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Marin Independent Journal — THE OLD JOKE in medical school was that you weren’t an alcoholic unless you drank more than your physician. Come to think of it, that wasn’t funny then, and it isn’t funny now.

Lately, a number of people have been telling me about friends or family members who may have a drinking problem, and they ask me, "Is he an alcoholic?" Sometimes they’ll tell me: "Well, she may have a drinking problem, but at least she isn’t an alcoholic."

Although we have all grown up knowing the word "alcoholic," this term is very nonspecific and means something very different to each of us.

In the medical profession, we do not use this term because it is so vague. Instead, we describe the illnesses, collectively known as substance-related disorders, in several categories based on specific criteria, as defined in a text known as the DSM IV R, which defines criteria for all psychiatric and behavioral disorders. The advantage of this specificity, instead of using the term "alcoholic," is that it helps guide treatment as well.

One diagnosis within the category of substance-related disorders is "Alcohol Abuse," which is coded in the text as DSM 305. To be diagnosed with alcohol abuse, a person must show "a destructive pattern of alcohol abuse, leading to significant social, occupational or medical impairment, as manifested by at least one of the following within a 12 month period:

- Recurrent substance use resulting in failure to fulfill major obligations.

- Recurrent substance use in situations in which it is physically hazardous.

- Recurrent substance-related legal problems.

- Continued substance use despite persistent or recurrent social or interpersonal problems related to alcohol.

For example, two traffic violations for DUI (driving under the influence) within one year would meet the criteria. If one is repeatedly late for work, or coming to work "hung over," this would also meet these criteria.

Another diagnosis is Alcohol Dependence, coded as DSM 303.9. The criteria for this diagnosis reflect that the patient is physiologically dependent upon alcohol, and would suffer alcohol withdrawal symptoms when he stops drinking. To be diagnosed with Alcohol Dependence, one must meet three of the following criteria:

- Alcohol withdrawal symptoms, such as rapid heartbeat, sweating or confusion.

- Alcohol tolerance - need for increased amounts, or diminished effect.

- Alcohol taken in larger amounts over a longer period than intended.

- Persistent desire or unsuccessful effort to cut down on alcohol consumption.

- Increased time spent attempting to obtain alcohol.

Many people who are alcohol dependent try to hide their alcohol consumption from friends or family. They travel out of town to purchase alcohol. Some try to stop, or at least verbalize that they wish to stop, but cannot.

Alcohol withdrawal is more than just the "shakes." It is a true cardiovascular emergency, with rapid heartbeat (tachycardia), fever and very high blood pressure, which occurs as the autonomic nervous system, which has become accustomed to a certain level of alcohol in the body, now tries to adapt to its absence.

Alcohol-related disorders are rampant, as are substance disorders related to other drugs, such as narcotics, cocaine and crystal meth. People who suffer these disorders hide them well, rarely exhibiting the stereotypic behaviors that we all describe as those of an "alcoholic."

I remember one family member whom everyone decided was not an alcoholic because they never saw him drunk. He was generally jovial and charming, and was the center of attention at a party, although he could be withdrawn on occasion. He drank a minimum of five mixed drinks every day, starting around noon.

If you are wondering if a person might be an "alcoholic," or if you find yourself questioning a loved one’s consumption, please put the term "alcoholic" out of your mind. It will lead you astray. Instead, contact your physician and describe the behaviors that you have witnessed.

Please act before it is too late.

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(HealthDay News) – Sticking to a regimen of prescribed medications is the most effective way to reduce withdrawal symptoms and urges to drink alcohol in those being treated for alcohol dependence, according to a U.S. study.

The study compared two medications (naltrexone and acamprosate) used in combination with two behavioral treatments — low-intensity medical management (MM) and moderately intensive combined behavioral intervention (CBI).

The researchers analyzed data from 846 males and 380 females who took part in the National Institute of Alcohol Abuse and Alcoholism’s Combine study, a large-scale, multi-site, combined medication and behavioral treatment study.

The participants were randomly assigned to one of eight different combination treatments involving naltrexone, acamprosate, a placebo, MM, and CBI. After 16 weeks of treatment, the patients’ primary outcomes — including percent days abstinent and time to first heavy drinking — were compared.

"First, high medication adherents fared better than low medication adherents across all combinations of behavioral and pharmacological treatment conditions," Allen Zweben, associate dean for academic affairs and research in Columbia University’s school of social work, said in a prepared statement.

"Second, CBI — a specialty alcohol treatment — surprisingly had a beneficial impact on nonadherents receiving the placebo. This raises the issue of whether or not CBI may serve as a cushion or have a protective function for these patients," said Zweben, the corresponding author for the study.

"Conversely, CBI did not provide similar benefits for naltrexone-treated patients; their relapse rates appeared to be more a function of inadequate exposure to naltrexone and less influenced by CBI," he added.

Overall, specialized CBI did not perform better than the more primary-care MM.

"Both of these behavioral treatments performed equally as well with regard to treatment adherence and medication adherence rates," Zweben said.

The findings show that combing MM and naltrexone could benefit a large percentage of alcohol-dependent patients.

"Alcohol-dependent patients could be managed in nonspecialized or general health care settings, which, in turn, could broaden the treatment options for individuals diagnosed as alcohol-dependent," Zweben said. "We will need to adapt these findings to ‘real world’ medical settings and follow the results."

The study was released online by the journal Alcoholism: Clinical and Experimental Research and was to be published in the September print issue.

BBC News — Twin research projects have offered both present and future hope to people suffering from alcohol addiction.

US researchers say that epilepsy drug topiramate boosts general health as well as cutting the craving for drink.

A UK specialist said the potential side-effects of topiramate still merited caution.

A separate project showed that a single injection of a protein into the brains of rats almost immediately stopped them wanting alcohol.

Topiramate is not licensed in the UK for the treatment of alcohol addiction, although doctors are allowed to prescribe it if they wish, and occasionally do.

The latest study results, published in the journal Archives of Internal Medicine, could increase the number of doctors willing to do this.

Researchers from the University of Virginia analysed the results of the US-wide trial, which took 371 people with a heavy drinking problem, and gave them either topiramate or a placebo "dummy" drug.

They found, that over 14 weeks, those taking topiramate not only had fewer obsessive thoughts and compulsions about using alcohol, but had generally improving health.

Their weight, cholesterol and blood pressure dropped, and levels of liver enzymes linked to "fatty liver" disease, the forerunner of cirrhosis, also fell away.

Lead researcher Professor Bankole Johnson said: "What we’ve found is that topiramate treats the alcohol addiction, not just the ’symptom’ of drinking."

Side effects

Dr Jonathan Chick, a specialist in the psychiatry of addiction, welcomed the results, particularly the figures which proved better health, rather than relying on an estimate of reduced drinking levels, which could prove misleading.

He said: "There are other drugs which were originally developed to prevent epileptic seizures, which have also shown promise in reducing relapse in alcoholism, but topiramate is so far the most convincing."

However, he said that his own limited use of topiramate had been very carefully monitored to minimise the powerful side-effects of the drug.

In the other study, the Proceedings of the National Academy of Sciences Journal reported on a study in rats carried out at the University of California at San Francisco.

The scientists injected a brain protein called GDNF directly into a part of the brain called the ventral tegmental area, which is thought to be heavily involved in "drug-seeking" behaviour.

The rats were placed in an environment designed to mimic human social drinking, with a lever that could be pushed to deliver an alcoholic drink.

Rat rehab

The protein began working almost immediately, with effects noticed within 10 minutes.

The research also suggested that other cravings were unaffected, as the rats’ desire for their supply of sugary water continued unabated.

In addition, once treated with GDNF, rats seemed to be less likely to "relapse" to alcoholism after a "rehab" situation, in which the alcohol supply was cut off for a period of time, then reintroduced.

"Our findings open the door to a promising new strategy to combat alcohol abuse, addiction and especially relapse," said lead author Dr Dorit Ron.

Dr Chick said that there had been various attempts to interfere directly with the brain systems controlling alcohol cravings, although these had only achieved "mixed success" when transferred from experimental animals to humans.

Washington Post – When it comes to treatment, the experts think alcoholism needs to catch up to depression.

Three decades ago, long before the dawn of the Prozac Era, depression was a disease rarely treated in its mild form, reluctantly treated with drugs and usually treated by experts only. Today, signs of depression are actively sought, drugs are prescribed early and often, and most cases are handled by nonpsychiatrists.

With alcohol abuse, however, most physicians don’t go looking for trouble and don’t recognize it until it’s breathing in their face. Over-drinking patients often don’t think of looking for help even if they know they are heading in the wrong direction. And society as a rule looks at alcohol treatment as a last-chance, 90-degree corner taken only at high speed.

Simplify screening

All this will change if American physicians adopt the new guidelines for "Helping Patients Who Drink Too Much" promulgated by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.

The idea is to simplify the screening for excessive alcohol use in general medical practice and to convince clinicians and patients that early intervention for drinking that hasn’t yet wreaked havoc is both possible and useful.

"We’re trying to increase the accessibility and attractiveness of treatment to a much broader spectrum of people," said Mark L. Willenbring, a psychiatrist who directs the Division of Treatment and Recovery Research at NIAAA.

Those especially targeted in the guidelines are heavy drinkers who are not yet physically dependent on alcohol but are at risk for becoming so.

"We know that that group responds very, very well to what we call facilitated self-change and brief motivational counseling. We could make that very widely available without much cost," Willenbring said.

A big part of the new strategy is to make primary care physicians — people without specialized training in addiction medicine — think about alcohol abuse the way many now think about depression, anxiety and obsessive-compulsive disorder. Which is to say, they need to think of it as something common, diagnosable and within their capacity to treat. The guidelines make this easy: The screening tool for alcohol problems consists of a single question. For men: How many days in the past year have you had five or more drinks? For women: How many days in the past year have you had four or more drinks?

"Most doctors don’t know how to make the diagnosis and don’t really try to do anything about it until it is so easy to diagnose that all you have to do is glance at the patient," said Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania who has been treating alcoholics for 38 years.

"It used to be said that you can’t treat somebody until they are down and out. But when they are down and out, they are really hard to treat," O’Brien said.

Willenbring concurs.

"I think there is a belief that people with more moderate levels of dependence don’t know they have a problem. I think they do. But they don’t think rehab is the model of treatment for them — and I don’t, either."

The sort of therapy both advocate does not involve magic bullets or easy answers or effortless behavior change. But it does enlist pills that help a little, quite a bit of talk and lots of self-discipline.

And what does it get a person?

Perhaps not surprisingly, there’s evidence that getting control of a drinking problem early can improve one’s health, completely apart from the social, psychological and familial benefits it brings.

Looking at death rates

A study published two years ago looked at the experience of 628 men and women who entered alcoholism treatment (either in residential rehab or as outpatients) in their mid-30s and were followed for 16 years.

Over that period, 121 died, or 1.2 percent a year. The average age of death was 48. But the chance of dying was significantly lower in people who after the first year were abstinent or had no drinking-related problems or symptoms.

So how successful is treatment, or at least how successful has it been?

Researchers in 2000 analyzed seven studies, one going back to the late 1970s, in which more than 8,000 people were treated for alcoholism in various ways, including with drugs. After a single course of treatment, one-fourth were abstinent for at least a year and one-tenth dramatically decreased their drinking. The rest, about two-thirds of the subjects, drank less often and in quantities averaging less than half of what they consumed before treatment. Mortality in the first year was 1.5 percent.

Some of those patients had a four-week stay in "rehab," but most did not. A long treatment-center admission as the optimal strategy to stop a serious drinking problem is much more the model of the 1980s than the 2000s. The newer one emphasizes outpatient treatment — occasionally after a brief hospital stay for acute detoxification, if necessary — with care provided by non-specialists in many cases.

How often contemporary treatment succeeds was also explored in a complicated clinical trial of about 1,400 alcohol-dependent men and women, average age 44 and consuming 12 drinks a day, that was published in the Journal of the American Medical Association in 2006.

The researchers randomly assigned the patients to nine groups. Four of the groups got nine sessions, conducted by a doctor or nurse and lasting at least 20 minutes, that reviewed the health consequences of excessive drinking, encouraged abstinence and attendance at Alcoholics Anonymous meetings, and urged adherence to the study medicines. Four of the groups also got intensive counseling by alcohol-addiction experts — up to 20 hour-long sessions.

Drug therapy

Some of the patients were assigned to take a drug for three months: either naltrexone, which blocks opiate receptors in the brain that are involved in alcohol’s "reward pathways," or acamprosate, which works through so-called GABA receptors to decrease the anxiety and restlessness that can come with abstinence. Some got placebo pills.

A year later, there were no big differences among any of the groups, although there were some interesting small ones. (This was true even with what the researchers considered the placebo group, the people who received specialized alcohol counseling but no time with a physician and no pills.)

People who met regularly with a doctor or nurse and then got either naltrexone or the intensive counseling did equally well; about 66 percent were abstinent. People who had those sessions and got placebos did less well; 59 percent were abstinent. Those who got intensive counseling but no pills, neither active ones nor placebos, had an intermediate outcome, with 62 percent abstinent.

Unlike some other studies, this one showed no benefit from acamprosate. But that may not be the last word.

Interesting findings

A clinical trial not yet published showed the drug worked only when started during a period of abstinence, not while a person was still drinking. And last month researchers reported more evidence that GABA receptors play a role in alcohol addiction. Laboratory rats that got the drug gabapentin, which enhances the action of GABA, drank less — but only if they were already chronically exposed to alcohol. Those that used alcohol only occasionally did not show such an effect, suggesting the pre-existing state was crucial to the response.

Abstinence, in almost all practitioners’ minds, is always the goal. But its absence doesn’t signal abject failure.

"It is a fiction that the typical change process is a sudden transformation," Willenbring said. "The more common is a change process that lasts years and is characterized by lengthening periods of sobriety and shorter relapses until they are gone."

In that way, alcohol abuse is like depression. In another way, too.

"Recovery from depression requires effort. The same is true for alcohol dependence," he said.

And in both cases, he thinks they’re really worth the effort.

Fox News — The U.S. leads the world in marijuana and cocaine experimentation, as well as in lifetime tobacco use, according to a survey released this week by the World Health Organization.

For the survey, which was partially funded by a division of the U.S. National Institutes of Health, researchers at the University of New South Wales in Sydney, Australia looked at drug, alcohol and tobacco use in 17 countries throughout North and South America, Europe, Asia, the Middle East, Africa and Oceania. More than 54,000 people participated in the survey.

"The United States, which has been driving much of the world’s drug research and drug policy agenda, stands out with higher levels of use of alcohol, cocaine, and cannabis, despite punitive illegal drug policies, as well as (in many U.S. states), a higher minimum legal alcohol drinking age than many comparable developed countries," the authors wrote in the study, which was published in the July 1 issue of the journal PLoS Medicine.

"The Netherlands, with a less criminally punitive approach to cannabis use than the U.S., has experienced lower levels of use, particularly among younger adults," they added.

The U.S. had the highest percentage of respondents admitting to lifetime tobacco use at 74 percent, followed by Lebanon at 67 percent, and Mexico and the Ukraine at 60 percent, according to the study.

The lowest percentages of lifetime tobacco use were found in the African countries of South Africa with 32 percent and Nigeria with 17 percent.

More U.S. respondents said they used marijuana at 42.4 percent, followed by New Zealand at 41.9 percent. Lifetime marijuana use was virtually non-existent in Asian countries, however.

Sixteen percent of U.S. survey participants said they used cocaine at least once, followed by Colombia, Mexico, Spain and New Zealand where between 4 and 4.3 percent of respondents admitted to use.

The only area where U.S. respondents trailed was in alcohol use. Almost 92 percent of U.S. respondents said they used alcohol, compared to 97 percent of Ukrainians and 95.3 percent of Germans. Just 40 percent of South African respondents used alcohol.

WASHINGTON (AP) — Many of the nation’s estimated 10.8 million underage drinkers are turning to their parents or other adults for free alcohol.

A government survey of teens from 2002 to 2006 said slightly more than half had engaged in underage drinking.

Asked about the source of alcohol, 40 percent they got it from an adult for free over the past month, the survey said. Of those, about one in four said they got it from an unrelated adult, one in 16 got it from a parent or guardian and one in 12 got it from another adult family member.

Roughly 4 percent reported taking the alcohol from their own home.

"In far too many instances parents directly enable their children’s underage drinking — in essence encouraging them to risk their health and well-being," said acting Surgeon General Steven K. Galson. "Proper parental guidance alone may not be the complete solution to this devastating public health problem — but it is a critical part."

The nationwide study by the Substance Abuse and Mental Health Services Administration, being released Thursday, tracks the social contexts involved in underage drinking, a problem leading to thousands of alcohol-related traffic deaths and injuries each year.

About one out of five of those aged 12 to 20 — or roughly 7.2 million people — said they had taken part in binge drinking, defined as consuming five or more drinks on at least one occasion in the past month, the survey said. Rates were significantly higher if they lived with a parent who engaged in binge drinking.

The study, which uses data from the National Surveys on Drug Use and Health, is based on a scientific random sample of 158,000 people aged 12 to 20 in the United States. Among the other findings:

• Over half of current underage alcohol users were at someone else’s home when they had their last drink, while 30.3 percent were in their own home. About 9.4 percent were at a restaurant, bar or club.

• About 3.5 million teens aged 12 to 20 each year meet the diagnostic criteria for having an alcohol use disorder, such as dependence or abuse.

• Among younger teens, slightly more girls reported drinking than boys did. In the middle teens, they drank at roughly the same rate. Among 18 to 20-year-olds, boys outpaced the girls.

• Rates of underage drinking and binge drinking were slightly higher at the opposite ends of the economic spectrum.

• Rates of current and binge alcohol use among 12 to 20 year olds were higher in the Northeast and Midwest than in the South or West.

• Rates of alcohol use disorder among those aged 12 to 20 was higher for American Indians or Alaska Natives (14.9 percent) than for whites (10.9 percent), blacks (4.6 percent), Hispanics (8.7 percent) and Asians (4.9 percent).

"This report provides unprecedented insight into the social context of this public health problem and shows that it cuts across many different parts of our community," said Terry Cline, administrator of SAMHSA. "Its findings strongly indicate that parents and other adults can play an important role in helping influence — for better or for worse — young people’s behavior with regard to underage drinking."