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February 2, 2009 — Men have more than a 1 in 5 lifetime risk of developing alcohol abuse or dependence, and while there is a widespread public perception that treatment for alcohol abuse is ineffective, the majority of patients — both men and women — do well after therapy, according to a review article published online January 23 in The Lancet.

"Despite perceptions to the contrary, efforts to help patients decrease heavy drinking commonly result in changes in behaviors, and most patients with alcohol-use disorders do well after treatment," author Marc A. Schuckit, MD, from the University of California, San Diego, writes.

"Treatment can include motivational interviewing to help people to evaluate their situations, brief interventions to facilitate healthier behaviors, cognitive-behavioral therapies, and the judicious use of drugs to improve outcomes for alcohol-use disorders," he adds.

About 1 in 5 men and 1 in 10 women have a lifetime risk for alcohol abuse or alcohol dependence.

"Busy clinicians — whether in primary practice or in psychiatry — will see a lot of patients with alcohol-use disorders. The challenge for clinicians is to learn enough about these disorders to be able to identify them, since missing this diagnosis can complicate the treatment of other medical and psychiatric illnesses," Dr. Schuckit told Medscape Psychiatry.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines alcohol dependence as repetitive problems meeting 3 or more criteria, including tolerance, withdrawal, greater use than intended, inability to control use, devoting large amounts of time to alcohol, neglecting school or work, or continued use despite health problems.

Alcohol abuse is defined as 1 or more of the following problems in 1 year: alcohol-related failure to meet obligations; alcohol-related recurrent legal problems; use of alcohol in hazardous situations; or continued alcohol use despite social or interpersonal problems.

To screen alcohol-use disorders in a clinical setting, a careful clinical interview is best, but self-administered questionnaires can also be used.

In the same way that clinicians counsel patients for risky behaviors such as being overweight, clinicians should screen patients to detect unhealthy drinking patterns, such as consuming more than 3 to 4 standard drinks a day, Dr. Schuckit writes.

In the United Kingdom, a standard drink is defined as 8 g of ethanol, whereas in the United States a standard drink is 10 g of ethanol, which is roughly 12 oz of beer, 4 oz of wine, or a single shot of an 80-proof beverage such as whiskey, said Dr. Schuckit. This is important to keep in mind when comparing studies from the 2 countries, he said.

Depression, Psychotic Episodes, Early Death
"Repeated heavy drinking in alcohol-use disorders is associated with a 40% risk of temporary depressive episodes, associated suicidal ideas and attempts, and severe anxiety and insomnia," Dr. Schuckit writes. However, many of these substance-induced health outcomes are likely to improve within 2 to 4 weeks of abstinence.

As many as 80% of alcohol-dependent individuals are regular smokers, which could either reflect an overlapping genetic predisposition or use of the second drug to deal with effects of the first drug.
About 3% to 5% of people with alcohol dependence develop a substance-induced psychotic episode requiring temporary treatment with antipsychotic medications, said Dr. Schuckit.

"Continued alcohol problems increase the rate of early death by 3 or 4 times, most commonly due to early onset of heart disease, stroke, and cancer and a high risk of accidents, suicide, and liver cirrhosis," he writes.

Young Onset
Patients with alcohol disorders can present at any age, said Dr. Schuckit. The majority of individuals tend to drink the most when they are age 18 to 22 years and then begin to moderate their drinking as their life responsibilities increase. Those who do not moderate their drinking often begin to abuse alcohol or become dependent on alcohol in their early- to mid-20s.

"In all likelihood, if you are going to develop alcohol dependence, about 75% of the risk has passed by age 30, and about 90% of the risk has passed by age 40, but about 10% of people develop alcohol-use disorder when they are older than 40," said Dr. Schuckit.

Genetic factors account for about 40% to 60% of the risk for alcohol-use disorders and environmental factors, such as alcohol availability, attitudes toward drinking, peer pressure, stress levels, coping strategies, and drinking laws, account for the rest of the risk, he added.

Treatment Approaches
"Although many clinicians believe that medications are helpful, the core of treatment rests with motivational interviewing, brief interventions, and cognitive-behavioral approaches," he writes.

Abstinence is usually the first goal of treatment in the United States, whereas efforts to control drinking or reduce harm are more often deemed appropriate goals in the United Kingdom and other parts of Europe.
Intervention, the first stage of treatment, "effectively starts the process of recovery and can be delivered by the general practitioner," Dr. Schuckit writes. This includes motivational interviewing to help people evaluate their drinking behaviors, brief interventions to facilitate healthier habits, or both strategies.

About 50% of alcohol-dependent patients develop withdrawal symptoms and require detoxification treatment.
The next treatment step is rehabilitation, to ensure that the patient remains highly motivated, has a positive attitude toward recovery, and has a lower risk for relapse.

Cognitive-behavioral strategies can help people change the way they think about alcohol and learn new avoidance strategies to either remain abstinent or diminish their drinking and avoid relapse. The Alcoholics Anonymous 12-step program has been reported to increase the likelihood of successful rehabilitation.
Since alcohol-use disorder is characterized by wide fluctuations in consumption and by high rates of spontaneous remission, placebo-controlled trials are needed to determine whether a drug is truly effective, said Dr. Schuckit.

Evidence suggests naltrexone, acamprosate, combined naltrexone and acamprosate, and disulfiram can be used to diminish cravings or discourage relapse.


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