Alcohol, Opioids, and Other Substance-Related Disorders
I. Introduction
Despite the high prevalence and comorbid presence of substance disorders, clinicians variably include additional treatment in general practice. These disorders, however, have a growing array of psychopharmacological and psychotherapeutic treatments and reflect a complex set of biological, genetic, and social/environmental factors that impact and utilize the range of psychiatric clinical skills.
Substance abuse problems cause significant disabilities for a relatively high percentage of the population. Illicit substance abuse affects multiple areas of functioning, and comorbid diagnosis occurs in about 60% to 75% of patients with substance-related disorders. About 40% of the U.S. population have used an illicit substance at one time, and about 15% of persons over the age of 18 are estimated to have one of these disorders in their lifetime. Substance-induced syndromes can mimic the full range of psychiatric illnesses, including mood, psychotic, and anxiety disorders.
II. Classification
Brain-altering compounds are referred to as substances in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) and the related disorders as substance-related disorders. Diagnostic criteria for these generally capture patterns of toxicity, that is changes in mood, behavior, and cognition, as well as impairment in social or occupational functioning, tolerance, or dependence that results from continued and prolonged use of the offending drug or toxin. There are many classes of substances that are associated with these disorders.
Alcohol (ethanol): wood alcohol (methanol) may be used as an adulterant with ethanol and is toxic, also producing blindness.
Amphetamine: amphetaminelike substances are included here, such as 3,4-methylenedioxyamphetamine (MDMA).
Caffeine.
Cannabis (marijuana).
Cocaine: crack is a rock base form of cocaine.
Hallucinogens: these include mescaline (present in the peyote cactus), psilocybin (present in mushrooms), and lysergic acid derivatives (LSD). These drugs are also known as psychedelics.
Inhalants: these include solvents such as toluene and gasoline and gases such as nitrous oxide.
Nicotine.
Opioids.
Phencyclidine (PCP).
Sedatives, hypnotics, and anxiolytics: depending on dose, these drugs are often interchangeable and can produce sedation (a calming effect), hypnosis (referring to promoting sleep), or act as anxiolytics (reducing anxiety).
Prescribed drugs and over-the-counter (OTC) medications: These include pain-killers, such as OxyContin (an opioid), and over-the-counter preparations, such as ephedra (a stimulant now banned from sale in the United States).
Anabolic–androgenic steroids: testosterone and human growth hormone (HGH). Each of these classes of drugs is discussed separately below.
III. Terminology
A. Dependence.
The repeated use of a drug or chemical substance, with or without physical dependence. Physical dependence indicates an altered physiologic state due to repeated administration of a drug, the cessation of which results in a specific syndrome. (See Withdrawal Syndrome below.) See Table 11-1.
B. Abuse.
Use of any drug, usually by self-administration, in a manner that deviates from approved social or medical patterns. See Table 11-2.
C. Misuse.
Similar to abuse but usually applies to drugs prescribed by physicians that are not used properly.
D. Addiction.
The repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again and which leads also to physical and mental deterioration. The term is no longer included in the official nomenclature, as it has been replaced by the term dependence, but it is a useful term in common usage.
E. Intoxication.
A reversible syndrome caused by a specific substance (e.g., alcohol) that affects one or more of the following mental functions: memory, orientation, mood, judgment, and behavioral, social, or occupational functioning. See Table 11-3.
F. Withdrawal.
A substance-specific syndrome that occurs after stopping or reducing the amount of the drug or substance that has been used regularly over a prolonged period of time. The syndrome is characterized by physiological signs and symptoms in addition to psychological changes such as disturbances in thinking, feeling, and behavior. Also called abstinence syndrome or discontinuation syndrome. See Table 11-4.
G. Tolerance.
Phenomenon in which, after repeated administration, a given dose of a drug produces a decreased effect or increasingly larger doses must be administered to obtain the effect observed with the original dose. Behavioral tolerance reflects the ability of the person to perform tasks despite the effects of the drug.
H. Cross-tolerance.
Refers to the ability of one drug to be substituted for another, each usually producing the same physiologic and psychological effect (e.g., diazepam and barbiturates). Also know as cross-dependence.
Table 11-1 DSM-IV-TR Diagnostic Criteria for Substance Dependence | ||||||||||||
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Table 11-2 DSM-IV-TR Criteria for Substance Abuse | ||
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Table 11-3 DSM-IV-TR Criteria for Substance Intoxication | ||
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I. Co-dependence.
Term used to refer to family members affected by or influencing the behavior of the substance abuser. Related to the term enabler, which is a person who facilitates the abuser’s addictive behavior (e.g., providing drugs directly or money to buy drugs). Enabling also includes the unwillingness of a family member to accept addiction as a medical–psychiatric disorder or to deny that the person is abusing a substance.
IV. Evaluation
Substance-abusing patients are often difficult to detect and evaluate. Not easily categorized, they almost always underestimate the amount of substance used, are prone to use denial, are often manipulative, and often fear the consequences of acknowledging the problem. Because these patients may be unreliable, it is necessary to obtain information from other sources, such as family members. Perhaps more than other disorders, understanding the interpersonal, social, and genetic contexts of those behaviors is central to evaluation and treatment.
When dealing with these patients, clinicians must present clear, firm, and consistent limits, which will be tested frequently. Such patients usually require a confrontational approach. Although clinicians may feel angered by being manipulated, they should not act on these feelings.
Psychiatric conditions are difficult to evaluate properly in the presence of ongoing substance abuse, which itself causes or complicates symptoms seen in other disorders. Substance abuse is frequently associated with personality disorders (e.g., antisocial, borderline, and narcissistic). Depressed, anxious, or
psychotic patients may self-medicate with either prescribed or nonprescribed substances.
psychotic patients may self-medicate with either prescribed or nonprescribed substances.
Table 11-4 DSM-IV-TR Criteria for Substance Withdrawal | ||
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Clinical Hint
Substance-induced disorders should always be considered in the evaluation of depression, anxiety, or psychosis. Underlying substance use is often present when psychiatric disorders do not respond to usual treatments.
A. Toxicology.
Urine or blood tests are useful in confirming suspected substance use. The two types of tests are screening and confirmatory. Screening tests tend to be sensitive but not specific (many false-positive results). Confirm positive screening results with a specific confirmatory test for an identified drug. Although most drugs are well detected in urine, some are best detected in blood (e.g., barbiturates and alcohol). Absolute blood concentrations can sometimes be useful (e.g., a high concentration in the absence of clinical signs of intoxication would imply tolerance). Urine toxicology is usually positive for up to 2 days after the ingestion of most drugs. See Table 11-5.
B. Physical examination
Carefully consider whether concomitant medical conditions are substance related. Look specifically for the following:
Subcutaneous or intravenous abusers: AIDS, scars from intravenous or subcutaneous injections, abscesses, infections from contaminated injections, bacterial endocarditis, drug-induced or infectious hepatitis, thrombophlebitis, and tetanus.
Snorters of cocaine, heroin, or other drugs: deviated or perforated nasal septum, nasal bleeding, and rhinitis.
Cocaine freebasers; smokers of crack, marijuana, or other drugs; inhalant abusers: bronchitis, asthma, chronic respiratory conditions.
C. History.
Determine the pattern of abuse. Is it continuous or episodic? When, where, and with whom is the substance taken? Is the abuse recreational or
confined to certain social contexts? Find out how much of the patient’s life is associated with obtaining, taking, withdrawing from, and recovering from substances. How much do the substances affect the patient’s social and work functioning? How does he or she get and pay for the substances? Always specifically describe the substance and route of administration rather than the category (i.e., use “intravenous heroin withdrawal” rather than “opioid withdrawal”). If describing polysubstance abuse, list all substances. Substance abusers typically abuse multiple substances.
confined to certain social contexts? Find out how much of the patient’s life is associated with obtaining, taking, withdrawing from, and recovering from substances. How much do the substances affect the patient’s social and work functioning? How does he or she get and pay for the substances? Always specifically describe the substance and route of administration rather than the category (i.e., use “intravenous heroin withdrawal” rather than “opioid withdrawal”). If describing polysubstance abuse, list all substances. Substance abusers typically abuse multiple substances.
Table 11-5 Drugs of Abuse That Can Be Tested in Urine | ||||||||||||||||||||||||||||||
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D. Diagnoses.
Abuse is the chronic use of a substance that leads to impairment or distress and eventually produces dependence on the drug with tolerance and withdrawal symptoms.
E. Treatment.
The management of dependence involves observation for possible overdose, evaluation for polysubstance intoxication and concomitant medical conditions, and supportive treatment, such as protecting the patient from injury. The management of abuse or dependence involves abstinence and long-term treatment often relies on creating adaptive social supports and problem solving, with psychopharmacologic strategies generally managing withdrawal, substituting for dependence antagonizing substance effects or mediating craving and reward mechanisms.
V. Specific Substance-Related Disorders
A. Alcohol-related disorders.
Almost any presenting clinical problem can be related to the effects of alcohol abuse. Although alcoholism does not describe a specific mental disorder, the disorders associated with alcoholism generally can be divided into three groups: (1) disorders related to the direct effects of alcohol on the brain (including alcohol intoxication, withdrawal, withdrawal delirium, and hallucinosis), (2) disorders related to behavior associated with alcohol (alcohol abuse and dependence), and (3) disorders with persisting effects (including alcohol-induced persisting amnestic disorder, dementia, Wernicke’s encephalopathy, and Korsakoff’s syndrome). Table 11-6 lists all the DSM-IV-TR alcohol-related disorders.
B. Alcohol dependence and abuse
Definitions. Alcohol dependence is a pattern of compulsive alcohol use, defined in DSM-IV-TR by the presence of three or more major areas of impairment related to alcohol occurring within the same 12 months. These areas may include tolerance or withdrawal, spending a great deal of time using the substance, returning to use despite adverse physical or psychological consequences, and repeated unsuccessful attempts to control alcohol intake. Alcohol abuse is diagnosed when alcohol is used in physically hazardous situations (e.g., driving). Alcohol abuse differs from alcohol dependence in that it does not include tolerance and withdrawal or a compulsive use pattern; rather, it is defined by negative consequences of repeated use. Alcohol abuse can develop into alcohol dependence, and maladaptive patterns of alcohol consumption may include continuous heavy use, weekend intoxication, or binges interspersed with periods of sobriety.
Table 11-6 DSM-IV-TR Alcohol-Related Disorders
Alcohol use disorders
Alcohol dependence
Alcohol abuse
Alcohol-induced disorders
Alcohol intoxication
Alcohol withdrawal
Specify if:
With perceptual disturbances
Alcohol intoxication delirium
Alcohol withdrawal delirium
Alcohol-induced persisting dementia
Alcohol-induced persisting amnestic disorder
Alcohol-induced psychotic disorder, with delusions
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced psychotic disorder, with hallucinations
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced mood disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced anxiety disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-induced sexual dysfunction
Specify if:
With onset during intoxication
Alcohol-induced sleep disorder
Specify if:
With onset during intoxication
With onset during withdrawal
Alcohol-related disorder not otherwise specified
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.
Pharmacology
Pharmacokinetics. About 90% of alcohol is absorbed through the stomach, the remainder from the small intestine. It is rapidly absorbed, highly water-soluble, and distributed throughout the body. Peak blood concentration is reached in 30 to 90 minutes. Rapid consumption of alcohol and consumption of alcohol on an empty stomach enhance absorption and decrease the time to peak blood concentration. Rapidly rising blood alcohol concentrations correlate with degree of intoxication. Intoxication is more pronounced when blood concentrations are rising rather than falling. Ninety percent of alcohol is metabolized by hepatic oxidation; the rest is excreted unchanged by the kidneys and lungs. Alcohol is converted by alcohol dehydrogenase into acetaldehyde, which is converted to acetic acid by aldehyde dehydrogenase.
The body metabolizes about 15 dL of alcohol per hour, which is equivalent to one moderately sized drink (12 g of ethanol—the content of 12 oz of beer, 4 oz of wine, or 1 to 1.5 oz of an 80-proof liquor). Patients who use alcohol excessively have up-regulated enzymes that metabolize alcohol quickly.
Neuropharmacology. Alcohol is a depressant that produces somnolence and decreased neuronal activity. It can be categorized with the other sedative–anxiolytics, such as benzodiazepines, barbiturates, and carbamates. These agents are cross-tolerant with alcohol, produce similar profiles of intoxication and withdrawal, and are potentially lethal in overdose, especially when taken with other depressant drugs. According to the various theories regarding the mechanism of action of alcohol on the brain, alcohol may affect cell membrane fluidity, dopamine-mediated pleasure centers, benzodiazepine receptor complexes, glutamate-gated ionophore receptors that bind N-methyl-D-aspartate (NMDA), and the production of opioidlike alkaloids.
Epidemiology. Approximately 10% of women and 20% of men have met the diagnostic criteria for alcohol abuse during their lifetimes, and 3% to 5% of women and 10% of men have met the diagnostic criteria for the more serious diagnosis of alcohol dependence. See Table 11-7. The lifetime risk for alcohol dependence is about 10% to 15% for men and 3% to 5% for women. Whites have the highest rate of alcohol use—56%—and 60% of alcohol abusers are men. The higher the educational level, the more likely is the current use of alcohol, in contrast to the pattern for illicit drugs. Among religious groups, alcohol dependence is highest among liberal Protestants and Catholics. The orthodox religions appear to be protective against alcohol dependence in all religious groups. About 200,000 deaths each year are directly related to alcohol abuse, and about 50% of all automotive fatalities involve drunken drivers.
Etiology. Data supporting genetic influences in alcoholism include the following: (1) close family members have a fourfold increased risk, (2) the identical twin of an alcoholic person is at higher risk than a fraternal twin, and (3) adopted-away children of alcoholic persons have a fourfold increased risk. The familial association is strongest for the son of an
alcohol-dependent father. Ethnic and cultural differences are found in susceptibility to alcohol and its effects. For example, many Asians show acute toxic effects (e.g., intoxication, flushing, dizziness, headache) after consuming only minimal amounts of alcohol. Some ethnic groups, such as Jews and Asians, have lower rates of alcohol dependence, whereas others, such as Native Americans, Inuits, and some groups of Hispanic men, show high rates. These findings have led to a genetic theory about the cause of alcoholism, but a definitive cause remains unknown.
Table 11-7 Alcohol Epidemiology
Condition
Population (%)
Ever had a drink
90
Current drinker
60–70
Temporary problems
40+
Abusea
Male: 10+
Female: 5+
Dependencea
Male: 10
Female: 3–5
a20%–30% of psychiatric patients.
Comorbidity. The sedative effect and its ready availability make alcohol the most commonly used substance for the relief of anxiety, depression, and insomnia. However, long-term use may cause depression, and withdrawal in a dependent person may cause anxiety. Proper evaluation of depressed or anxious patients who drink heavily may require observation and reevaluation after a period of sobriety lasting up to several weeks.
Many psychotic patients medicate themselves with alcohol when prescribed medications do not sufficiently reduce psychotic symptoms or when prescription medications are not available. In bipolar patients, heavy alcohol use often leads to a manic episode. Among patients with personality disorders, those with antisocial personalities are particularly likely to exhibit long-standing patterns of alcohol dependence. Alcohol abuse is prevalent in persons with other substance use disorders, and the correlation between alcohol dependence and nicotine dependence is particularly high.
Diagnosis, signs, and symptoms
Alcohol dependence. See Table 11-8. Tolerance is a phenomenon in the drinker, who with time requires greater amounts of alcohol to obtain the same effect. The development of tolerance, especially marked tolerance, usually indicates dependence. Mild tolerance for alcohol is common, but severe tolerance, such as that possible with opioids and barbiturates, is uncommon. Tolerance varies widely among persons. Dependence may become apparent in the tolerant patient only when he or she is forced to stop drinking and withdrawal symptoms develop. The clinical course of alcohol dependence is given in Table 11-9.
Alcohol abuse. Chronic use of alcohol that leads to dependence, tolerance, or withdrawal. See Table 11-10.
Evaluation. The proper evaluation of the alcohol user requires some suspicion on the part of the evaluator. In general, most people, when questioned, minimize the amount of alcohol they say that they consume.
Table 11-8 DSM-IV-TR Diagnostic Criteria for Alcohol or Other Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
- tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
- the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
- the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
- the substance is often taken in larger amounts or over a longer period than was intended
- there is a persistent desire or unsuccessful efforts to cut down or control substance use
- a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
- important social, occupational, or recreational activities are given up or reduced because of substance use
- the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
Specify if:
With physiologic dependence: evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)
Without physiologic dependence: no evidence of tolerance or withdrawal (i.e., neither item 1 nor 2 is present)
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.
Other questions that may provide important clues include how often and when the patient drinks, how often he or she has blackouts (amnesia while intoxicated), and how often friends or relatives have told the patient to cut down on drinking. Always look for subtle signs of alcohol abuse, and always inquire about the use of other substances. Physical findings may include palmar erythema, Dupuytren’s contractures, and telangiectasia. Does the patient seem to be accident-prone (head injury, rib fracture, motor vehicle accidents)? Is he or she often in fights? Often absent from work? Are there social or family problems? Laboratory assessment can
be helpful. Patients may have macrocytic anemia secondary to nutritional deficiencies. Serum liver enzymes and γ-glutamyltransferase (GGT) may be elevated. An elevation of liver enzymes can also be used as a marker of a return to drinking in a previously abstinent patient (Table 11-11). The following subtypes of alcohol dependence have been described:
Table 11-9 Clinical Course of Alcohol Dependence
Age at first drinka
13–15 years
Age at first intoxicationa
15–17 years
Age at first problema
16–22 years
Age at onset of dependence
25–40 years
Age at death
60 years
Fluctuating course of abstention, temporary control, alcohol problems
Spontaneous remission in 20%
aSame as general population.
Table by Marc A. Schuckitt, M.D.
Table 11-10 DSM-IV-TR Diagnostic Criteria for Alcohol or Substance Abuse
- A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
- recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
- The symptoms have never met the criteria for substance dependence for this class of substance.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.
Type A: late onset, mild dependence, few alcohol-related problems, and little psychopathology (sometimes called type I).
Type B: severe dependence, early onset of alcohol-related problems, strong history of family alcohol use, high number of life stressors, severe psychopathology, polysubstance use, and high psychopathology (sometimes called type II).
Affiliative drinkers: tend to drink daily in moderate amounts in social settings.
Schizoid-isolated drinkers: tend to drink alone and subject to binge drinking.
Gamma alcohol dependence: persons unable to stop drinking once they start.
Table 11-11 State Markers of Heavy Drinking Useful in Screening for Alcoholism
Test
Relevant Range of Results
γ-Glutamyltransferase (GGT)
>30 U/L
Carbohydrate-deficient transferrin (CDT)
>20 mg/L
Mean corpuscular volume (MCV)
>91 µm3
Uric acid
>6.4 mg/dL for men
>5.0 mg/dL for women
Aspartate aminotransferase (AST)
>45 IU/L
Alanine aminotransferase (ALT)
>45 IU/L
Triglycerides
>160 mg/dL
Adapted from Marc A. Schuckitt, M.D.
- tolerance, as defined by either of the following:
Treatment. The goal is the prolonged maintenance of total sobriety. Relapses are common. Initial treatment requires detoxification, on an inpatient basis if necessary, and treatment of any withdrawal symptoms. Coexisting mental disorders should be treated when the patient is sober.
Insight. Critically necessary but often difficult to achieve. The patient must acknowledge that he or she has a drinking problem. Severe denial may have to be overcome before the patient will cooperate in seeking treatment. Often, this requires the collaboration of family, friends, employers, and others. The patient may need to be confronted with the potential loss of career, family, and health if he or she continues to drink. Individual psychotherapy has been used, but group therapy may be more effective. Group therapy may also be more acceptable to many patients who perceive alcohol dependence as a social problem rather than a personal psychiatric problem.
Alcoholics Anonymous (AA) and Al-Anon. Supportive organizations, such as AA (for patients) and Al-Anon (for families of patients), can be effective in maintaining sobriety and helping the family to cope. AA emphasizes the inability of the member to cope alone with addiction to alcohol and encourages dependence on the group for support; AA also utilizes many techniques of group therapy. Most experts recommend that a recovered alcohol-dependent patient maintain lifelong sobriety and discourage attempts by recovered patients to learn to drink normally. (A dogma of AA is, “It’s the first drink that gets you drunk.”)
Psychosocial interventions. Often necessary and very effective. Family therapy should focus on describing the effects of alcohol use on other family members. Patients must be forced to relinquish the perception of their right to be able to drink and recognize the detrimental effects on the family.
Psychopharmacotherapy
Disulfiram (Antabuse). A daily dosage of 25 to 500 mg of disulfiram may be used if the patient desires enforced sobriety. The usual dosage is 250 mg/day. Patients taking disulfiram have an extremely unpleasant reaction when they ingest even small amounts of alcohol. The reaction, caused by an accumulation of acetaldehyde resulting from the inhibition of aldehyde dehydrogenase, includes flushing, headache, throbbing in the head and neck, dyspnea, hyperventilation, tachycardia, hypotension, sweating, anxiety, weakness, and confusion. Life-threatening complications, although uncommon, can occur. Patients with
preexisting heart disease, cerebral thrombosis, diabetes, and several other conditions cannot take disulfiram because of the risk of a fatal reaction. Disulfiram is useful only temporarily to help establish a long-term pattern of sobriety and to change long-standing alcohol-related coping mechanisms.
Naltrexone (ReVia). This agent decreases the craving for alcohol, probably by blocking the release of endogenous opioids, thereby aiding the patient to achieve the goal of abstinence by preventing the “high” associated with alcohol consumption. A dosage of 50 mg once daily is recommended for most patients.
Acamprosate (Campral). This drug is used with patients who have already achieved abstinence. It helps patients remain abstinent by a yet unexplained mechanism involving neuronal excitation and inhibition. It is taken in a delayed release tablet in dosages of 2 g once a day.
Medical complications. Alcohol is toxic to numerous organ systems. Complications of chronic alcohol abuse and dependence (or associated nutritional deficiencies) are listed in Table 11-12. Alcohol use during pregnancy is toxic to the developing fetus and can cause congenital defects in addition to fetal alcohol syndrome.
Clinical Hint
When obtaining a history of the degree of alcohol use, it can be helpful to phrase questions in a manner likely to elicit positive responses. For example, ask “How much alcohol do you drink?” rather than “Do you drink alcohol?”
Clinical Hint
When doing individual therapy, if the patient comes to a session under the influence of alcohol, the session should not be held. If suicidal ideation is expressed, hospitalization should be obtained.
Clinical Hint
Advise patients using Antabuse not to use any after-shave lotions or colognes that contain alcohol. Inhalation of the alcohol can produce a reaction.
C. Alcohol intoxication
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