Almost every day someone walks into my office and asks, “Am I an alcoholic?” Or “Do you think I have a problem with alcohol?” And sometimes, “My partner says I drink too much.”
Alcohol is a drug that has its roots in Australian life. If you are happy, sad, bored, got a promotion, lost a family member, bought a house, or graduated from college, it can all be considered a reason to drink. Drinking alcohol is so common that if a person says they don’t, it lends itself to generally negative and intrusive comments.
The lines become blurry when it comes to deciding whether a person has a drinking problem and whether they have developed an alcohol use disorder (formerly known as alcohol dependence). This is colloquially known as being an alcoholic – a term we avoid in addiction psychiatry. It’s no surprise to hear that family, partners or co-workers tell people with AUD that their drinking is a problem. Based on your upbringing, cultural background, and exposure to alcohol, you may think that drinking a six-pack most of the time is “normal” and that the problem with drinking occurs when you are start drinking liters of cask wine per day.
AUD is a term from the Diagnostic and Statistical Manual of Mental Disorders. It is defined as a problematic pattern of alcohol use resulting in clinically significant impairment or distress, as evidenced by at least two of the 11 criteria over a 12 month period. Some of the criteria are: alcohol taken in larger amounts than expected; have a strong desire to consume alcohol; increased time spent getting alcohol; tolerance – increasing amounts of alcohol are used to achieve intoxication; and experience withdrawal symptoms when alcohol is stopped.
Most people are best served by making an appointment with their GP for a formal assessment.
For example, Sarah * is a 35 year old woman who came to my office because her fiancé, Ibrahim, thinks she drinks too much and it affects their relationship. Sarah is a lawyer and has noticed that she is increasing her alcohol consumption due to stress at work and planning a wedding. His alcohol consumption went from a glass of wine to a bottle of wine every night. A critical event was getting drunk at a dinner party with her friends as she celebrated her engagement, which led to her engaging in a verbal altercation with a stranger and having to be escorted out of the restaurant . Sarah only asked for help when her fiancé threatened to call off the engagement. She had tried to quit the “turkey cold” but had had severe withdrawals, suffering from insomnia, increased tremors, poor concentration, a gloomy mood, nausea and intense cravings. alcohol that resulted in a relapse.
Sarah hastens to tell me that she doesn’t think she has a drinking problem but that she is ready to attend sessions if it allows her to get rid of Ibrahim. In addition, she says she has only been drinking heavily for less than 12 months. Unfortunately, her liver ultrasound shows that she has fatty liver disease (an early sign of liver damage) and that she has probably been drinking heavily for a long period of time. Sarah tells me that she is surprised by this, but mentions moderate drinking in her mid-20s, suggesting a 10-year period of heavy drinking. Additionally, her father was a heavy drinker, which suggests a genetic and behavioral component.
The first intervention to consider is medical detoxification and whether it can be done at home or in hospital. During this time, withdrawal symptoms are managed with diazepam (valium) and thiamine (vitamin B1). This allows a period of abstinence from alcohol and allows you to put in place essential supports. Unfortunately, many people think of detox as the start and end of treatment, with many clients withdrawing from treatment afterwards and with high relapse rates.
Most people are not familiar with the different drugs we have for AUD, such as naltrexone, acamprosate, and disulfiram. Naltrexone works by blocking the mu-opioid receptor, which is responsible for the pleasurable effects of alcohol consumption. Acamprosate reduces food cravings by altering the responses between excitatory and inhibitory neurotransmitters. Disulfiram (an aversive agent) discourages indirect consumption by causing unpleasant effects such as sweating, headache, palpitations, nausea and vomiting if a person drinks alcohol while taking it.
These anti-craving drugs are most effective when combined with psychosocial interventions, ranging from brief interventions (usually delivered by general practitioners), motivational interviewing, cognitive behavioral therapy, case management and programs. rehabilitation in an establishment. In addition, there are self-help groups such as Alcoholic Anonymous, Al-Anon (a support group for friends and family of those addicted to alcohol) and self-management and recovery training, also known as under the name of Smart Recovery. It has its roots in Cognitive Behavioral Therapy (CBT) and is an alternative for people who are uncomfortable with the religious aspects of AA.
Sarah refuses medical rehab but accepts Naltrexone and is referred to a psychotherapist experienced in alcohol dependence. Unfortunately, she does it twice and her fiancé cancels their engagement. At this point, she agrees to embark on a seven-day detox and begins Disulfiram, with dosing overseen by her local pharmacy. A month after her rehab, she managed to stay sober and her relationship with Ibrahim is improving.
After six months of abstinence and active treatment, she is able to come to terms with the fact that she has AUD. She asks, “Does this mean that I will have a drinking problem forever?” “
Sarah realized that at 35, she envisions her life without alcohol. I answer that I do not know if it will ever be able to achieve controlled consumption. Dejected and visibly disappointed, she leaves my office but agrees to see me in three months.
She never comes back for this date and doesn’t return phone calls. I often wonder if she managed to stay sober.
Dr Xavier Mulenga is an addiction psychiatrist based in Sydney
* Names have been changed to protect identities