Alcoholism

Although alcohol abuse and dependence are commonly called alcoholism DSM-IV-TR does not use the term because it lacks a precise definition.

Alcohol abuse

             Alcohol abuse is a maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by one or more of the following occurring within twelve-month period.

1. Recurrent alcohol use resulting in a failure to fulfill major role obligation at work, college or home. (e.g. absenteeism, suspension, child neglect)
2. Recurrent alcohol use in situations where it is physically harmful (e.g. drunk driving)
3. Recurrent alcohol related legal problems
4. Continues alcohol use despite having persistent or recurrent, social or interpersonal problems caused or exacerbated by alcohol use.

Alcohol dependence:

             is a maladaptive pattern of alcohol use leading to clinically significant impairment or distress as manifested by three or more of the following occurring within twelve-month period.

1. Tolerance as defined by either of the following.
• A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of alcohol.
2. Withdrawal as manifested by either of the following
• The characteristic withdrawal syndrome due to cessation of alcohol use that has been heavy and prolonged which causes clinically significant distress Or impairment in social, occupational or other areas of functioning
• Alcohol is taken to relieve or avoid withdrawal symptoms.
3. Alcohol is often taken in larger amounts or over a longer period then was intended
4. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
5. A great deal of time is spent in activities necessary to obtain alcohol drinking or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having persistent or recurrent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (continue drinking despite recognition that an ulcer was made worse by alcohol consumption.

Teenager is the individual in age group 13 to 19 years. Teenagers are not little adults. They live somewhere between childhood and adulthood with specific needs different from the needs of children and adults. They often look like adults, but their behavior often looks childlike. They carry difficult and varied issues. Each brings varying experience and maturity to the day. Some are growing up “normally” and some suffer impaired or disordered development.

Alcoholism is one of the most important disorder that may be seen in teenagers.

Epidemiology

            In U.S. alcohol leads all other substances in substance related deaths. Alcohol related disorders constitute the 3rd largest health problem after heart disease & cancer. Annually 2,00,000 deaths are due to alcohol related disorders like suicide, cancer, cardiac & hepatic diseases. 50% of overall automotive accidents & 75% of late night accidents are caused by drunk drivers. Alcohol abuse and alcohol dependence affect a significant number of adolescents and young adults between the ages of 12 and 20, even though drinking under the age of 21 is illegal.

The average age when youth first try alcohol is 11 years for boys and 13 years for girls.

More than 10 million current drinkers in the United States are between the ages of 12-20. Of these young drinkers, 20% engage in binge drinking and 6% are heavy drinkers.

Due to heavy or binge drinking, nearly one out of every six teenagers (16%) has experienced "black outs," after which they could not remember what happened the previous evening. [Summary Findings American Academy of Pediatrics Survey: Teen Alcohol Consumption, American Academy of Pediatrics, September 1998]

The three leading causes of death for 15- to 24-year-olds are automobile crashes, homicides and suicides -- alcohol is a leading factor in all three. (National Clearinghouse for Alcohol and Drug Information.)

Young people who begin drinking before age 15 are four times more likely to develop alcohol dependence than those who begin drinking at age 21. (Grant, B.F., & Dawson, D. A. (1997). Age at Onset of Alcohol Use and its Association with DSM-IV Alcohol Abuse and Dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, vol. 9, p. 103-110.)

Teens under 15 who have ever consumed alcohol are twice as likely to have sex as those who have not. Nearly 4 in 10 (39%) sexually active teens those use alcohols have sexual intercourse with four or more individuals. [Dangerous Liaisons: Substance Abuse and Sex, Center on Addiction and Substance Abuse, Columbia University, 1999.] Underage drinking costs Americans nearly $53 billion annually. [Costs of Underage Drinking, Pacific Institute for Research and Evaluation, 1999.]

Researchers estimate that alcohol use is implicated in one to two-thirds of sexual assault and acquaintance or "date" rape cases among teens and college students. [Youth and Alcohol: Dangerous and Deadly Consequences, Office of the Inspector General, U.S. Department of Health and Human Services, 1992.]

In a survey it was found that 50% of Indian men drink, 2% are addicted to alcohol. 20% of the alcoholics drink heavily & physically abuse their wives.

Alcohol use is increasingly becoming popular among youth in all towns right from metros to state capitals, towns & villages. [Outlook, 18 August 2003]

Males are more likely to be alcoholic than females. It is more common in urban areas among illiterate, delinquents and poor. Alcoholics may also suffer from other psychiatric illnesses like anxiety and depression. About 10% alcoholics commit suicide. Factors associated with suicide among alcoholics are depression, weak psychosocial support serious physical illness and unemployment. [Synopsis of Psychiatry, 9th edition, Benjamin James Sadock, M.D. & Virginia Alcott Sadock]

As per survey by Banjara Academy Banglore 68% of the 321 youth Surveyed (194 Girls) admitted to having consumed alcohol. 14% of the girls admitted to drinking on a regular basis, and 14% drank occasionally. Only 1% admitted to drinking daily. The average age of having the first taste of alcohol is 16 years. 46% of the youth were induced into their first drink by relatives and parents and 36% by friends. [Lokmat Times 25th July 2003]

In fact LOKMAT, printed front-page story about how easily children can buy alcohol from liquor shops despite the fact that it is illegal to sell alcohol to minor. [Lokmat 29th July 2003]

Teenagers’ Beliefs About Alcohol:

• Very young children – even preschoolers – can tell that alcohol has an effect on people that other beverages do not. In fact, children begin forming opinions about alcohol at an early age, and they tend to view it negatively.
• Boys’ beliefs tend to be more favorable toward drinking than those of girls. Boys also tend to associate drinking with being more grown up – a perceived positive outcome of drinking.
• Teenagers believe that the positive benefits of drinking (feeling good, fitting in with peers) are more likely to occur than the negative effects of drinking (feeling sick, causing serious health problems). [Gilmore, M.R., et al., “Children’s beliefs about drinking,” American Journal of Drug and Alcohol Abuse, Volume 24 (1), 1998]
• Teenagers who expect to gain greater social acceptance from drinking are more likely to begin to drink as well as to consume alcohol at faster rates.
• Teenagers see other people, including their parents, as less disapproving of their engaging in drinking than do younger children.
• Alcohol advertising encourages teenagers to drink.
• Seventy-five percent of teenagers believe that alcohol is readily available to them for consumption.

Eighty percent of teenagers surveyed think that alcohol negatively affects scholastic performance, and it increases the likelihood of getting into trouble.

By pharmacological definition, alcohol is a drug and may be classified as a sedative, tranquillizer, hypnotic or anaesthetic, depending upon the quantity consumed. Of all the drugs, alcohol is the only drug whose self-induced intoxication is socially acceptable.

Alcohol is rapidly absorbed from the stomach and small intestine. Within 2-3 minutes of consumption, it can be detected in the blood-the maximum concentration is usually reached about one hour after consumption. The presence of food in the stomach inhibits the absorption of alcohol because of dilution.

Over the past 30-40 years, increasing percentages of young people have started to drink alcoholic beverages, their alcohol consumption has increased in quantity and frequency, and the age at which drinking starts has declined. This situation is disturbing because the young people concerned may run a greater risk of alcoholic problems in later life and also, in the short term, because of increased rates of drunkenness and involvement in road accidents.

Alcohol has a marked effect on the central nervous system. It is not a "stimulant" as long believed, but a primary and continuous depressant. Alcohol produces psychic dependence of varying degrees from mild to strong. Physical dependence develops slowly.

According to current concepts, alcoholism is considered a disease and alcohol a "disease agent" which causes acute and chronic intoxication, cirrhosis of the liver, toxic psychosis, gastritis, pancreatitis, cardiomyopathy and peripheral neuropathy. Also, evidence is mounting that it is related to cancer of the mouth, pharynx, larynx and oesophagus. Further, alcohol is an important etiologic factor in suicide, automobile and other accidents, and injuries and deaths due to violence. The health problems for which alcohol is responsible are only part of the total social damage that includes family disorganization, crime and loss of productivity.

Risk Factors for Adolescent Alcohol Use:

The reasons why adolescents use alcohol are complex but include curiosity, a need to fit in with friends, and a desire to relax and escape problems. For some, additional factors may be involved.

Highlights from the National Institute on Alcohol Abuse and Alcoholism Alcohol Alert on Youth Drinking include the following risk factors:

Genetic Factors: Children of alcoholic are 4 times more likely to initiate drinking during adolescence and to develop alcohol use disorders, but the relative influences of environment and genetics have not been determined and vary among young people. Exact gene responsible for this has not been identified.

Childhood Behavior: Children who are very restless and impulsive at age 3 are twice as likely to be diagnosed with alcohol dependency at teenage. Aggressiveness in children as young as ages 5 to 10 has been found to predict alcohol and other drug use in teenage.

Behavioral Factors: Certain behavioral principles work to induce substance-seeking behavior. Alcohol produces a positive experience after their first use, and thus it acts as a positive rein-forcer for alcohol seeking behavior. Alcohol seeking behavior is associated with cues that become connected with drinking e.g. before dinner, parties, festivals.

Psychiatric Disorders: Among 12- to 16-year-olds, regular alcohol use has been significantly associated with conduct disorder; whether anxiety and depression lead to or are consequences of alcohol abuse is unresolved. In a study of college freshmen, a DSM-III diagnosis of alcohol abuse or dependence was twice as likely among those with anxiety disorder as those without this disorder. In another study, college students diagnosed with alcohol abuse were almost four times as likely as student without alcohol abuse to have a major depressive disorder. In most of these cases, depression preceded alcohol abuse. Delinquency may also lead a person in bad company, resulting in drinking.

Undesirable situations:Teenagers with low self-esteem tend to turn towards drinking in undesirable situations to fulfill their dependency needs. They may not be able to deal with the reality & may feel themselves misfit in mainstream. Some teenagers start drinking after failure. Their harsh punitive super ego leads them to drinking. Superego is soluble in alcohol. Experiencing learning disorders or other academic problems may push a teenage towards drinking behavior. Teen Pregnancy may serve as a stressor pushing the unwed mother to alcoholism. School drop outs & unemployed turn to drinking.

Parental and Peer Influences: Parents’ drinking behavior and favorable attitudes about drinking have been associated with adolescents’ initiating and continuing drinking. Early initiating of drinking has been identified as an important risk factor for later alcohol-related problems. Lack of parental support, monitoring, and communication also has been significantly related to frequency of drinking, heavy drinking, and drunkenness among adolescents. Peer drinking and acceptance also influences adolescent drinking behaviors. Being a sibling of an adolescent who uses alcohol is also a risk factor for initiating drinking at an early age.

Expectancies: Positive expectations from alcohol use have been found to increase with age and to predict the onset of drinking among adolescents.

Neurochemical Factors

Receptors and receptor systems: The long-term use of alcohol may eventually modulate receptor systems in the brain so that the presence of alcohol is needed to maintain homeostasis. Such a receptor-level process may be the mechanism for developing tolerance within the central nervous system (CNS).

Pathways and Neurotransmitters: The major neurotransmitters possibly involved in developing substance abuse and substance dependence are the opioid, catecholamine (particularly dopamine), and γ–amunobutyric acid (GABA) systems. The locus ceruleus, the largest group of adrenergic neurons, probably mediates the effects of the opiates and the opioids. These pathways have collectively been called the brain-reward circuitry.

Motives for drug dependence with descriptive words such as pleasure, desire to experiment, sense of adventure, wish for self-knowledge, and desire to escape.

Environmental factors

Man is the social animal & lives in society. Hence social factors play major role in shaping behavior of a person.

This is because of social acceptability of alcohol as a recreational drink. In fact there is an effort being made to make light Beer easily available. The chances of children of alcoholics becoming alcohol abusers are high because of their exposure to alcohol from early age. It is also considered in thing to drink alcohol. Peer pressure is the main factor in initiating teenagers into alcoholism.

Some social settings like military camps & college hostels lead to excessive drinking.

Islam has declared alcohol haraam (prohibited) hence incidence of alcohol consumption is less among Muslims as compared to other communities.

In our country there is excessive alcohol consumption during festivals particularly holi.

Among the environmental factors attributed to drug dependence are rapid technological developments with associated need for extended periods of education, along with the in-applicability of old solutions to novel problems. Television, world travel, affluence, freedom to speculate and experiment has encouraged youngsters to question and often reject the values and goals of their parents. Established social values are perceived as irrelevant, all to be stripped away, partly through the use of alcohol in order to reveal the real person, the real humanity, and the real goals of mankind.

Fatigue, repeated health complaints, red and glazed eyes, and a lasting cough.

Personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest.

Starting arguments, breaking rules or withdrawing from the family.

Decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems.

New friends who are less interested in standard home and school activities, problem with the law, and changes to less conventional styles in dress and music.

Parents may recognize signs of trouble & take patient to a psychiatrist or mental health professional.

• It is defined as two or more illnesses in the same person at the same time. In various studies, a range of 50 percent of patients with alcoholism also meet the diagnostic criteria for antisocial personality disorder.
• About 40% of all those with alcoholism meet the criteria for major depression sometime during their lives.
• Alcoholism is also a major precipitating factor for suicide. Alcoholics are about 20 times more likely to die by suicide than the general population. About 15 percent of persons with alcoholism have been reported to commit suicide.

Treatment:

Parents can help through early education about drugs, open communication, good role modeling, and early recognition if problems are developing. If there is any suspicion that there is a problem, parents must find the most appropriate intervention for their child. The decision to get treatment for a child or adolescent is serious. Parents are encouraged to seek consultation from a psychiatrist or mental health professional when making decisions about substance abuse treatment for children or adolescents.

Parents and families must be informed consumers and should be involved in their child's recovery. No single treatment is appropriate for all teens. It is important to match treatment settings, interventions, and services to each individual's particular problems and needs. This is critical to his or her ultimate success in returning to healthy functioning in the family, school, and society. Effective treatment must attend to the multiple needs of the individual -- not just the drug use.

Any associated medical, psychological, social, and cognitive problem must be addressed. Remaining in treatment for an adequate period of time is critical for treatment effectiveness and positive change. Each person is different and the amount of time in treatment will depend on his or her problems and needs. Research shows that for most individuals, the beginning of improvement begins at about 3 months into treatment. After this time, there is usually further progress toward recovery. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment. In therapy, teens look at issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding behaviors, and improve problem-solving skills. Behavioral therapy also facilitates interpersonal relationships and the teen's ability to function in the home and community.

Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, individuals should be assessed and treated for the co-occurrence of the other type of disorder.

Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.

Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, school setting, or juvenile justice system can increase significantly both treatment entry and retention rates and the success of drug treatment intervention. Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning.

Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence. Parents should ask what aftercare treatment services are available for continued or future treatment. Information provided by the American Academy of Child and Adolescent Psychiatry (AACAP) and the National Institute of Drug Abuse.

The most common and effective way for an individual to combat his or her addictive behaviors is through a self-help support group, with advice and support from a health care professional. Treatment should also involve family members because family history may play a role in the origins of the problem and successful treatment cannot take place in isolation.

• Treatment cannot take place unless the individual attends for treatment. He must come to terms with the possibility of a life without drug taking. Unfortunately, drug takers, as a rule, have little or no motivation to undergo treatment. Alcoholics tend to deny that their consumption is abnormal; others openly defend their habits.
• Long-term treatment is not only a medical problem, but needs the cooperation of psychologists and sociologists. There is a high relapse rate with all treatment methods.
• Though drug addiction may be considered as a social problem, the first step in its management is medical care, which includes, identification of drug addicts and their motivation for detoxication (requires hospitalization) post-detoxication counselling and follow-up (based on clinic and home visits).
• In patient treatment is required for Deaddiction from Alcohol.
• Alcoholics can also be treated on OPD basis. They can be treated with after taking their consent in presence of first degree family members or spouse.
• First of all patient has to be detoxified i.e. substance has to be removed from his body. During this he feels withdrawal symptoms for which specific medicines depending on the substance abused are given.
• Various specialists are consulted & tests are done if necessary to find out physical & mental damage caused by addiction & respective medicines are given.
• Once the patient is out of withdrawal stage he is motivated for giving up the alcohol. Patient is put on certain medicine, which helps reducing the craving for alcohol.

• There are certain medicines that are helpful in preventing relapse of specific drug use. E.g. Disulfiram is used in alcoholics for relapse prevention (details will be mentioned later.)
• Along with medical treatment psychotherapy also plays an important role. Patient is taught about art of living & facing problems head on. At this stage help of spiritual leaders can also be taken.
• Family is taught about their behavior with the patient to prevent relapse. They have to bear with patient, they should not show their lack of faith in-patient, they should not criticize patient for loss caused by him during his addiction, they should help in his rehabilitation.
• The family members are strictly told that even if patient refuses to follow up they should visit hospital regularly & make patient take medicines regularly with or without his knowledge.

Simultaneously with medical treatment, changes in environment (home, school, college, social circles) are important. The patient must affect a complete break with his group; otherwise the chances of relapse are 100 per cent. Psychotherapy has a valuable place in the management of the addict.

Success of the treatment necessitates the adoption of mature and realistic attitude by the local community and the avoidance of panic, moral condemnation and discrimination. Facilities for vocational training and sometimes the provision of sheltered work opportunities are useful in rehabilitation and help to prevent relapse.

It is suggested that when there is evidence of significant "alienation" among a group, especially of younger persons, it should be regarded as indication of possible presence of actual or potential drug-takers, and should lead to an analysis of the situation and to such preventive or remedial action as may be indicated.

Approaches to prevention of drug dependence should have realistic aims. Over-ambitious hopes of eradicating a drug problem in a short time are likely to lead to policies that are unrealistic and self-discrediting. Changes in culture attitudes and alteration in relevant aspects of the environment can be brought about only slowly.

The legal control on the distribution of drugs, is an important approach in the prevention of drug abuse. Controls may be designed to impose partial restriction or to make a drug completely unavailable. Legislation may be directed at controlling the manufacture, distribution, prescription, price, time of sale, or consumption of a substance.

Legislation restricting or prohibiting advertisements that directly or indirectly promote use of tobacco and alcohol has been increasingly common in recent years.

The minimum age, at which minors may legally have access to alcoholic beverages, has been raised in some countries. There is also legislation controlling the distribution of alcohol in some countries, Mandatory jail sentences for drunken driving have not been very effective.

Educational approach: Educational approaches to the prevention of alcohol use and alcohol-related problems have been used in many countries.

1. Educational programmes for school children and
2. Public information campaigns on electronic media.

The message should be clear and unambiguous to the intended audience, and come from credible source of information. The Message should also provide specific advice, rather than general, and as far as possible the information should be new to the audience and should be capable of provoking discussion or action. Educational approach should not be planned and carried out as isolated activity. To be effective, such approaches should be regarded as a part of integrated plan of action involving other strategies.

A popular approach to the prevention of drug abuse is provision of alternative activities, which may help to prevent drug abuse - e.g., teen centers providing activities attractive to the adolescents who might otherwise drift in to drinking subculture. Such activities include the establishment of groups or organizations interested in athletics, sports, music, public policy, religion, artistic activities of various kinds, and improvement of the environment through the prevention of pollution. Nongovernmental organizations play a crucial role in the development of such activities and are likely to become important.

“Your Time – Their Future” is a campaign of the Center for Substance Abuse prevention of the Substance Abuse and Mental Health Services Administration. It urges adults to become actively involved in working with children, ages 7 to 14, to develop healthy and useful skills and interests. The campaign encourages adults to volunteer to spend more quality time with youngsters in need of guidance and mentor them toward productive and rewarding lives. Research has shown that such adult involvement can and does help children and young adolescents to resist the use of alcohol, tobacco, and illicit drugs which are dangerous and illegal.

References:

1. Encyclopedia Encarta 99 C.D.
2. Lokmat Times
3. Park’s Text Book of Preventive & Social Medicine, K. Park.
4. Synopsis of Psychiatry, 9th edition, Benjamin James Sadock, M.D. & Virginia Alcott Sadock.

[Summary of Findings from the 1999 National Household Survey on Drug Abuse, U.S. Department of Health and Human Services, August 2000]