What is Alcohol Dependence Syndrome?
Alcohol has been a part of many cultures for a very long time. In the western countries like the UK more than half of the population drinks alcohol. Alcohol contains ethanol (ethyl alcohol) as the main chemical component which is responsible for most of the effects on our body. Ethanol increases the functions of neurotransmitter Gamma aminobutyric acid (GABA) in the brain which is responsible for blocking or decreasing the activity of the brain. The effects may be seen as “drunkenness” as a behavioural outcome which includes feeling relaxed, overjoyed, uncoordinated movements of hand and feet, feeling sleepy, having increased sexual urge etc.
While occasional use or low use (around 7 pints of beer or around a bottle of wine in a week) rarely causes any problem but, in few individuals, use of alcohol may become problematic. As one drinks alcohol regularly the brain gets accustomed to the effects of the alcohol and eventually requires a higher dose than earlier. This process is called tolerance which leads to a gradual increase in the overall amount of alcohol consumed. At higher levels, the activity of the brain gets used to the signal blocking effect of alcohol so that the production of endogenous molecules responsible for this function ceases. At this stage brain requires alcohol for normal functioning and without which there are typical withdrawal symptoms. These withdrawal symptoms include having sweating, palpitations, nausea, vomiting, insomnia, headache, and in severe cases hallucinations, seizures (fit), or even disorientation. Also, with prolonged use the person may develop a habit of taking substance and always thinking about the it (Preoccupation with substance). There may be a few failed efforts to cut down the use (Impaired capacity to control substance) and occasional intense desire (Craving) to have the substance instead of choosing to drink. Over a long time, the person might develop physical complications like liver dysfunction, nutritional deficiency, problems in normal brain function etc. But, despite knowing these adverse effects the person still continues the intake and further degrading their own health (Continued use despite harm). At these later stages the mind and the body becomes dependent on the use of alcohol.
What can the problems be from using alcohol?
As mentioned above consuming alcohol regularly affects our body in many ways. Apart from its psychological effects and the withdrawal symptoms, alcohol can also damage our liver, heart, blood, brain etc. It is also associated with cancers of the intestine and mouth. It can also cause metabolic side effects and nutritional deficiencies.
Apart from the direct health hazards it also causes many indirect problems. Using alcohol may lead to an increase in unhealthy sexual practice, incoordination caused may lead to impaired driving and accidents. Similarly, there may be other social reciprocations to the excessive use of alcohol. It may also cause psychiatric disorders like dementia, depression and psychosis in some vulnerable individuals.
When does a person have Alcohol Dependence?
According to International Classification of Diseases – 10, a person can be diagnosed with dependence when they have three or more criteria fulfilled from these over the past one year:
- Having specific withdrawal state
- Impaired capacity to control substance
- Preoccupation with substance
- Continued use despite harm
ICD 10 also uses a category to include people having significant harm to their physical or mental health called Alcohol Harmful Use.
Is it all right to have alcohol occasionally?
Having alcohol occasionally usually does not lead to major problems. But some people like to drink excessively on a few occasions (more than 8 units of alcohol for men and 6 units for women) which might be associated with an increased rate of deaths. It has also been linked to more psychiatric symptoms and increased rates of clinical depression.
How can I cut down or leave alcohol?
If the person is consuming lower doses it is easier for them to cut down the dose further by themselves to a less harmful level. One can make a plan and cut down at their own pace. One may also seek help from an expert in case they face any problem in this process. But in some cases, it may not be advisable to cut down (drinking large amounts of alcohol) or it is not medically recommended (e.g. having a history of seizure while reducing dose). In such cases a longer plan may be made to get them abstinent from substance use.
Psychosocial interventions like motivation enhancement therapy may be planned to keep them motivated enough to be involved in treatment and to be abstinent from alcohol. Once the person is motivated enough to seek treatment, they would be offered treatment according to their need.
The treatment is divided into a detoxification phase where the person who is in active withdrawal may be offered sedative with long duration of action like Diazepam under supervision, the dose of which will be reduced over a few days to ease the process of getting back to normal. People who have liver problems may be offered a safer medicine like Oxazepam or Lorazepam but this requires a closer monitoring thus the patient may be admitted for some days. In this phase some blood tests are also performed including Liver function test to screen any medical complications of alcohol use. Multivitamins, thiamine, and antacids may also be prescribed during this phase.
In the next phase i.e. the maintenance phase the focus is on relapse prevention and rehabilitation. Long term medication which may reduce craving or other medications which makes one feel uncomfortable to use of alcohol might be started after discussion with the patient; popular options being Disulfiram or Acamprosate.
Using Alcohol along with consumption of Disulfiram results in a reaction with symptoms of flushing, nausea, vomiting, palpitations etc. This discourages the patient to use alcohol. For this reason, it is preferred in a motivated patient with effective supervision.
Acamprosate on the other hand replaces the lost balance of GABA in the brain thus reducing the cravings. Both are effective and may be preferred on case by case basis. There may be other alternatives like Naltrexone, topiramate etc. which may be used in special circumstances as evaluated by the psychiatrist.
Alongside pharmacotherapy, psychosocial interventions like Relapse prevention therapy may be started to prevent the relapse of alcohol. This therapy involves teaching the person to say no to Alcohol when offered, managing their cravings and how to handle risky situations like party/function etc. they are also explained how to structure their free time.
Other programmes with goals of maintaining abstinence may be offered such as the 12 step Alcoholics Anonymous program, group therapy, or Cognitive behavioural therapy which have almost similar efficacy.
Where should I seek help from?
If you or your dear ones are having symptoms mentioned above with significant distress or problems in carrying normal activities, you should consult your Psychiatrist/physician immediately. The psychiatrist/ Physician will evaluate thoroughly and evaluate for symptoms of alcohol dependence, whether you require treatment or not and order any investigations if required. The majority of patients improve with pharmacological and psychological help, but few would require admission to avoid grave physical consequences like seizures.
After relevant examination, the decision to treat on an out-patient basis or in-patient basis will be taken. The cases where admission may be indicated is – if the patient has a high suicidal risk, there is a risk of medical complication, inability to take adequate self-care, danger to others, need for intensive therapy, or any medical/psychiatric complication.
- Drugs and alcohol: information for young people | Royal College of Psychiatrists. RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Available from: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/young-people/drugs-and-alcohol-for-young-people
- Alcohol and depression | Royal College of Psychiatrists. RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Available from: https://www.rcpsych.ac.uk/mental-health/problems-disorders/alcohol-and-depression