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Fig. 10.4 Features of alcohol dependence.

Nineteen features of alcohol dependence

Occasional relief drinking

Occasional relief drinking

Constant relief drinking begins

Surreptitious drinking

Surreptitious drinking

Feeling of'jjuilt

Unable to discuss problem_

Before court for drunk driving

Feeling of'jjuilt

Unable to discuss problem_

Before court for drunk driving

Loss of control

Grandiose and aggressive behaviour

Promises and resolutions fail

Family and ■Hinds avoided

Work and money troubles

Grandiose and aggressive behaviour

Promises and resolutions fail

Family and ■Hinds avoided

Work and money troubles

Unreasonable resentments

Unreasonable resentments

Neglect of food

Moral deterioration

Neglect of food

Moral deterioration

Impa'.reä thinking

leexXED

Unable to initiate action

Vague spiritual leexXED

Unable to initiate action

Vague spiritual

Complete defeat admitted

Obsessive drinklna continues In vicious _circles_

Complete defeat admitted

Obsessive drinklna continues In vicious _circles_

10-50 mg qid, gradually reducing over 7-10 d. Longer exposure to chlordiazepoxide should be avoided as it has the potential to induce dependence. A |3-adrenoceptor blocker may be given to attenuate symptoms of sympathetic overactivity. General aspects of care, e.g. attention to fluid and electrolyte balance, are important. It is usual to administer vitamins, especially thiamine, in which alcoholics are commonly deficient, and i.v. glucose unaccompanied by thiamine may precipitate Wernicke's encephalopathy.

Treatment of alcohol dependence

Psychosocial support is more important than drugs, which nevertheless may help.

Acamprosate bears a structural resemblance to both glutamate and GABA and appears to reduce the effect of excitatory amino acids such as glutamate, and modifies GABA neurotransmission. Taken for 1 year (accompanied by counselling and psychosocial support), acamprosate increases the number of alcohol-free days and also the chance of subsequent complete abstinence. The benefit may last for 1 year after stopping treatment. Acamprosate may cause gastrointestinal adverse effects, and cutaneous eruptions.

Disulfiram (Antabuse). In alcoholics who are well and motivated, an attempt may be made to discourage drinking by inducing immediate unpleasantness. Disulfiram inhibits the enzyme aldehyde dehydrogenase so that acetaldehyde (toxic metabolite of alcohol) accumulates. The objective of administering disulfiram is that patients will find the experience so unpleasant that they will avoid alcohol. It should be administered only under specialist supervision.

A typical reaction of medium severity comes on about 5 min after taking alcohol and consists of generalised vasodilatation and fall in blood pressure, sweating, dyspnoea, headache, chest pain, nausea and vomiting. It may result from even small amounts of alcohol (such as may be present in some oral medicines or mouthwashes). Severe reactions include convulsions and circulatory collapse; they may last several hours. Some advocate the use of a test dose of alcohol under supervision (after the fifth day), so that patients can be taught what to expect and also to induce an aversion from alcohol.

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