Treatment of alcoholism
When talking about chemical dependence, the biggest concern is with illicit drugs, cocaine, marijuana, crack, ecstasy, among many others. However, the great enemy is camouflaged under the mantle of the socially acceptable. Alcohol is not even considered a drug that causes physical and psychological dependence by much of society. Its sale is free and it integrates the current culture linked to leisure and sociability. A meeting at friends' house, happy hour after a rough day, the ballad on Saturday night, the stop at the bar outside the office are meaningless without the alcohol.
The relaxing effect of the initial doses, however, disappears with increasing consumption. If living with a drunk person bothers you, this is nothing in the face of the ills that alcohol can cause and are not restricted to liver disease. The emotional lability that instantly turns the laughing alcoholic into a violent individual is responsible not only for the increase in crime but also for the disruption of many families.
Drinking in moderation is possible, but rare are those who acknowledge being abusive and harmful use of alcohol. Many are still not dependent, but incur risks that should and could be avoided. One can not forget that the vast majority of traffic accidents occur when a person is drunk driving.
ALCOHOL CONSUMPTION STANDARDS
Drauzio - The number of people who drink is enormous. From the medical point of view when you say that a person is an alcoholic?
Ronaldo Laranjeira - A distinction must be made between three patterns of alcohol consumption. There are those who have no problem drinking, those who abuse alcohol and those who are addicted to it. Today it is more or less established that the person without problems, if he is a healthy man, can drink the equivalent of two or three glasses of wine, or two glasses of draft, or a small dose of distillate. When it comes to women, the doses should be a little smaller, since they are more sensitive to the biological damage caused by the drink. This contained pattern of use of alcohol is what most people develop.
Substantial numbers of people, however, make harmful use of alcohol because occasionally or regularly drinks above the above amounts. If at a party, the person drinks five glasses of beer or three of whiskey, is ingesting more than his body tolerates in terms of alcohol intoxication.
It is clear that from a biological point of view drinking three times a dose of whiskey or drip regularly causes significant biological impact such as hypertension or gastric and liver diseases related to alcohol consumption. The person may not be dependent, but nevertheless does not stop injuring the body when exaggerating in the drink.
In Brazil, 13% of the adult male population have problems with alcohol and two thirds of those 13% abuse their use. They drink three servings of whiskey - or a substantial serving worth three - and say, I'm not an alcoholic because I only drink it and nothing else.
Drauzio: Would you classify these people as alcoholics?
Ronaldo Laranjeira - No. Technically the World Health Organization considers that these people use harmful alcohol, but they do not become addicted, because they can spend a few days without drinking, do not drink in the morning nor do they feel the need to drink at other times. Many adopt a fairly regular pattern of consumption. Sometimes they only drink on weekends, for example, but drink large quantities which do not preserve them from the harmful physical and behavioral effects of alcohol.
In Brazil, this pattern of use is becoming typical of adolescents. More exposed to the culture that values and facilitates the consumption of alcohol than the young people of years ago, exaggerate in the doses at the weekends. Studies leave no doubt that this progressive increase in consumption is directly related to the increase in the number of traffic or domestic accidents and cases of violence.
Harmful use of alcohol always involves risk: physical risk to health and behavioral risk to the environment. A complex society like ours is not equipped to protect the intoxicated individual. Numerous research on the subject makes clear the great social cost of harmful use of alcohol.
We live in a culture that stimulates and facilitates the consumption of alcoholic beverages. The advertisements give the impression that alcohol does not hurt. Many parents say - my child only drinks, does not use drugs - as if that does not represent reason for worries. In fact, if we calculate the number of accidents and deaths caused by drugs, especially among young people, that of alcohol fires in front of any other as the main culprit.BIOLOGICAL DEPENDENCE MECHANISM
Drauzio - What are the people you classify as alcoholics?
Ronaldo Laranjeira - The person becomes an alcoholic as he prolongs and repeats the harmful use of alcohol and the repetitive hangovers arise. What is the hangover? In some ways, it is the brain's response to an excessive dose of alcohol.
There are two components of hangover. One is the toxic component of alcohol. A poor wine causes a worse hangover because it contains more impurities, more methanol, more lead. The other component is the pharmacological action of alcohol in the brain. Alcohol is a central nervous system depressant and the brain responds with the rebound effect if exposed to larger amounts of that substance. Contrary to the relaxing and pleasurable effect of the initial doses, one wakes up the next day to the most excited, irritable, restless and anxious drinking, but it feels better if you start drinking earlier because it relieves the symptoms of the withdrawal crisis. The repetitive hangovers are part of this syndrome and are a way for the body to demonstrate that it resents the lack of alcohol.
From this stage on, a person drinks no more because it is pleasant and socially opportune, but to alleviate the discomfort caused by alcohol itself. This is more or less the biological mechanism of alcohol dependence. When the picture worsens, people are awakened with tremors, sweating, very angry and tense. They drink in the morning to feel calmer and continue drinking all day to relieve withdrawal symptoms.
Drauzio - Are the withdrawal symptoms getting more frequent and intense?
Ronaldo Laranjeira - They are staying, and the person has to use the very substance with which he was intoxicated to relieve the symptoms. This is what is basically the dependency mechanism.
Drauzio - Sometimes people say, I'm not good at drinking today or I'm good at drinking today. What explains this different feeling from one day to the next?
Ronaldo Laranjeira - I think alcohol is a drug that produces so many effects that, sometimes, through a series of physical problems, the person may not feel ready to drink. However, for the vast majority who are in the process of harmful use or addiction there are no more or less comfortable days in relation to alcohol, because the need to drink always speaks louder. This is the best evidence of the transition between harmful use and dependence. The more dependent the person is, the greater the need and the fewer bad days to drink.
Drauzio - Actually, it's going to be a bad day to not drink ...
Ronaldo Laranjeira - The days will be bad if the dependent does not drink. Trembling and irritation increase and he can not control himself or function properly. It is a mechanism similar to that of cigarette addiction which, to a certain extent, is even more powerful. Abstinence symptoms are intense because the brain complains about the lack of nicotine. In the case of alcoholics, he complains about lack of alcohol.
HANGOVER
Drauzio - Why is not hangover always the same? Sometimes it is more intense although the person has drank proportionately less.
Ronaldo Laranjeira - The intensity of the hangover depends, in part, on the quality of the drink. Depending on the amount consumed, generally good Scotch whiskey and the best French wine cause milder hangovers, more related to the pharmacological effect of alcohol.
Mixing beverages - wine, beer, distillates, egg liquor, whatever it is - causes much worse hangovers, because in addition to ethyl alcohol, several other toxic components of these beverages were ingested.In summary, two factors influence the intensity of the hangover: quality and composition of the drink and amount of alcohol ingested.
Drauzio: So the belief that blending is not good has some foundation?
Ronaldo Laranjeira - It has a lot of foundation. Mixing drinks means ingesting other harmful components in addition to the ethyl alcohol.
FAMILY CULTURE AND GENETIC PREDISPOSITION
Drauzio - Certain families have a higher concentration of people with problems related to alcohol use. Are there genetic factors involved with alcoholism?
Ronaldo Laranjeira - To analyze family histories of people involved with alcohol, it is necessary to distinguish between family culture in relation to the use of this substance and genetic aspects. For example, in certain families there are more doctors or lawyers and you can not talk about the force of genetics in choosing these professions. It is undoubtedly an environmental component transmitted from generation to generation that will influence personal choices.
In my view, this family component is the most powerful argument for explaining why cases of alcohol problems occur in certain family groups that value and facilitate alcohol use. In relation to men, drinking means a kind of rite of passage into adulthood and a sign of masculinity.
There is also very strong evidence that in one family there is a biological vulnerability to alcohol in some members who feel very good when they drink. This reinforcing side of alcohol is powerful especially if the individual is embedded in a culture that values its use. The tendency, in this case, especially of men, is to repeat this behavior and, generation after generation, alcohol consumption will be a problem for them. On the contrary, however, there are families in which the toxic reactions that alcohol produces most weigh heavily. This is the case with certain families of Japanese who are deficient in an enzyme, which leads to the production of acetaldehyde, a substance responsible for intense discomfort even when the doses ingested are small. These are biologically protected because they are naturally discouraged to repeat consumption.
PERSONALITY PROFILES OF ALCOHOLICS
Drauzio - In addition to these genetic-behavioral family factors, what kind of personality increases the risk of a person developing alcoholism?
Ronaldo Laranjeira - Much has been written about the personality profile associated with alcohol use. In the 1950s and 1960s, it was thought that there would be a personality type that would favor alcoholism. The research did not confirm this assumption and a recent study that accompanied alcoholic patients for 60 years did not allow to determine a personality profile characteristic of these people.
However, some personality traits are risk factors for alcohol dependence. The impulsivity and irritation that mark the way of being of certain people or the shyness and the social isolation of others are characteristics that facilitate the consumption of alcohol, since it can be used to mitigate these difficulties. The tendency of the impulsive subject who benefits from the relaxing effect of alcohol is undoubtedly to repeat consumption. The more timid individual, more socially isolated, who discovers in alcohol an instrument to improve his social performance, will use it on several occasions.
TREATMENT OPTIONSDrauzio - From the behavioral point of view, what treatment resources exist for people who are dependent on alcohol, who can not get through a day without drinking?
Ronaldo Laranjeira - Before beginning the treatment of alcohol dependence, it is essential to make an accurate clinical evaluation to evaluate the type of treatment appropriate for each case. The population of alcohol dependents is quite heterogeneous. An alcoholic is only equal to the other if looked at from a distance. Suffering is always different.
In the face, one must evaluate whether there is psychiatric comorbidity, in addition to depression and anxiety, in addition to chemical dependence. The association of these disorders with alcohol is very common and requires specific treatment.
This diagnosis is important for solving most of the problems and improving the discomfort they cause. It is common to install depression and anxiety from the third decade of life and there is a significant relationship between alcohol use and these psychiatric disorders. In view of this, treating only alcoholism and forgetting depression is of no use, because it is a powerful mechanism that induces relapses.
Incredibly, whether a person has both illnesses improves the prognosis if they are identified and the patient receives effective treatment for each. With depression and anxiety controlled, the risk factor that would perpetuate alcohol dependence disappears, and the progression of the condition is much better.
For people without psychiatric disorders but alcohol dependent, there are numerous treatment options. In Brazil, however, there is a shortage of supply. In fact, on the front line, stand out the Alcoholics Anonymous, self-help group that exists in more than 50 countries and for more than 80 years, with wide experience in the care of alcohol dependents. They offer a good and cheap treatment based on the generosity of volunteers who are predisposed to help others overcome a problem that in some ways is theirs. It's a wonderful job, absolutely fundamental in the area of alcoholism. AAs are the salt of the earth in order to facilitate access and adherence to treatment without regard to color, origin, sex, or socioeconomic condition. Whoever adapts to self-help groups should look for and stay in AA groups.
However, for a number of reasons, a significant number of people do not adapt to the culture of the group or because they are carriers of psychiatric comorbidity, or because they do not associate with the other participants. For these people, it would be necessary to offer treatment options that would include group and individual therapies, but this is not always possible.
Currently, psychological therapies have evolved a lot, and the tendency is to focus on the behavior associated with drinking. Therapist and drinker, together, should identify which risk factors for alcohol intake. It is very common for a person to belong to a circle of friendships that perpetuates the habit of drinking. In this case, it must reinvent a scheme or lifestyle of which the drink is not part and seek sources of support to help it not drink. In a way that's what Alcoholics Anonymous does. When joining the group, the dependent that spent hours and hours in the bars happens to live with a social network of abstinent people and this difference is fundamental for the control of the disease.
Drauzio - It really helps a lot to be around people who do not drink.
Ronaldo Laranjeira - This protective social network is very important in AA as in any other treatment system. It helps a lot to have friends you can call Saturday night and book a program that does not involve alcohol. Therefore, the orientation is always to seek social relationships with non-drinkers and to develop forms of leisure that are far from the culture of the bar.
The purpose of individual therapy is primarily to prevent the relapse that characterizes most addiction cases. Identifying risk factors and developing behavioral strategies not to relapse is an important line of behavior in the psychological treatment of alcoholism.
PHARMACOLOGICAL TREATMENTIn the past, the only pharmacological treatment of alcoholism consisted of the famous Antabuse, a remedy that women put in their husbands' food and provoked a terrible reaction when they drank. Many thought the drink was making them ill and stopped drinking. Is this treatment still accepted or is it considered a prehistoric method?
Ronaldo Laranjeira - Dissulfiran, which is the component of Antabuse, continues with FDA approval and is still used if the person agrees to receive this type of medication. It is a good and inexpensive remedy for the treatment of alcoholism. When the patient agrees with the use of Dissulfiran and understands its mechanism of functioning, it serves as psychological break before the drink. In fact, in the past, women put this medicine in their husbands' food without their knowledge, but the most common thing was that they stopped eating at home and continued drinking at the bar.
Today there are new drugs that decrease the urge to drink. It may seem strange, but that's exactly what they do. They act on the action of alcohol in the brain and not only diminish the urge to drink but lessen the pleasant effects of alcohol.
Drauzio - Do they also intensify the unpleasant effects?
Ronaldo Laranjeira - They do not cause unpleasant effects, but they interfere with the reinforcing effect of alcohol. More than 15 studies attested to the effect of Naltrexone (name of the chemical in this remedy). Under the effect of this medicine, people feel less the pleasant effects of the drink and lose the will to continue drinking.
Drauzio - Is it an easy drug to administer? Causes unpleasant side effects?
Ronaldo Laranjeira - In fact, Naltrexone is one of the safest drugs in psychiatry. The patient takes one 50mg tablet a day and there are almost no side effects. At the beginning of treatment, he may feel some nausea that goes away in a few days. Its effect on the urge to drink is not absolute, but at least doubles the chance of the person staying abstinent over weeks or, at worst, drinking less. Naltrexone does not represent a cure for alcoholism, but greatly improves the progression of the condition.
But it is important that the dependent wants to take the remedy for the treatment to succeed.
Ronaldo Laranjeira - This is the big problem: adherence to treatment. It is necessary to persuade the patient to take the medicine for several months without interruption. Irregular use of the medication impairs the results and discourages the patient. There are people who take the medicine for a day or two, stop because they have drunk or go to drink and then return to take the medication, which seriously harms the treatment.
Drauzio - Are there other medications besides Naltrexone that help treat alcoholism?
Ronaldo Laranjeira - There is Acamprosate, widely used in Europe and possibly approved by the FDA. It also decreases the urge to drink. Its pharmacological action is somewhat different and longer than that of Naltrexone.
Recently, a study has been published on an anticonvulsant drug called Topimarate, used in other psychiatric settings that seems to also decrease the desire to drink and increase abstinence periods for weeks.
These four drugs - Dissulfiram, Naltrexone, Acamprosate and Topiramate - are good coadjuvants in the treatment of alcoholism, as they help in the abstinence process and in the prevention of relapses.
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