Medical Director Cygnet Hospital Ealing, 22 Corfton Rd, Ealing
London W5 2HT
The Priory Hospital, Priory Lane, Roehampton, London SW15 5JJ
And: 51 Sloane St, London, SW1X 9SW
And: 19 Cliveden Place, Sloane Square, London, SW1W 8HD
Addiction to alcohol causes physical harm, psychological damage and problems with relationships at home and at work. It can exist as an illness on its own or it may arise in someone who has another physical illness, mental illness or who is addicted to another substance. Although it is more common in certain groups of people it is an illness that can affect anyone. Addiction to alcohol is often thought of as more minor than addiction to other drugs but because it is common it causes unhappiness and damage to more people than any other addiction.
It is quite obvious that different people are able to drink different amounts of alcohol. We all know people who get affected by quite small amounts of alcohol and therefore get noticeably affected by a glass or two of wine. Equally there are people who seem to be able to drink a lot and yet seemingly stay sober. Large men can usually drink more than small women. This is partly because of the difference of size since alcohol is more diluted when absorbed into a larger volume. Men and women have some differences in the chemical nature of their bodies too which may make a difference. The national guidelines on drinking are designed to give guidance as to the maximum amount you can safely drink. The trouble is that different people are very different in their tolerance to alcohol. Some people drink a lot for years and don’t develop problems whereas others seem to get into difficulty soon after they try alcohol for the first time. Because most of us recognise these variations there is a natural tendency to think we ourselves will be all right and to ignore the guidelines, but this is a mistake. They aren’t perfect but they do give an idea of how much it is fairly safe to drink and drinking much more than recommended is unwise. Of course the only absolutely safe amount to drink is no alcohol at all!
Women 14 units per week
Men 21 units per week
1 unit = I small glass of wine = 1/2 pint beer or lager = I pub measure of spirits.
Most of the other guidance that can be given about how much someone can drink safely is really a matter of common sense. It isn’t sensible to get drunk. Alcohol poisons the body and particularly the brain and if you repeat it often it can lead to permanent damage. Getting drunk alters your behaviour so you are more likely to be careless with your own and other’s safety. Drinking alcohol is supposed to be a pleasure and most sources of pleasure are better sampled from time to time rather than every day. Having days which are free from alcohol is good for health. With all addictive drugs, stronger versions of the drug are more addictive than weaker ones. Spirits are more addictive than wine, and wine more addictive than beer. So it makes sense to be particularly careful about drinking spirits.
There is no satisfactory definition of alcoholism. Although it has something to do with drinking too much, the amount someone who is not alcoholic drinks can vary a great deal. Drinking too much is not quite the same as being addicted to alcohol. The pattern of excessive drinking varies widely. In France a common form of alcoholism is to drink wine steadily throughout the day leading to constant high blood alcohol levels. In Northern Europe it is more common to find people drinking in binges, episodes of very heavy drinking, punctuated by periods of abstinence. There are many other patterns of drinking between these two extremes.
An alcoholic is addicted to alcohol which raises the next question. What is addiction? Again this is not an easy term or concept to define. Something that you know you shouldn’t do because it’s bad for you, that you try to stop doing and that you fail to stop doing, is usually an addiction. If you limit this definition to things that are to do with chemical substances then most people would probably accept it. People who work in addictions often include within the definition of addiction behaviours that aren’t restricted to the use of drugs that influence feelings and in that case eating disorders and gambling can be regarded as forms of addiction.
Alcoholics are addicted to alcohol. They have an illness that leads to damage in three main areas. Alcoholism damages many organs of the body, especially the liver and brain. It leads to psychological damage as alcohol effects mood, intellect and personality. Finally the illness has huge social consequences and often leads to the break up of marriages, loss of jobs and can have massive financial implications. Alcoholics experience their most severe problems in one of these three different areas. One may lose his job and marriage and has to face his problem as a result, but remains well physically. Another may appear to be functioning quite well socially but will suddenly becomes jaundiced with liver problems, this being the first sign of illness.
People often think they aren’t alcoholic because they aren’t drinking methylated spirits living as a down and out. The reality is that it is a slowly progressive illness. At the beginning there may be few or no external signs of illness. Gradually though, the problems associated with it increase. If allowed to progress to its natural conclusion then an alcoholic will often end up homeless, without a family, jobless, penniless, and physically ill.
In the later stages of the illness the signs are really quite obvious. An alcoholic then is likely to be drinking quite early in the day and although not necessarily showing signs of being drunk, they will often be moody, irritable and bad tempered. Alcoholics may be sleepy in the middle of the day, are liable to forget things and miss appointments and they become unreliable at work. Often they seem intolerant of small mistakes made by others and they turn into less nice people who are self centered and insensitive to others around them. They become clumsy and drop and break things. They become less interested in doing things socially, less interested in going out, meeting people or seeing films or plays. They are only really interested in drinking. They are much more likely to get into trouble with the police and if they continue to drive are at risk of being involved in accidents and of being banned.
As the illness progresses further they may stagger around, lose their temper and get sent home from work. They pass out in a chair rather than going to bed. They may become violent when angry and become careless of personal hygiene, washing less and taking less care of their clothing. Words become slurred sometimes and their tendency to forget things becomes more obvious. They may suffer with hangovers and may choose to use alcohol in the morning to reduce the unpleasant symptoms of withdrawal. If they attempt to stop drinking they may suffer with severe withdrawal symptoms and so can find it hard or even impossible to stop.
A more difficult problem is often how to tell that someone is slipping into alcoholism at an early stage. It is helpful for an alcoholic to recognise these early signs for himself as it gets more difficult to acknowledge the problem as symptoms progress. There are no completely reliable ways of identifying someone, including oneself, as suffering with early alcohol dependency. You can use questionnaires that try to identify the illness by asking questions that relate to drinking behaviour, and some of these can be helpful. A typical example is the CAGE Questionnaire
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or
to get rid of a hangover (Eye opener)?
A positive response to more than one of these questions is regarded as clinically
significant.
Or there is the Michigan Alcoholism Screening Test (MAST) found on http://counsellingresource.com/quizzes/alcohol-mast/index.htm
I personally use certain questions when I am trying to decide if someone is or isn’t alcoholic. These questions do not provide an absolute guide but if the answers are positive then there is reason in my view to consider alcoholism likely. The first is to do with greed. Are you greedy with alcohol? Do you therefore tend to drink more quickly than others around you? Do you tend to drink more than your friends? If you go to a dinner party do you worry that no one will offer to refill your glass. Do you get a bit agitated when your glass is not topped up for too long. If you leave the table for coffee in another room do you finish up your neighbour’s glass given half a chance? When you get home later do you have a glass of something at home before going to bed?
The second question has to do with control. Do you decide before an evening when you will be drinking, how much you might allow yourself to drink? For example, if you have to give a presentation on the following day or have an important meeting, do you then decide to limit your intake to two or three glasses? If so are you able to succeed? Or do you often fail to keep to your limits? This question is probably the really crucial one. People sometimes think that they can’t be alcoholic because they can stop drinking altogether for a while. But most alcoholics, unless they get bad withdrawal symptoms, can spend several days or weeks not drinking. Binge drinking alcoholics routinely spend days at time dry. No, the critical question is if you start drinking can you drink in a normal civilised way and can you stop when you want to stop?
The third question is related to the previous one. When you drink do you always drink more or less the same amount? If you ask someone who smokes how many cigarettes they smoke they will usually tell you that it is 20 or 40 or more per day. They know the answer. They know that if they have a late night with drinking they will smoke more than on other occasions but they realise that they smoke about the same amount most days. The amount of alcohol consumed can be a bit more difficult to judge because alcohol is usually taken in a range of drinks of variable strengths. In later stages of alcohol dependency a sufferer may favour a particular form of alcohol to the exclusion of all else, but in earlier stages he is more likely to drink a mixture of wine or beer and spirits. If they are able to assess how much alcohol is drunk over a given period then it will usually be fairly constant. This is very different from a social drinker who is likely to drink in a much more variable way.
Anyone who drinks can lose control of their drinking and develop an alcohol dependency syndrome. It runs in families so anyone with a close family member who is alcoholic should recognise their increased risk and choose to avoid alcohol or drink with caution. It is more likely to develop in people who drink more than in those who drink less but some people seem very susceptible to losing control of drink. Because it runs in families it is also more common in some groups of people. In the United Kingdom it is more common among the Celtic races, so it is found most commonly among the Scots, Irish and Welsh rather than among the Anglo-Saxons who most often live in the central areas of England.
Many parts of the body can be damaged by drinking too much alcohol over too long a period. The intestinal tract and the pancreas can be damaged and quite a number of different cancers are made more common, but the most common organs affected are the liver and the brain. The reason the liver is vulnerable is because it is the first place that blood containing alcohol reaches after it has been absorbed. The liver is a large chemical factory that normally gets rid of a lot of the alcohol from the blood before it can do damage by passing on to other organs by way of the main circulation. Fortunately the liver is two or three times as big as we normally need at the start of life. Too much alcohol will kill liver cells because alcohol is a poison. When liver cells die the cell wall dies so the enzymes (chemicals), that are normally kept inside the cell, leak out. When a doctor takes blood for liver function tests he is measuring the amount of enzymes that are leaking out into the blood stream. So this is a measure of how many cells are dying at the time the test is done. An alcoholic who is in an early stage of illness and who stops drinking after finding abnormal liver function tests will allow them to return to normal. This is good news because it indicates cells are not continuing to die. But it isn’t very good news because it doesn’t mean that the cells that have died will recover and they don’t; it suggests only that the liver is again able to function normally. Cells that have been killed stay dead and as with all complex cells in the body they are then replaced with fibrous tissue. The replacement of normal liver cells with fibrous tissue makes the liver shrink in size and become irregularly shaped. This is called cirrhosis. If an alcoholic starts to drink again then more cells will die and the tests will again become abnormal. If this goes on for long enough, or if it is repeated often enough then the number of liver cells left will eventually become too little for the liver to function normally. When that happens the liver function tests don’t go back to normal after stopping drinking. This is very bad news because it indicates that the liver is failing.
The other organ that is particularly sensitive to alcohol damage is the brain. In the early stages of using alcohol most people experience getting drunk which is simply the effect of poisoning the brain with alcohol. In later stages of alcoholism the liver gets less good at cleaning the blood so more alcohol gets through to the brain. As a result an alcoholic will often find that he or she can’t drink as much alcohol as before without sustaining a greater effect. When this happens the brain is likely to sustain more permanent damage, experienced as memory impairment. This is because the parts of the brain associated with memory function are easily damaged both by alcohol and by a shortage of vitamin B. An alcoholic often eats badly and in addition alcohol inhibits the absorption of vitamin B so that severe chronic use can reduce its levels. Someone who is in a severe toxic state from alcohol is at risk of damaging their memory permanently which is why in hospital they will be given vitamin B by injection. Other changes to the brain are progressive and more subtle. These changes account for changes of personality and physical ability. Eventually alcohol can lead to a progressive dementia not much different from Alzheimer’s disease.
Most people find that drinking alcohol tends to accentuate whatever mood they are in. If down in the dumps they become more miserable. When in a good, outgoing, party mood they become more elated. As you drink more you become less aware of problems in your life. It reduces worry and helps you to forget the causes of those worries which is why people who have major problems may drink to forget. It is sedative and so makes you sleepy. Some people experience changes to the way they feel much more strongly than others. Some people become angry and violent when drinking whereas others are more likely to just get sleepy and a bit amorous. Some people believe that certain forms of alcohol make anger more likely; whisky is often referred to as firewater. I believe that people who experience greater changes of personality from alcohol than is usual, particularly becoming angry and violent, are at greater risk of developing alcohol dependency in the future.
Alcohol can be a trigger leading to relapse for people who are at risk of developing a psychotic illness, usually schizophrenia or bipolar illness. It is also quite common to find people who are alcoholic and at the same time show signs of a depressive illness. One illness is then liable to make the other much more difficult to manage and treat. Depression can be a major factor in the cause of alcoholism as alcohol is an natural drug to use in an attempt at self medication when someone feels low in mood. It also appears that prolonged heavy drinking may lead to depression. The reason may be partly a chemical one but of course excessive drinking may lead to many social disasters that may in turn induce depression. It is only after someone has given up alcohol that it is possible to be sure of the particular relationship between alcohol and depression in that individual.
A lot of alcoholics smoke; they often smoke heavily. When someone gives up one addictive substance they often increase the use of other addictive substances. So when an alcoholic gives up drinking he or she may smoke more. Although smoking may be regarded as a less important problem at first, it is so dangerous to health in the medium to longer term that giving up should be a part of the longer term plan for any addict. The other substance that is often abused by alcoholics is cocaine. Cocaine may be used by an alcoholic because it keeps you awake longer while you are drinking and enables an alcoholic to party for much longer and also drink more. Of course this makes the addiction to alcohol more severe and also adds the considerable problems associated with cocaine addiction to the problems already being faced. Sometimes an addict is addicted to a whole range of different substances at the same time.
This is a very difficult question. Everyone associated with the treatment of alcoholics will have had the frustrating experience of trying to get them to accept help and being left feeling totally frustrated and useless when those efforts are not successful. An alcoholic is frequently in a state of denial, which is discussed below in more detail. Then whatever steps you as a relative may take you are likely to fail. It is helpful to recognise this so that you don’t make the mistake of blaming yourself and by so doing take over the responsibility for their illness. If you do that then it allows the sufferer to give over that responsibility to you and so avoid facing their problem as it needs to be faced.
The first problem is to decide whether and when should you confront the sufferer with the evidence of illness as well as how should you do it. It is nearly always right to decide to take some sort of active steps. If you don’t it is very unlikely that he or she will face up to the addiction until everything has got much worse. The earlier an intervention is made the more likely it is to provoke a reasonable response. Because alcoholism is a progressive illness, if you wait you are more likely to find that the sufferer has undergone the sort of personality changes described above and these make everything more difficult. The exact approach you take will be guided to some extent by the knowledge you have of the person you are dealing with. In general being aggressive, threatening or over forceful are likely to provoke a defensive rather than an open type of response. At the same time you will probably need to be quite firm about your observations and opinions as they are unlikely to be welcome. Even if you have read a lot about the illness you may find it better to engage in a learning curve with the alcoholic rather than turn yourself into the teacher and know all. The object of the discussion is to help the person to recognise and take responsibility for getting caught up in a process that they are losing control of. So some balance of being firm about the problem and sympathetic about the difficulties it causes needs to be found.
If this approach is not successful then what else can be tried? It may be useful to try and enlist the help of other family members or friends to add weight to the confrontation. It may be worth trying to identify the problems that are being created by the illness and continue to draw attention to them. A difficult decision is whether to add threats to the confrontation. Threats are seldom effective more than very occasionally. They work best if they are real and they can work with careful escalation. For example let us say that you are the wife of an alcoholic man. If you are getting to the end of your tether you may feel that you are on the point of leaving the marriage. You could say that you will not stay if he doesn’t stop drinking. If he doesn’t you could tell him that as he is still drinking you are leaving for a week but will return at the end of that time. You then leave. You would also tell him that if he still doesn’t stop, having had a week to think about it and see you really mean it, then you will leave permanently because life is intolerable and unacceptable for you otherwise. This sort of threat really only works if you have decided you are ready to carry it out.
The term denial means something slightly different when using it formally in this context than it does in general english usage. Here it is used to describe the state of mind that many addicts get into when they seem unable to recognise their difficulties. Denial is a psychological defense mechanism and occurs in a range of differing circumstances. It seems to be a way in which we cope with things that are unacceptably frightening and yet that we have to do. So for example if you drive a car fast up a motorway the reality is that you are doing something that can kill you as a result of the errors of others or failure of mechanism of the car, let alone the errors of your own. These things are largely outside of your direct control. But you don’t think about them much and we all tend to have an attitude that “it couldn’t really happen to me”. Other circumstances show the mechanism in its normal useful form. Soldiers in times of war have to be prepared to risk their lives and being able to switch off from fear helps them to do the job. Some people who develop cancer are unable to see themselves as dying and continue to believe they are getting better even when there is overwhelming evidence to the contrary. In addictive illness it is a mechanism that prolongs illness and makes risk greater. Cigarette smokers are indulging in a behaviour that is closely associated with many severe medical risks. It is totally illogical for them to continue and yet millions continue to smoke. They ought to be so frightened by the consequences of smoking that they would run a mile from their next cigarette, but they don’t. They enter a state of denial and so continue as if there was no risk at all. Alcoholics show similar attitudes much of the time. They are liable to continue drinking despite the increasing evidence of the damage they are doing themselves and to those around them. Their behaviour often shows that the wish to recover is short lived and not very determined as if they simply can’t recognise the problems they cause to themselves and others in a normal way. They are in denial.
The management of Alcohol Dependency is well established and is based almost universally on the principal of withdrawal from alcohol and support for the maintenance of abstinence. (see below). Treatment on the other hand is much less well established and of far more doubtful effect. It depends on finding ways of enabling an alcoholic to regain the ability to drink normally or to reduce feelings that lead him or her to relapse.
One of the first treatments methods is by using a training programme designed to make a return to normal drinking possible. These usually involve some suggestions designed to help limit alcohol intake. Usually you will be recommended to avoid the stronger forms of alcohol. There may be a structure of drinking suggested, e.g. to use just one glass at table and to fill it with alcohol, usually wine. The same glass is then filled with water and not filled again with wine until the water has been drunk. Sometimes you may be advised to keep a diary of drinking and sometimes to only drink when there are other people around. The problem with this is that it can only work with someone in the earliest stages of alcoholism. Although it might, on the rare occasions it is successful, slow down progression to more severe illness it doesn’t seem to help for long. Actually my view is that the major advantage to this attempt is that by failing at it a sufferer may be helped to face up to the unpalatable fact that he or she really has to stop drinking.
The first drug approved to help prevent relapse is Disulfuram (Antabuse). It
blocks the chemical pathway that breaks down alcohol. When drinking this causes
a build up of chemicals that have extremely unpleasant effects. It causes flushing
and headache and vomiting and stomach cramps. In a vulnerable individual the
effect can be dangerous as it may lead to a heart attack or stroke. It is rather
out of favour as a treatment at present but it still can have a useful place.
Some people find it easier to decide not to drink soon after getting up in the
morning. If they take the drug then, when motivation is strong, they find they
are protected from being tempted to drink later in the day when they know they
find it more difficult to resist.
Naltrexone is an opiate antagonist. It inhibits the effect of opiates and the
idea behind its use is that it reduces the pleasurable effects of drinking and
so makes you less likely to want another drink. It is not altogether clear from
the research how effective this is, partly perhaps because it has been often
been tested as a drug that is supposed to stop relapse and craving. It makes
more sense to test it on alcoholics who are drinking to see if it allows them
to return to a normal and non-addicted pattern of drinking. When this is done
there is at least some evidence that it may achieve its goal in a few people.
There is some doubt about how much benefit this gives and for how long the effect
continues. It is quite clear that some patients don’t get benefit.
Acamprosate works quite differently and is thought to reduce feelings of withdrawal and craving. Again the evidence that it works is a bit patchy but it probably helps at least some people to remain abstinent. It is certainly worth a try for those people who find that craving alcohol is a big problem after they have given up drinking. There are a significant number of addicts who appear not to get useful benefit.
Other drugs that have been tried are the S.S.R.I. antidepressants. These may help those who have depression and perhaps are liable to relapse as a result but the drugs don’t seem to have any direct effect on alcohol dependency. If they are used while someone is drinking they are liable to make the dependency worse as they have an adverse effect on alcohol tolerance. Lithium is used as a mood stabiliser for people with a bipolar illness, which is an illness that leads to episodes of depression and mania. Lithium may help someone with such an illness to be more stable and if they drink primarily because of instability of mood it may help. But once again there is no evidence that it has a direct effect on alcoholism.
Most alcoholics need to stop drinking permanently otherwise their illness will progress. Management is aimed at achieving this and involves several different tasks. The first is to get the sufferer to want to stop and this involves trying to help them break through the state of denial. The second task is achieving withdrawal from alcohol safely. The third is helping them to sustain abstinence. The fourth task is trying to help the family of alcoholics.
The first stage is in many ways the most difficult and the most important. It is achieved by different routes for different people. Families and friends may play a part (see above). When motivation to abstinence is weak but not completely absent, spending time with an experienced counsellor may help a sufferer to see his or her problems more clearly. It can take an admission to a rehabilitation unit to start the breakdown of denial. People have all sorts of reasons for entering such a unit and often they do so partly at least as the result of pressure from others. But the intensity of therapy and the sharing with others who have similar problems is often an effective way of helping them to face the issues for the first time.
The next step in treatment is to find a way of becoming safely alcohol free. Do you need to have a medically supervised withdrawal from alcohol? If you have attempted to stop drinking before then you will probably know whether you need this. Not all alcoholics will have significant withdrawal effects so not all need it. A medically managed withdrawal will usually provide a benzodiazepine, a valium like drug, in reducing doses to reduce the tremor and anxiety and general discomfort of withdrawal. The doctors will also take a decision about whether specific indications exist for using an antiepileptic drug, when the risk of a withdrawal fit is considered high, and vitamins by injection, if there are reasons to suspect low levels. The fact that you may not need a medically supervised withdrawal does not indicate that you do not have alcohol dependency syndrome. If the withdrawal is not severe it can be managed at home but most sufferers who need this support will be withdrawn in hospital. It is a process you can expect to complete in about 5 days.
Once free from alcohol (dry) the need is to remain so. This is often the most difficult part of the treatment and unfortunately many alcoholics relapse after periods that vary from immediately after drying out to many years later. The difficulty seems to be that of continuing to accept two fundamental things.
1. That someone suffering with alcohol dependency drinks out of the need to
achieve a certain level of effect. They cannot drink in a controlled way.
And
2. That for however long an addict stops having an addictive substance the illness
doesn’t get better. The risk of drinking therefore remains the same, indefinitely.
Rehabilitation programmes are designed to provide patients with the best start. After the medically supervised withdrawal, when this has been necessary, sufferers usually enter a group based programme. The groups, which are shared by people with a range of addictive behaviour, are used to educate sufferers about addiction and their specific addiction. They are helpful to break though the defense of denial. They are also used to explore underlying psychological issues so as to find out as far as possible why alcohol may have trapped the individual in addiction. They also help sufferers develop a range of alternative non-addictive behaviours so as to manage life issues in alcohol free ways. These programmes often include some one to one counseling and are almost all based on the Minnesota 12 step treatment system. They start links between clients and Alcoholics Anonymous so that attendance there will be continued following discharge.
It sometimes becomes apparent during rehab that a sufferer is at high risk of relapse following an inpatient programme. In that case they may move on to secondary care. This is usually in a hostel and involves some continuation of a group programme and one to one support at a less intense level than the rehab programme described above. In some cases patients are able to start working from this environment.
Following rehab most patients return home and are strongly encouraged to attend A.A. meetings on a regular and frequent basis at first. Regular attendance like this is one of the few things that is proven to be of real help. Continuation of meetings with an alcohol counselor or their psychiatrist may also be helpful. Some patients will benefit from the assistance that can come from using medication.
Dr Rowan's Secretary is stationed in the Priory Hospital, Roehampton.
Direct line Telephone Number: (0044) or (0) 208 392 4211
Fax: (0044) or (0) 208 876 4015
Email peter.rowan@psychiatrist4u.co.uk