Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Rehabilitation for alcoholics James W. Smith To cite this article: James W. Smith (1978) Rehabilitation for alcoholics, Postgraduate Medicine, 64:6, 143-149, DOI: 10.1080/00325481.1978.11715006 To link to this article: http://dx.doi.org/10.1080/00325481.1978.11715006
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 13 August 2017, At: 13:06
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Seventh of seven symposium articles in this issue
Rehabilitation for alcoholics Consider What cautions should be observed in prescribing disulfiram? Roughly what success rates with behavior modification techniques are being reported in the treatment of alcoholics? How often and for how long should the recovered alcoholic be seen for follow-up?
James W. Smith, MD
Chemotherapy, psychotherapy, behavior modification, and participation in Alcoholics Anonymous have been used successfully to treat the alcoholic patient, but all have limitations and some have potential dangers. All require longterm follow-up and family participation.
Once an alcoholic patient has agreed to enter treatment, the primary care physician must decide whether hospitalization is necessary and what treatment approach or combination of approaches to use. The decision to hospitalize or not depends on the patient's medical and psychiatric condition and general life situation. The treatment techniques described here are divided into the categories of chemotherapy, psychotherapy, and behavior modification. The benefits and potential dangers of various approaches in each category are discussed, together with a brief description of Alcoholics Anonymous (AA) and a discussion of the importance of follow-up and of family participation in the treatment plan. Inpatient vs outpatient treatment
One major factor in deciding whether to hospitalize the alcoholic patient is whether a serious medical problem exists in addition to alcoholism. In general, I believe that patients with other serious problems, such as heart disease, pancreatitis, or advanced liver disease, should be treated in the hospital, where intensive medical attention is available and where the effects of withdrawal can be monitored and managed. A second major factor is whether the patient has a condition which renders him or hernonfunctional in the home setting (eg, organic brain syndrome) or is in a serious crisis which would be best handled in a more sheltered environment than could be provided in an outpatient setting. A third factor is whether a severe psychiatric disturbance is present that may cause the patient continued VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
143
Inpatient treatment ctf alcohol ~----------·--------.----------------------
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
addiction permits thu patient to get away from the daily c:ues for drinking and to focus on ah::oholism without the distracti•J,ns of day-to-day problems ;at home and at work.
to harm himself or herself or to be a threat to others. Alcohol in high doses, even in a patient with primary alcoholism, can cause a clinical picture of paranoia which may be identtcal to that of paranoid schizophrenia or psychosis resulting from amphetamine or barbiturate .'lbuse. 1 Such a disturbance will usually clear after days or weeks of abstinence from alcohol even without specific antipsychotic medication. 2 Tie patient may also have a primary affective disorder (either depressive or manic-depressive illness:! with secondary alcoholism*). All such patients need skilled psychiatric evaluation and treatment by therapists familiar with alcoholism. The patient with alcoholism secondary to affective:: disorder may require tricyclic antidepressants for control of depression or lithium for contr·)l of mania, 4.5 but there is no evidence that these drugs are of use in controlling alcoholism per se. 5 When a patient is referred to inpatient treat*See page 123.
James W. Smith Dr S nith is director, Shick's Shade! Hospital, Seattle, and chief medical officer, Shick Laboratones, !ne, Los Angeles. His resean h has centered primarily on the physiology and treatment of alcoholism.
144
ment specialists, it is important that the primary care physician maintain contact with both patient and treatment personnel to give encouragement during hospitalization and to facilitate effective continuation of treatment once the patient returns home. If outpatient treatment is the choice, the primary care physician must decide whether to refer the patient to an established alcoholism outpatient treatment resource in the community or to undertake full responsibility for care in his or her own office. If referral is chosen, the primary care physician should stay in close contact with the referral agency and should, of course, continue to manage any medical problems. A third choice available to most physicians is to undertake primary responsibility for treatment but to also use community resources such as AA, clergymen, or counselor consultants. My bias is toward inpatient treatment, at least initially. This affords the patient an opportunity to be sequestered for a time from the many daily cues for drinking and to focus attention on alcoholism in a concentrated rather than in a sporadic, piecemeal fashion in addition to coping with the day-today problems of living. Chemotherapy Disulfiram-An exhaustive description of the mechanism of action of this widely used chemotherapeutic agent can be found in Sauter and associates.6 The general principle involved is that alcohol ingestion after a course of disulfiram therapy causes a severe reaction. A loading dose of 0.5 gm daily for five days is given, followed by 0.25 gm daily thereafter. If alcohol in any form (cough syrup as well as whiskey) is drunk within one week (in some cases up to two weeks) of discontinuing use of the drug, unpleasant symptoms occur. These include flushing, throbbing headache, respiratory difficulties, nausea and vomiting, palpitations, tachycardia, hypotension, and syncope.
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Disulfiram effectively curbs the ability to enjoy drinking but unfortunately does not curb the desire to drink.
Patients, who must be thoroughly educated about the process beforehand, know that if they give in to an urge to drink they will be severely uncomfortable or ill. Disulfiram does not decrease the desire for a drink, and unfortunately many alcoholics can plan their drinking a week or more ahead and simply stop taking the drug. This problem may be countered by having patients on a monitored disulfiram program, in which they come to the physician's office (or other designated place) to take each dose under supervision. Subcutaneous implantation of disulfiram pellets has been attempted experimentally but has been rather disappointing because of the low blood levels achieved. 7 The technique has not been approved for use in the United States. There are potential dangers involved in taking disulfiram. Caution is necessary to avoid adverse
Illustration: Alan E. Cober
VOL 641NO 61DECEMBER 19781POSTGRADUATE MEDICINE
drug interactions, which will occur with any drug having acetaldehyde as one of its products of metabolism (eg, paraldehyde). Disulfiram may also affect the metabolism of drugs such as phenytoin or the anticoagulants, with the result that toxic blood levels may be reached with standard doses of these drugs. Side effects of disulfiram include skin rash, drowsiness or easy fatigability, headache, bad taste in the mouth, garlic-like odor on the breath, impotence, and (rarely) peripheral neuropathy. Disulfiram should be used only with extreme caution in patients with other serious conditions such as cerebral damage, chronic or acute nephritis, liver failure, severe diabetes, and severe cardiovascular disease. Citrated calcium carbimide-This drug has an action similar to that of disulfiram. It is available in Canada and some other countries but has not been cleared by the Food and Drug Administration for use in the United States. Sedatives and tranquilizers-These drugs have been the most used and perhaps the most controversial of any used for alcoholism, beginning with the bromides, then the barbiturates, and later still the antianxiety and antipsychotic drugs (eg, chlordiazepoxide, diazepam, chlorpromazine). Literature surveys8·9 of the use of such drugs in alcoholism treatment have concluded that no drug per se has been shown to be effective for this purpose. While these drugs may be lifesaving during alcohol withdrawal, beyond this point most "alcohologists" would agree that hypnotics and tranquilizers have no place in the treatment of primary alcoholism.2 Megavitamin therapy-Enthusiasts for megavitamin therapy (ie, vitamins in very high doses) have listed alcoholism among the indications for this type of orthomolecular psychiatry. While proponents of megavitamin therapy claim beneficial results, the American Psychiatric Association reports that these claims have not been continued
145
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Psychotherapy, like any potent therapy, should be use!d cautiously and selectively. "Real i·ty therapy" seems to have the bes1: results.
confirmed and that "serious and major attempts to demonstrate the value of ni•;otinic acid have uniformly been negative in the hands of independent investigators. "10 Psychotherapy The high level of interest in ::lsychotherapy for treatment of alcoholism stems primarily from the early concept that alcoholism is simply an outward sign of some deeper underlying emotional problem. While there is no doubt that alcoholics, like anyone else, can have psychiatric disorders (indeed, in secondary alcoholism the psychiatric problem is a major factor in the whole disease picture), there is no evidence that any one specific form of psychotherapy is beneficial. Psychotherapeutic approaches-In general, supportive therapy and "reality therapy"ll (direct problem solving) have contributed the most to successful long-term results (where psychotherapy was needed at all) at the least cost in counselor training and patient time. Almost all alcoholism treatment programs use some form of group therapy. This includes didactic groups, where information about the physiology of alcoholism, its physical psychologic, and social effects, and the consequences to family and job are discussed and strategies for control are presented to the group. The purpos•~ of these groups is to help change attitudes and beb.avior through increased knowledge of the disease. My view of psychotherapy in alcoholism is that, like any potent therapy, it should be used cautiously and at appropriate times in appropriate cases. The use of intense psychotherapy for every alcoholic would be as foolish (and potentially as dangerous) as applying a cast 1:0 the right leg of everyone who came into the offtce. When psychotherapy is needed, the more pragmatic reality therapy seems to have the best result:; with alcoholics. Results-Emrick 12 reviewed 265 studies in which psychotherapy was the primary treatment
146
for alcoholism and found that about one third of the patients were abstinent at follow-up and another one third were "improved" but still drinking. In a subsequent study 13 he further noted that abstinence rates were no different in patients assigned to no treatment or to minimal treatment than in groups given extensive psychotherapeutic treatment. Behavior modification Behavior modification, in general, involves applying techniques worked out in the experimental laboratory in a consistent, organized manner to modify a person's behavior. After careful analysis of the current behavior, a program is individually tailored to achieve the desired target behavior. Behavior modification techniques are usually combined with other procedures such as group therapy, use of disulfiram, or AA membership to form a more comprehensive treatment program. Although results may vary depending on the specific population studied and the specific technique or group of techniques used, outcome studies generally report success rates above 60%. This general background provides a basis for consideration of the various techniques (table 1). A version therapy-This type of conditioning, perhaps the oldest and most thoroughly studied behavioral procedure,t 4 usually involves inducing nausea with a drug such as emetine, then presenting alcohol for the patient to look at, smell, and taste. After several such pairings (average of five as practiced today),ts a level of negative response (aversion) develops to the sight, smell, and taste of alcohol. Another aversion stimulus is a mild electric shock to the forearm (usually the drinking arm). This technique has the advantage of being usable in patients for whom nausea and vomiting might be physically dangerous (eg, those with esophageal varices, severe cardiovascular disease, or other conditions where the stress of vomiting would be
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Alcoholism is a lifelong di-se in the sense that the alcoholic can never return to drinking. Therefore, the patient should be seen by the physician at regular intervals for life.
hazardous). One recent studyt6 showed no difference in the two-year outcome between patients treated with emetine and those treated with electric shock. Covert sensitization-In this procedure alcoholic patients are taught muscle relaxation, after which they are instructed to imagine that they are about to drink their favorite alcoholic beverage in a customary setting but that they experience nausea and vomiting.' 7 In addition to therapistguided sessions, patients are given homework assignments in which they practice visualizing the scene twice a day. Cautela 17 reported that treatment periods of 6 to 12 months are required, and he and others'S.' 9 advocate the supplemental use of other therapeutic procedures. Covert sensitization and an almost identical technique termed verbal aversion therapy20. 21 have been reported to be successful in a majority of cases. Other behavioral approaches-Hypnosis, which has been used off and on in the treatment of alcoholism for many years, seems to have little long-term benefit as a primary therapeutic procedure22 but may be of considerable benefit in those patients who learn the technique of self-hypnosis for relaxation. Other frequently used behavior modification procedures in alcoholism are described briefly in table I. Alcoholics Anonymous AA is the most widely known and available treatment resource for alcoholics. The fellowship, made up of persons who are themselves "recovering" from alcoholism, established a milieu in which alcoholics have help available 24 hours a day, seven days a week by just picking up a telephone.23 Early in the recovery phase they are usually encouraged to attend AA meetings daily. Here, members share their experiences in recovery, demonstrating to new members that they are not alone and that a sober life-style is possible. continued
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Table 1. Behavior modification therapy for alcoholism Technique
Description
Aversion therapy
Negative conditioning by inducing nausea or applying mild electric shock, then presenting alcohol
Covert sensitization
Teaching of muscle relaxation, after which patient is instructed to imagine being about to drink a favorite alcoholic beverage in a customary setting but experiencing nausea and vomiting
Hypnosis
Self-hypnosis for relaxation
Behavioral contracting
Specifying a behavior (eg. taking disulfiram daily) mutually agreed to by patient and physician and writing up a formal contract which patient signs
Incompatible response
Analysis of specific danger areas related to drinking and development of nondrinking alternatives (eg. taking a different route home from work to avoid passing a favorite bar)
Role playing
Developing rehearsed responses to specific situations where drinks are likely to be offered, so they can be turned down in a comfortable manner (usually combined with other techniques such as assertiveness training)
Relaxation training
Training to control tension and insomnia without use of potentially addictive sedatives and tranquilizers. Patients are also ur!;led to develop recreational. creative. or other healthful outlets for tension
147
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
The spouse and childrEtn of an alcoholic patient may be as sick as the patient and need eldensive counseling and supportive care.
Membership spans the entire socioeconomic range. Each group tends to develop its own personality, so that a patient who does not fit comfortably into one may do well in another. Two offshoots of AA that may be of great value to the family of an alcoholic patient are Alanon (for the spouse) and Alateen (for the children). These groups offer discussions and strategies for leading a normal life despite living with an alcoholic. Leach,24 analyzing publinhed studies of abstinence rates for AA members in the United States and in other countries, reported that roughly one third were abstinent for one to five years and about one fourth more were abstinent for five years or more. Follow-up Follow-up is an extremely important part of any alcoholic treatment program. Alcoholism is a lifelong disease, at least in the sense that the patient cannot be expected ever to return to social drinking. In this respect, an alcoholic patient should be regarded in much th~ same light as the diabetic and should be seen at regular intervals for life. In follow-up visits the "rough spots" can be ironed out. Situations in which the urge to have a drink is strong can be discussed and strategies can be developed to get the patient ·:hrough these periods without alcohol. These follow-up visits also offer the physician the opportunity to monitor the patient's state of health and to give continued encouragement. Minor problems of maintaining an abstinent life-style can thus be handled in a timely manner before they develop into larger problems which may eventually precipitate a relapse. Patients should probably be ~:een weekly for the first two or three months (the most critical time for relapse). The frequency may thm be gradually decreased, depending on the individual case, so that visits are monthly from six months until the end of
the first year. Patients should then be seen every one to two months for the second year and at least quarterly from then on. It generally takes two years for alcoholics to develop a well-established set of nondrinking habit patterns so that they do not have to be constantly on guard against taking a drink out of habit. Family participation Alcoholism is generally conceded to be a "family disease." Therefore, every effort should be made to include the family in the treatment plan of the alcoholic patient. Educating family members as to the nature and natural course of the disease is essential. In many cases, the spouse and children may be at least as sick as the alcoholic and may need extensive counseling and supportive care. Community resources, including Alanon and Alateen, may be of great value in these cases. Conclusions Whatever method of therapy is undertaken, the goal in treating alcoholic patients should be total abstinence. Despite occasional reports suggesting that some alcoholics may be taught controlled drinking, the majority of "alcohologists" agree that abstinence is the preferred and the safest goal. Address reprint requests to James W. Smith, MD, Schick's Shade! Hospital, lnc, 12101 Arnbaum Blvd SW, Seattle, WA 98146. CME Credit Quiz begins on page 155. References I. Ellinwood EH Jr: Assault and homicide associated with amphetamine abuse. Am J Psychiatry 127:1170-1175, 1971 2. Schuckit MA: Treatment of alcoholism in office and outpatient settings. In Mcndelson JH, Mello NK (Editors): Diagnosis and Treatment of Alcoholism (in press) 3. Woodruff RA, Goodwin DW, Guze SB: Psychiatric Diagnosis. New York, Oxford University Press Inc, 1974 4. Hollister LE: Clinical Use of Psychotherapeutic Drugs. Springfield, Ill, Charles C Thomas Publisher, 1976
continued on page 152
148
VOL 64/NO &/DECEMBER 1978/POSTGRADUATE MEDICINE
Zaroxolyn (metolazone) Pennwalt
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Long-acting Step-1 antihypertensive diuretic Before prescribing, see complete prescribing information in the package insert. or in PDR. or available fr·Jm your Pennwalt representative. The following is a brief summary. Indications: Zaroxolyn (metolazone) is an antihypertensive diuretic indicated for the management of mild to moderate eSl:ential hypertension as sole therapeutic agent and in the more severe forms of hypertension in conjunction with other antihypertensive agents. Also, edema associated with heart failure anj renal disease. Routine use in pregnancy is inappropriate. C:ontraindications: Anuria. hepatic coma or precoma; allergy or hypersensitivity to Zaroxolyn. Warnings: In theory cross-allergy may occur in patients allergic to sulfonamide-derived druqs, thiazides or quinethazone. Hypokalemia may occur, and is a particular hazard in digitalized patients; dangerous or fatal arrhythmias may occur. Azotemia and hyperuricemia may be noted or precipitated. Considerable potentiation may occur when !liven concurrently with furosemide. When used concurrently w th other antihypertensives, the dosage of the other agents should be reduced. Use with potassium-sparing diuretics may cause potassium retention and hyperkalemia. Administration to women of childbearing age requires that potential benefits oe weighed against possible hazards to the fetus. Zaroxolyn appaars in the breast milk. Not for pediatric use. Precautions: Perform periodic examination of serum electrolytes. BUN, uriis and hypokalemia. These determinations are particularly impor:ant when there is excessive vomiting or diarrhea. or when pamnteral fluids are administered. Patients treated with diuretics or corticosteroids are susceptible to potassium depletion. Caution should be observed when administering to patients with gout or hyperuricemia or those with severely impaired renal function. Insulin requirements may be affected in diabetes. Hyperglycemia and glycosuria may occur in latent diabetes. Chloride deficit and hypochloremic alkalosis may occur. Orthosta·:ic hypotension may occur. Dilutional hyponatremia may occur. Atlverse Reactions: Constipation. nausea, vomiting, anorexia, disrrhea. bloating, epigastric distress. intrahepatic cholestatic jaundice, hepatitis, syncope, dizziness. drowsiness. vertigo, headache, orthostatic hypotension. excessive volume depletion, hemoconcentration. venous thrombosis, palpitation, chest pain, le·ukopenia, urticaria, other skin rashes, dryness of mouth, hypokale!mia, hyponatremia, hypochloremia, hypochloremic alkalosis, hyperuricemia, hyperglycemia. glycosuria, raised BUN or creatinine. fatigue, muscle cramps or spasm, weakness. restlessness, eh ilis, and acute gouty attacks. Usual Initial Once-Daily Dosages: m Id to moderate essential hypertension-2~ to S mg; edema of cardiac failureS to 10 mg; edema of renal disease-S to 20 mg. Dosage adjustment is usually necessary during the course of therapy. How Supplied: Tablets, 2~. Sand 10 mg.
Reference 1. Sambhi MP, Eggena P, Barrett JD. et al: A crossoJer comparison of the effects of metolazone and hydrochlorothiazide therapy on blood pressure and renin angiotensin system in patients with essential hypertension. in Sambhi MP (ed): Systemic Effects of Antihyperten::ive Agents. New York. Stratton. 1976.
5. Merry J, Reynolds CM, Bailey J, et al: Prophylactic treatment of alcoholism by lithium carbonate. Lancet 2:481-482, 1976 6. Sauter AM, Boss D. Von Wartburg JP: Reevaluation of the disulfiram-alcohol reaction in man. J Stud Alcohol 38:1680-1695, 1977 7. Wilson A: Disulfiram implantation in alcoholism treatment: A review. J Stud Alcohol36:555-565, 1975 8. Benor D, Ditman KS: Tranquilizers in the management of alcoholics: A review of the literature to 1964, Pt 11. J Clin Pharmacal 7:17-25, 1967 9. Viamontes JA: Review of drug effectiveness in the treatment of alcoholism. Am J Psychiatry 138:1570-1571, 1972 10. Megavitamin and orthomolecular therapy in psychiatry: Statement by American Psychiatric Association. Nutr Rev 32(Suppl):44-47, 1974 11. Glasser WR: Reality Therapy. New York, Harper & Row Publishers Inc. 1965 12. Emrick CD: A review of psychologically oriented treatment of alcoholism. I. The use and interrelationship of outcome criteria and drinking behavior following treatment. J Stud Alcohol 35:523-549, 1974 13. - - - : A review of psychologically oriented treatment of alcoholism. II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. J Stud Alcoho136:88-108, 1975 14. Voegtlin WL, Lemere F, Broz WR: Conditioned reflex therapy of alcoholic addiction: An evaluation of present results in light of previous experiences with this method. J Stud Alcohol 1:501-516, 1940 15. Smith JW: Conditioned reflex aversion treatment in alcoholism. (Suppl) Western Med J, Dec 1966 16. Jackson TR, Smith JW: Comparison of two aversion treatment methods for alcoholism. J Stud Alcohol39: 187-191, 1978 17. Cautela JR: The treatment of alcoholism by covert sensitization. Psychother: Theory, Res Practice 7(2):86-90, 1970 18. Lazarus AA: Aversion therapy and sensory modalities: Clinical impressions. Percept Mot Skills 27:178, 1968 19. Bandura A: Principles of Behavior Modification. New York, Holt Rinehart & Winston, 1969 20. Anant SS: A note on the treatment of alcoholics by a verbal aversion technique. Canadian Psychol8a(l):l9-22, 1967 21. Elkins RL: Aversion therapy for alcoholism: Chemical, electrical or verbal imaginary? Int J Addict 10(2): 157-209, 1975 22. Edwards G: Hypnosis in treatment of alcohol addiction: Controlled trial, with analysis of factors affecting outcome. J Stud Alcohol27:221-241, 1966 23. Alcoholics Anonymous. J A MA 236: 1505-1506, 1976 24. Leach B: Does Alcoholics Anonymous really work? In Bourne PG, Fox R (Editors): Alcoholism: Progress in Research and Treatment. New York, Academic Press Inc, 1973
Pennwalt Prescription Products Pharmaceutical Division Pennwalt Corporation Rochester. New York 14603
VOL 64/NO &/DECEMBER 1978/POSTGRADUATE MEDICINE
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Rehabilitation for alcoholics James W. Smith To cite this article: James W. Smith (1978) Rehabilitation for alcoholics, Postgraduate Medicine, 64:6, 143-149, DOI: 10.1080/00325481.1978.11715006 To link to this article: http://dx.doi.org/10.1080/00325481.1978.11715006
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 13 August 2017, At: 13:06
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Seventh of seven symposium articles in this issue
Rehabilitation for alcoholics Consider What cautions should be observed in prescribing disulfiram? Roughly what success rates with behavior modification techniques are being reported in the treatment of alcoholics? How often and for how long should the recovered alcoholic be seen for follow-up?
James W. Smith, MD
Chemotherapy, psychotherapy, behavior modification, and participation in Alcoholics Anonymous have been used successfully to treat the alcoholic patient, but all have limitations and some have potential dangers. All require longterm follow-up and family participation.
Once an alcoholic patient has agreed to enter treatment, the primary care physician must decide whether hospitalization is necessary and what treatment approach or combination of approaches to use. The decision to hospitalize or not depends on the patient's medical and psychiatric condition and general life situation. The treatment techniques described here are divided into the categories of chemotherapy, psychotherapy, and behavior modification. The benefits and potential dangers of various approaches in each category are discussed, together with a brief description of Alcoholics Anonymous (AA) and a discussion of the importance of follow-up and of family participation in the treatment plan. Inpatient vs outpatient treatment
One major factor in deciding whether to hospitalize the alcoholic patient is whether a serious medical problem exists in addition to alcoholism. In general, I believe that patients with other serious problems, such as heart disease, pancreatitis, or advanced liver disease, should be treated in the hospital, where intensive medical attention is available and where the effects of withdrawal can be monitored and managed. A second major factor is whether the patient has a condition which renders him or hernonfunctional in the home setting (eg, organic brain syndrome) or is in a serious crisis which would be best handled in a more sheltered environment than could be provided in an outpatient setting. A third factor is whether a severe psychiatric disturbance is present that may cause the patient continued VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
143
Inpatient treatment ctf alcohol ~----------·--------.----------------------
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
addiction permits thu patient to get away from the daily c:ues for drinking and to focus on ah::oholism without the distracti•J,ns of day-to-day problems ;at home and at work.
to harm himself or herself or to be a threat to others. Alcohol in high doses, even in a patient with primary alcoholism, can cause a clinical picture of paranoia which may be identtcal to that of paranoid schizophrenia or psychosis resulting from amphetamine or barbiturate .'lbuse. 1 Such a disturbance will usually clear after days or weeks of abstinence from alcohol even without specific antipsychotic medication. 2 Tie patient may also have a primary affective disorder (either depressive or manic-depressive illness:! with secondary alcoholism*). All such patients need skilled psychiatric evaluation and treatment by therapists familiar with alcoholism. The patient with alcoholism secondary to affective:: disorder may require tricyclic antidepressants for control of depression or lithium for contr·)l of mania, 4.5 but there is no evidence that these drugs are of use in controlling alcoholism per se. 5 When a patient is referred to inpatient treat*See page 123.
James W. Smith Dr S nith is director, Shick's Shade! Hospital, Seattle, and chief medical officer, Shick Laboratones, !ne, Los Angeles. His resean h has centered primarily on the physiology and treatment of alcoholism.
144
ment specialists, it is important that the primary care physician maintain contact with both patient and treatment personnel to give encouragement during hospitalization and to facilitate effective continuation of treatment once the patient returns home. If outpatient treatment is the choice, the primary care physician must decide whether to refer the patient to an established alcoholism outpatient treatment resource in the community or to undertake full responsibility for care in his or her own office. If referral is chosen, the primary care physician should stay in close contact with the referral agency and should, of course, continue to manage any medical problems. A third choice available to most physicians is to undertake primary responsibility for treatment but to also use community resources such as AA, clergymen, or counselor consultants. My bias is toward inpatient treatment, at least initially. This affords the patient an opportunity to be sequestered for a time from the many daily cues for drinking and to focus attention on alcoholism in a concentrated rather than in a sporadic, piecemeal fashion in addition to coping with the day-today problems of living. Chemotherapy Disulfiram-An exhaustive description of the mechanism of action of this widely used chemotherapeutic agent can be found in Sauter and associates.6 The general principle involved is that alcohol ingestion after a course of disulfiram therapy causes a severe reaction. A loading dose of 0.5 gm daily for five days is given, followed by 0.25 gm daily thereafter. If alcohol in any form (cough syrup as well as whiskey) is drunk within one week (in some cases up to two weeks) of discontinuing use of the drug, unpleasant symptoms occur. These include flushing, throbbing headache, respiratory difficulties, nausea and vomiting, palpitations, tachycardia, hypotension, and syncope.
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Disulfiram effectively curbs the ability to enjoy drinking but unfortunately does not curb the desire to drink.
Patients, who must be thoroughly educated about the process beforehand, know that if they give in to an urge to drink they will be severely uncomfortable or ill. Disulfiram does not decrease the desire for a drink, and unfortunately many alcoholics can plan their drinking a week or more ahead and simply stop taking the drug. This problem may be countered by having patients on a monitored disulfiram program, in which they come to the physician's office (or other designated place) to take each dose under supervision. Subcutaneous implantation of disulfiram pellets has been attempted experimentally but has been rather disappointing because of the low blood levels achieved. 7 The technique has not been approved for use in the United States. There are potential dangers involved in taking disulfiram. Caution is necessary to avoid adverse
Illustration: Alan E. Cober
VOL 641NO 61DECEMBER 19781POSTGRADUATE MEDICINE
drug interactions, which will occur with any drug having acetaldehyde as one of its products of metabolism (eg, paraldehyde). Disulfiram may also affect the metabolism of drugs such as phenytoin or the anticoagulants, with the result that toxic blood levels may be reached with standard doses of these drugs. Side effects of disulfiram include skin rash, drowsiness or easy fatigability, headache, bad taste in the mouth, garlic-like odor on the breath, impotence, and (rarely) peripheral neuropathy. Disulfiram should be used only with extreme caution in patients with other serious conditions such as cerebral damage, chronic or acute nephritis, liver failure, severe diabetes, and severe cardiovascular disease. Citrated calcium carbimide-This drug has an action similar to that of disulfiram. It is available in Canada and some other countries but has not been cleared by the Food and Drug Administration for use in the United States. Sedatives and tranquilizers-These drugs have been the most used and perhaps the most controversial of any used for alcoholism, beginning with the bromides, then the barbiturates, and later still the antianxiety and antipsychotic drugs (eg, chlordiazepoxide, diazepam, chlorpromazine). Literature surveys8·9 of the use of such drugs in alcoholism treatment have concluded that no drug per se has been shown to be effective for this purpose. While these drugs may be lifesaving during alcohol withdrawal, beyond this point most "alcohologists" would agree that hypnotics and tranquilizers have no place in the treatment of primary alcoholism.2 Megavitamin therapy-Enthusiasts for megavitamin therapy (ie, vitamins in very high doses) have listed alcoholism among the indications for this type of orthomolecular psychiatry. While proponents of megavitamin therapy claim beneficial results, the American Psychiatric Association reports that these claims have not been continued
145
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Psychotherapy, like any potent therapy, should be use!d cautiously and selectively. "Real i·ty therapy" seems to have the bes1: results.
confirmed and that "serious and major attempts to demonstrate the value of ni•;otinic acid have uniformly been negative in the hands of independent investigators. "10 Psychotherapy The high level of interest in ::lsychotherapy for treatment of alcoholism stems primarily from the early concept that alcoholism is simply an outward sign of some deeper underlying emotional problem. While there is no doubt that alcoholics, like anyone else, can have psychiatric disorders (indeed, in secondary alcoholism the psychiatric problem is a major factor in the whole disease picture), there is no evidence that any one specific form of psychotherapy is beneficial. Psychotherapeutic approaches-In general, supportive therapy and "reality therapy"ll (direct problem solving) have contributed the most to successful long-term results (where psychotherapy was needed at all) at the least cost in counselor training and patient time. Almost all alcoholism treatment programs use some form of group therapy. This includes didactic groups, where information about the physiology of alcoholism, its physical psychologic, and social effects, and the consequences to family and job are discussed and strategies for control are presented to the group. The purpos•~ of these groups is to help change attitudes and beb.avior through increased knowledge of the disease. My view of psychotherapy in alcoholism is that, like any potent therapy, it should be used cautiously and at appropriate times in appropriate cases. The use of intense psychotherapy for every alcoholic would be as foolish (and potentially as dangerous) as applying a cast 1:0 the right leg of everyone who came into the offtce. When psychotherapy is needed, the more pragmatic reality therapy seems to have the best result:; with alcoholics. Results-Emrick 12 reviewed 265 studies in which psychotherapy was the primary treatment
146
for alcoholism and found that about one third of the patients were abstinent at follow-up and another one third were "improved" but still drinking. In a subsequent study 13 he further noted that abstinence rates were no different in patients assigned to no treatment or to minimal treatment than in groups given extensive psychotherapeutic treatment. Behavior modification Behavior modification, in general, involves applying techniques worked out in the experimental laboratory in a consistent, organized manner to modify a person's behavior. After careful analysis of the current behavior, a program is individually tailored to achieve the desired target behavior. Behavior modification techniques are usually combined with other procedures such as group therapy, use of disulfiram, or AA membership to form a more comprehensive treatment program. Although results may vary depending on the specific population studied and the specific technique or group of techniques used, outcome studies generally report success rates above 60%. This general background provides a basis for consideration of the various techniques (table 1). A version therapy-This type of conditioning, perhaps the oldest and most thoroughly studied behavioral procedure,t 4 usually involves inducing nausea with a drug such as emetine, then presenting alcohol for the patient to look at, smell, and taste. After several such pairings (average of five as practiced today),ts a level of negative response (aversion) develops to the sight, smell, and taste of alcohol. Another aversion stimulus is a mild electric shock to the forearm (usually the drinking arm). This technique has the advantage of being usable in patients for whom nausea and vomiting might be physically dangerous (eg, those with esophageal varices, severe cardiovascular disease, or other conditions where the stress of vomiting would be
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Alcoholism is a lifelong di-se in the sense that the alcoholic can never return to drinking. Therefore, the patient should be seen by the physician at regular intervals for life.
hazardous). One recent studyt6 showed no difference in the two-year outcome between patients treated with emetine and those treated with electric shock. Covert sensitization-In this procedure alcoholic patients are taught muscle relaxation, after which they are instructed to imagine that they are about to drink their favorite alcoholic beverage in a customary setting but that they experience nausea and vomiting.' 7 In addition to therapistguided sessions, patients are given homework assignments in which they practice visualizing the scene twice a day. Cautela 17 reported that treatment periods of 6 to 12 months are required, and he and others'S.' 9 advocate the supplemental use of other therapeutic procedures. Covert sensitization and an almost identical technique termed verbal aversion therapy20. 21 have been reported to be successful in a majority of cases. Other behavioral approaches-Hypnosis, which has been used off and on in the treatment of alcoholism for many years, seems to have little long-term benefit as a primary therapeutic procedure22 but may be of considerable benefit in those patients who learn the technique of self-hypnosis for relaxation. Other frequently used behavior modification procedures in alcoholism are described briefly in table I. Alcoholics Anonymous AA is the most widely known and available treatment resource for alcoholics. The fellowship, made up of persons who are themselves "recovering" from alcoholism, established a milieu in which alcoholics have help available 24 hours a day, seven days a week by just picking up a telephone.23 Early in the recovery phase they are usually encouraged to attend AA meetings daily. Here, members share their experiences in recovery, demonstrating to new members that they are not alone and that a sober life-style is possible. continued
VOL 64/NO 6/DECEMBER 1978/POSTGRADUATE MEDICINE
Table 1. Behavior modification therapy for alcoholism Technique
Description
Aversion therapy
Negative conditioning by inducing nausea or applying mild electric shock, then presenting alcohol
Covert sensitization
Teaching of muscle relaxation, after which patient is instructed to imagine being about to drink a favorite alcoholic beverage in a customary setting but experiencing nausea and vomiting
Hypnosis
Self-hypnosis for relaxation
Behavioral contracting
Specifying a behavior (eg. taking disulfiram daily) mutually agreed to by patient and physician and writing up a formal contract which patient signs
Incompatible response
Analysis of specific danger areas related to drinking and development of nondrinking alternatives (eg. taking a different route home from work to avoid passing a favorite bar)
Role playing
Developing rehearsed responses to specific situations where drinks are likely to be offered, so they can be turned down in a comfortable manner (usually combined with other techniques such as assertiveness training)
Relaxation training
Training to control tension and insomnia without use of potentially addictive sedatives and tranquilizers. Patients are also ur!;led to develop recreational. creative. or other healthful outlets for tension
147
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
The spouse and childrEtn of an alcoholic patient may be as sick as the patient and need eldensive counseling and supportive care.
Membership spans the entire socioeconomic range. Each group tends to develop its own personality, so that a patient who does not fit comfortably into one may do well in another. Two offshoots of AA that may be of great value to the family of an alcoholic patient are Alanon (for the spouse) and Alateen (for the children). These groups offer discussions and strategies for leading a normal life despite living with an alcoholic. Leach,24 analyzing publinhed studies of abstinence rates for AA members in the United States and in other countries, reported that roughly one third were abstinent for one to five years and about one fourth more were abstinent for five years or more. Follow-up Follow-up is an extremely important part of any alcoholic treatment program. Alcoholism is a lifelong disease, at least in the sense that the patient cannot be expected ever to return to social drinking. In this respect, an alcoholic patient should be regarded in much th~ same light as the diabetic and should be seen at regular intervals for life. In follow-up visits the "rough spots" can be ironed out. Situations in which the urge to have a drink is strong can be discussed and strategies can be developed to get the patient ·:hrough these periods without alcohol. These follow-up visits also offer the physician the opportunity to monitor the patient's state of health and to give continued encouragement. Minor problems of maintaining an abstinent life-style can thus be handled in a timely manner before they develop into larger problems which may eventually precipitate a relapse. Patients should probably be ~:een weekly for the first two or three months (the most critical time for relapse). The frequency may thm be gradually decreased, depending on the individual case, so that visits are monthly from six months until the end of
the first year. Patients should then be seen every one to two months for the second year and at least quarterly from then on. It generally takes two years for alcoholics to develop a well-established set of nondrinking habit patterns so that they do not have to be constantly on guard against taking a drink out of habit. Family participation Alcoholism is generally conceded to be a "family disease." Therefore, every effort should be made to include the family in the treatment plan of the alcoholic patient. Educating family members as to the nature and natural course of the disease is essential. In many cases, the spouse and children may be at least as sick as the alcoholic and may need extensive counseling and supportive care. Community resources, including Alanon and Alateen, may be of great value in these cases. Conclusions Whatever method of therapy is undertaken, the goal in treating alcoholic patients should be total abstinence. Despite occasional reports suggesting that some alcoholics may be taught controlled drinking, the majority of "alcohologists" agree that abstinence is the preferred and the safest goal. Address reprint requests to James W. Smith, MD, Schick's Shade! Hospital, lnc, 12101 Arnbaum Blvd SW, Seattle, WA 98146. CME Credit Quiz begins on page 155. References I. Ellinwood EH Jr: Assault and homicide associated with amphetamine abuse. Am J Psychiatry 127:1170-1175, 1971 2. Schuckit MA: Treatment of alcoholism in office and outpatient settings. In Mcndelson JH, Mello NK (Editors): Diagnosis and Treatment of Alcoholism (in press) 3. Woodruff RA, Goodwin DW, Guze SB: Psychiatric Diagnosis. New York, Oxford University Press Inc, 1974 4. Hollister LE: Clinical Use of Psychotherapeutic Drugs. Springfield, Ill, Charles C Thomas Publisher, 1976
continued on page 152
148
VOL 64/NO &/DECEMBER 1978/POSTGRADUATE MEDICINE
Zaroxolyn (metolazone) Pennwalt
Downloaded by [Australian Catholic University] at 13:06 13 August 2017
Long-acting Step-1 antihypertensive diuretic Before prescribing, see complete prescribing information in the package insert. or in PDR. or available fr·Jm your Pennwalt representative. The following is a brief summary. Indications: Zaroxolyn (metolazone) is an antihypertensive diuretic indicated for the management of mild to moderate eSl:ential hypertension as sole therapeutic agent and in the more severe forms of hypertension in conjunction with other antihypertensive agents. Also, edema associated with heart failure anj renal disease. Routine use in pregnancy is inappropriate. C:ontraindications: Anuria. hepatic coma or precoma; allergy or hypersensitivity to Zaroxolyn. Warnings: In theory cross-allergy may occur in patients allergic to sulfonamide-derived druqs, thiazides or quinethazone. Hypokalemia may occur, and is a particular hazard in digitalized patients; dangerous or fatal arrhythmias may occur. Azotemia and hyperuricemia may be noted or precipitated. Considerable potentiation may occur when !liven concurrently with furosemide. When used concurrently w th other antihypertensives, the dosage of the other agents should be reduced. Use with potassium-sparing diuretics may cause potassium retention and hyperkalemia. Administration to women of childbearing age requires that potential benefits oe weighed against possible hazards to the fetus. Zaroxolyn appaars in the breast milk. Not for pediatric use. Precautions: Perform periodic examination of serum electrolytes. BUN, uriis and hypokalemia. These determinations are particularly impor:ant when there is excessive vomiting or diarrhea. or when pamnteral fluids are administered. Patients treated with diuretics or corticosteroids are susceptible to potassium depletion. Caution should be observed when administering to patients with gout or hyperuricemia or those with severely impaired renal function. Insulin requirements may be affected in diabetes. Hyperglycemia and glycosuria may occur in latent diabetes. Chloride deficit and hypochloremic alkalosis may occur. Orthosta·:ic hypotension may occur. Dilutional hyponatremia may occur. Atlverse Reactions: Constipation. nausea, vomiting, anorexia, disrrhea. bloating, epigastric distress. intrahepatic cholestatic jaundice, hepatitis, syncope, dizziness. drowsiness. vertigo, headache, orthostatic hypotension. excessive volume depletion, hemoconcentration. venous thrombosis, palpitation, chest pain, le·ukopenia, urticaria, other skin rashes, dryness of mouth, hypokale!mia, hyponatremia, hypochloremia, hypochloremic alkalosis, hyperuricemia, hyperglycemia. glycosuria, raised BUN or creatinine. fatigue, muscle cramps or spasm, weakness. restlessness, eh ilis, and acute gouty attacks. Usual Initial Once-Daily Dosages: m Id to moderate essential hypertension-2~ to S mg; edema of cardiac failureS to 10 mg; edema of renal disease-S to 20 mg. Dosage adjustment is usually necessary during the course of therapy. How Supplied: Tablets, 2~. Sand 10 mg.
Reference 1. Sambhi MP, Eggena P, Barrett JD. et al: A crossoJer comparison of the effects of metolazone and hydrochlorothiazide therapy on blood pressure and renin angiotensin system in patients with essential hypertension. in Sambhi MP (ed): Systemic Effects of Antihyperten::ive Agents. New York. Stratton. 1976.
5. Merry J, Reynolds CM, Bailey J, et al: Prophylactic treatment of alcoholism by lithium carbonate. Lancet 2:481-482, 1976 6. Sauter AM, Boss D. Von Wartburg JP: Reevaluation of the disulfiram-alcohol reaction in man. J Stud Alcohol 38:1680-1695, 1977 7. Wilson A: Disulfiram implantation in alcoholism treatment: A review. J Stud Alcohol36:555-565, 1975 8. Benor D, Ditman KS: Tranquilizers in the management of alcoholics: A review of the literature to 1964, Pt 11. J Clin Pharmacal 7:17-25, 1967 9. Viamontes JA: Review of drug effectiveness in the treatment of alcoholism. Am J Psychiatry 138:1570-1571, 1972 10. Megavitamin and orthomolecular therapy in psychiatry: Statement by American Psychiatric Association. Nutr Rev 32(Suppl):44-47, 1974 11. Glasser WR: Reality Therapy. New York, Harper & Row Publishers Inc. 1965 12. Emrick CD: A review of psychologically oriented treatment of alcoholism. I. The use and interrelationship of outcome criteria and drinking behavior following treatment. J Stud Alcohol 35:523-549, 1974 13. - - - : A review of psychologically oriented treatment of alcoholism. II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. J Stud Alcoho136:88-108, 1975 14. Voegtlin WL, Lemere F, Broz WR: Conditioned reflex therapy of alcoholic addiction: An evaluation of present results in light of previous experiences with this method. J Stud Alcohol 1:501-516, 1940 15. Smith JW: Conditioned reflex aversion treatment in alcoholism. (Suppl) Western Med J, Dec 1966 16. Jackson TR, Smith JW: Comparison of two aversion treatment methods for alcoholism. J Stud Alcohol39: 187-191, 1978 17. Cautela JR: The treatment of alcoholism by covert sensitization. Psychother: Theory, Res Practice 7(2):86-90, 1970 18. Lazarus AA: Aversion therapy and sensory modalities: Clinical impressions. Percept Mot Skills 27:178, 1968 19. Bandura A: Principles of Behavior Modification. New York, Holt Rinehart & Winston, 1969 20. Anant SS: A note on the treatment of alcoholics by a verbal aversion technique. Canadian Psychol8a(l):l9-22, 1967 21. Elkins RL: Aversion therapy for alcoholism: Chemical, electrical or verbal imaginary? Int J Addict 10(2): 157-209, 1975 22. Edwards G: Hypnosis in treatment of alcohol addiction: Controlled trial, with analysis of factors affecting outcome. J Stud Alcohol27:221-241, 1966 23. Alcoholics Anonymous. J A MA 236: 1505-1506, 1976 24. Leach B: Does Alcoholics Anonymous really work? In Bourne PG, Fox R (Editors): Alcoholism: Progress in Research and Treatment. New York, Academic Press Inc, 1973
Pennwalt Prescription Products Pharmaceutical Division Pennwalt Corporation Rochester. New York 14603
VOL 64/NO &/DECEMBER 1978/POSTGRADUATE MEDICINE
