Alcoholism is now officially called Alcohol Use Disorder. It is a common problem that affects 17.8% of adult Americans at sometime during their life. It is more common in men than in women, and it tends to run in families, at least partly because of genetic factors. It is a major cause of death from accidents including drowning, suicide, and complications from medical problems resulting from excess alcohol ingestion.
Medical and psychiatric complications of Alcohol Use Disorder include hepatitis, cirrhosis (scarring of the liver), depression, anxiety, cerebellum ataxia (staggering when walking), cardiomyopathy (damage to heart muscle), pancreatitis, several forms of cancer, high blood pressure, malfunction of nerves, problems with thinking, DTs, malnutrition, and anemia.
One common form of malnutrition is thiamine (vitamin B1) deficiency. It works with enzymes involved in metabolism. Inadequate thiamine can cause brain damage. A chronic form may present with amnesia, apathy, and confabulation (makes up answers to questions but does not realize they are just made up).
It is important to recognize and treat Alcohol Use Disorder as early as possible. People with this condition don't always recognize that they have it and are in denial ("I don't have a problem with drinking; I can stop whenever I want.".
Treatment should always include psychosocial approaches such as Alcoholics Anonymous. Family members can benefit from Al Anon, which helps them avoid enabling behaviors and provides support and education. Alcohol treatment centers can also provide group and individual counseling to patients with Alcohol Use Disorder.
In addition to psychosocial treatments there are medications that may help. Of all the medications available, I will discuss the four that have the best evidence for benefit. They work through their actions on different neurotransmitters or their receptors in the brain.
My first choice would be naltrexone, which has been shown to reduce relapse by half. It blocks receptors for certain natural opioids that reinforce the pleasure from drinking. It also prevents narcotics from working and can trigger withdrawal in patients taking a narcotic. It has the advantage of being able to be started while the patient is still drinking. It is not safe to use in patients with liver disease. The side effects tend to be mild and disappear with continued use. There is an oral form taken once a day and an injectable form given once a month.
A second medication is acamprosate that modifies a different neurotransmitter system but is not as effective as naltrexone. Also, it must be given three times daily so compliance is more difficult. It does have the advantage that it can be given to patients with active liver disease, which is common in these patients. It also has a benign side effect profile that usually resolves with continued use.
A third option is topiramate, which is not FDA approved for this use. It is used for seizures, mood disorders, and migraine headache prevention. It is about as effective as naltrexone but works on different neurotransmitter systems. It also has more side effects including cognitive impairment, tingling and numbness in the legs, weight loss, headaches, fatigue, and dizziness. They can often be avoided by starting at a low dose and increasing slowly.
The fourth option is disulfiram, which has been used longer than the other medications for Alcohol Use Disorder. However, it is losing favor compared to the other three. It works in a very different way by blocking the metabolism of alcohol such that an aldehyde accumulates, which makes the patient very ill if he drinks alcohol in even small amounts. The patient is likely to experience severe nausea, pounding headache, flushing, lightheadedness, and very rapid heartbeat. The risk of developing these symptoms is intended to discourage the patient from drinking. The medication itself has side effects including abnormal liver tests so they must be monitored.
The bottom line is that Alcohol Use Disorder is common, causes significant medical and psychiatric problems and adversely affects the person's life. However, it can be treated. This should always include psychosocial treatment and often will benefit from medications.
