The most effective way to diagnose chronic alcoholism is to:
Correct Answer C:
Because denial is a key aspect of alcoholism, eliciting examples of loss of control as a consequence of drinking is an effective interview strategy.
Little can be accomplished when the patient is intoxicated.
Each of the following regarding alcohol abuse in the elderly is true, except:
Correct Answer E:
Late-onset drinkers have a better response rate to treatment.
→ Alcohol is the most common substance of abuse in people older than age 65 years (choice A). Although 30% of people with alcoholism older than age 65 began their abuse after age 60, the majority established their pathological use earlier.
→ Alcoholism is associated with higher prevalence of both mood and cognitive disturbances (choice B).
→ Tolerance is seen with continuous alcohol use, leading to a dependence on increased consumption. Therefore, alcohol dependence is differentiated from alcohol abuse by the presence of symptoms such as tolerance and withdrawal (choice D).
→ The principles of treatment for elderly alcoholics are similar to younger patients (choice C).
A 29 year old female presents with a 15-year history of drinking. She recently lost her job and is facing DUI charges for the 3rd time in the past 5 years. She asks you to prescribe disulfiram for her because she has met many people in A.A. who have stayed sober after using it. In reviewing the side effects with her you explain that if she ingests any alcohol she may experience flushing, tachycardia, nausea, diaphoresis, or severe anxiety.
These symptoms occur because disulfiram causes:
Correct Answer A:
The fear of the unpleasant symptoms of disulfiram is used as a deterrent to future drinking in those patients who are willing to take the medication. It works by causing a shift in the chemical reaction involved in metabolizing alcohol in the liver. The result is a shift toward the production of acetaldehyde. Severe reactions can occur if a patient drinks despite taking her disulfiram. In those cases an alternative method must be used.
The toxic effects of disulfiram are not a result of serotonin level changes.
An alternative agent to disulfiram is naltrexone, an opiate antagonist, which works by decreasing cravings and rates of relapse.
Though the sensation after ingesting alcohol is described like a panic attack, the mechanism of action of disulfiram is not thought to be through serotonin pathways.
Which medication works well to discourage people with alcohol abuse from drinking?
In the treatment of alcohol abuse, a rehabilitation program is often the best approach. Rehabilitation programs combine medical supervision and psychotherapy, including one-on-one and group therapy.
Alcoholics Anonymous (AA) has benefited alcoholics more than any other approach. The patient must find an AA group in which he is comfortable. AA provides the patient with nondrinking friends who are always available and a nondrinking environment in which to socialize.
Drug therapy should be used in combination with psychotherapy. Disulfiram interferes with the metabolism of acetaldehyde (an intermediary product in the oxidation of alcohol) so that acetaldehyde accumulates. Drinking alcohol within 12 hours of taking disulfiram produces facial flushing in 5 to 15 minutes, then intense vasodilation of the face and neck with suffusion of the conjunctivae, throbbing headache, tachycardia, hyperpnea, and sweating.
With high doses of alcohol, nausea and vomiting may follow in 30 to 60 minutes and may lead to hypotension, dizziness, and sometimes fainting and collapse. The reaction can last up to 3 hours. Few patients risk ingesting alcohol while taking disulfiram because of the intense discomfort.
A 35-year-old pharmacist has a positive response to the CAGE questionnaire. He admits to drinking at least a full case of beer (24 12-oz cans) each week. The history reveals evidence of tolerance and withdrawal. He smokes cigarettes, but denies other risky behaviors. He tells you that his marriage is failing.
The patient’s general health appears good otherwise. The only positive findings on the physical examination are a mild tremor, sweaty palms, and mild tachycardia.
In this situation, which one of the following would be most helpful in choosing whether to recommend an outpatient or inpatient detoxification program?
Because polysubstance abuse is common in patients with alcohol dependence, physicians may wish to perform a urine toxicology screen in these patients. Coexisting use of other addictive substances constitutes a relative contraindication for selecting patients for alcohol withdrawal outpatient treatment. In this case, a pharmacist would have relatively easy access to other addicting substances, even though he denies using them.
→ An EKG, EEG or chest radiograph should not be ordered unless there is a clinical indication, such as a seizure history indicating the need for an EEG.
→ Magnesium deficiency, if present, should be corrected during alcohol withdrawal syndrome, but it is not necessary as a screening test for detoxification.
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