, socia l interac ti o n gro ups, fa mil y ther;:ipy and occ upatio nal and recrea tio nal therapy. Min o r and major tranq uilli zers, ;:inti depressa nts, antabuse, vitamin s and oth er p h;:i rm acotherapy are co mm o n . M any programs foc us o n med ica l detoxi fi cati o n as th e entry po int fu r the pat ient, leadi ng to ea rl y recove ry anded uca ti o n phases, fo l low ed by rehabi litation. As the pa ti ent fee ls mo re co m fo rt ab le in co ntro llin g his own add ictio n, he may in vo lve himse lf w ith helping others, and recover ing alco ho li c th erap ists and co un-

wa,serman

413

se lo rs, armed w ith personal ex peri ence and fin e ly tuned em pathi c qu alities are frequentl y adj un cts to treatm ent prog rams. The average trea tment plan fo r the " new " alco ho li c entering therapy is o ne yea r- no miracl es, no cures but lots o f hard w ork . The outco me of treatment ca nnot be assessed by mo rtality or mo rb idity stati sti cs alo ne. It is estim ated that th ere are in the U .S. tod ay, som e 9 m illi o n alcoho li cs and the U .S. ranks th ird amo ng the natio ns of the world in inc idence of alco ho li sm . Treatment is sti l l foc used o n middl e and late ph ases of the di sease and ea rl y preventio n tec hniq ues are in their infan cy. It is know n th at the best results fo ll ow traditi o nal method s-ea rly di agnosis, co nfro ntati on, treatment of se ri o us related di sorders, ed uca ti o n, rei nfo rcement and continuity o f treatment, lead ing to rehab ilitati o n and future growth of the indi v idual. Alco ho li sm is presentl y a treatable di sease; educa tio n and resea rc h w ill lead to future improvements in methods, and in o utcome.

Italian Hospitals The Q-,ped.i le S,111 t,i M,iri,1 dell a Fede, situ.i ted in the suburb of th e Porta Cap uil na, ,111d beyond the e,1,1bli shme nt we have ju ' t no ticed, is compa rat ive ly small, be in g c. 1p.i bl e of .iccomm od.i ting littl e more th ,111 o ne hundred pa ti ents. It is under the im med i,1te d irec ti o n of the po li ce, and rese rved for the ad mi ss io n of prostitutes l.il iorin g under the ve nere.1 1 d ise.1se. W itho ut doubt it is the most d isgustingly fi lth y publi c e,1.ili li, hment of the kind, to be met w ith ;:i nyw here, ,rnd is scarce ly a degree better, in po int of nicety, th ,111 ou r co mmo n h og pe n ~. It s w ards are irreg ul ar ly di st ri buted, imperfec tl y ve ntil ,1ted, poor ly furni ~ h ed, and d re,1d full y kept. O ne w o ul d he .li mo>! inc l ined to bel ieve th.i t this est,1bli shment is the place of rend ezvo us of a large porti on of the fi e.is ,111 d o ther verm in of the ki ngdo m of Nap les, and eve ryo ne wh o h,1s tr.ive ll ed in th ,1 t be,wti ful co unt ry knowns, fro m pe rsonal ex peri ence, th at the qu.mtity of th ese is gre.iter there, th an pe rh aps in ,rn y co rn er of the c ivili zed world-Sp.i in .i lw.iys excepted. - Medic. 1/ /m titutiom of Nap /e.., . N. A m . Med . Surg . }. 21 , I BJ I .

Alcoholism.

Medical Rounds ALCOHOLISM THEODORE W. WASSERMAN, M .D. From the Dep artm ent of Psychiatry. Albert Ein stein M edica l Center. Oaroff Division, and...
2MB Sizes 0 Downloads 0 Views