Lesson 7: Drunkards, Alcoholics, and Problem Drinkers

Attention

Part four in the greatest drunks series, highlighting the great W.C. Fields, no stranger to a stiff drink on and off camera. This red-nosed comedic genius was a master juggler, expert at billiards, and a seasoned drinker - he said he never drank water, and he never met a booze he didn't like!

Fields died in 1946, from an alcohol-related stomach hemorrhage.

Click HERE to view this directly on YouTube

Learning Outcomes

Upon completion of this lesson's material, students will

• Be able to state different religious, ethnic, and medical views of human use of alcohol
• Be able to state the benefits and risks of "harm-reduction" vs "abstinence" treatment approaches
• Summarize recent research on health risks and/or benefits of alcohol
• Be able to describe different ways of treating AUD
• Reading Assignment: Chapter 8 on GABA in your e-textbook by Nutt and Nestor

Teaching

Reading

Chapters 12 and 13 in The Thirteenth Step

Alcohol as the product of fermentation of grain and grapes was probably discovered accidentally and then done intentionally. In ancient times there were few ways of preserving food and fermentation to an alcoholic beverage was one. Also, probably unbeknownst to ancient peoples, the fermented beverage did not support bacteria and therefore was safe to drink. Human alcohol use can be traced at least as far back as the Stone Age (10,000BCE)

History of alcoholic beverages (follow this link to learn more about alcohol through the ages)

Biblical Times

The Hebrew Bible mentions drunkenness and counsels moderation. In the Pentateuch, one of the blessings of the Promised Land (Israel) is wine (Deuteronomy 7.12,13). But the book of Proverbs counsels that strong drink is for the desperate and leads to life problems

It is not for kings, O Lemuel,
It is not for kings to drink wine,
Nor for princes intoxicating drink;

Lest they drink and forget the law,
And pervert the justice of all the afflicted.

Give strong drink to him who is perishing,
And wine to those who are bitter of heart.

Let him drink and forget his poverty,
And remember his misery no more.

Proverbs 31:4-7New King James Version (NKJV)

Jesus is seen as sharing wine with his disciples and may even have been accused of being a drunkard because he drank which apparently didn't match the stereotype for holy men (Luke 7.33,34). The overall judgment though seems to be that excessive drinking is a sin because it leads to out-of-control behavior.

American History

Heavy drinking was a fact of life in late 18th Century America. In 1790, United States government figures showed that annual per-capita alcohol consumption for everybody over fifteen amounted to thirty-four gallons of beer and cider, five gallons of distilled spirits, and one gallon of wine. However, in the late 19th and early 20th Centuries Progressives sought to improve the health and moral character of the country and eventually attained an Amendment to the Constitution banning alcohol. This was poorly enforced and widely ignored and was eventually repealed in 1933.

U.S. alcohol consumption through the years since repeal

National Institute on Alcohol Abuse and Alcoholism

International

Alcohol consumption differs from nation to nation. Some countries drink regularly with meals (France, Italy) and even children drink, but they don't seem to have high AUD rates perhaps because they have learned how to drink moderately and frown on drunkenness. Other countries see binge drinking as a social grace (Russia, Ireland). In the U.S., drinking is routinely portrayed as part of the good life and only occasionally portrayed as causing problems. The Islamic countries of North Africa and the Eastern Mediterranean have the lowest AUD rates probably because drinking is largely seen as contradictory to the principles of Islam.

Religion

Religion and Alcohol (follow this link to learn more about how the world’s religions view alcohol consumption)

Islam and various sects within other religions require complete abstinence.

In Christianity, the mainstream protestant churches (Lutheran, Presbyterian, Congregational, Methodist, Episcopalian) generally allow temperate use of alcohol while the evangelical protestant churches (Baptist, Pentecostal, etc.) generally do not. Orthodox and Catholic churches allow use of alcohol.

Judaism generally allows temperate use of alcohol.

Gender differences

Women are more susceptible to the effects of alcohol because they have more adipose tissue than men and consequently get alcohol into the bloodstream more quickly because fat cells do not absorb alcohol (in men some alcohol is stored in muscle tissue before entering the bloodstream). Also women may lack alcohol dehydrogenase in the gut and consequently get more alcohol into the bloodstream. It has been observed that with heavy drinking, AUD may progress more quickly for women than for men.

Benefits of Alcohol Use

Recent confusing research about health benefits of wine and beer. It is confusing because for the most part it follows a post hoc experimental design (where people are asked about their alcohol use and then compared on conditions such as heart disease, diabetes, etc) which does not allow inferences as to cause (because they may not be accurately reporting their use or there may be other factors, like subcultural membership that are the actual reason for differences in the conditions being studied). This retrospective design is not a true experimental design but can be a useful way of collecting preliminary data that can then be tested with a true experimental design. The true experimental design requires random assignment of subjects to an experimental and a control group. The experimental group then receives the treatment we are interested in studying (e.g. a 6 ounce glass of red wine each day) while the control group does not. If the two groups are different in rates of diabetes (for example) at the end of the study, we can reasonably infer that it’s due to their different pattern of wine consumption.

It is also confusing because different studies come up with different results. Again this is due to poor experimental design but it leaves the general public scratching their heads and saying, “Forget the research. I’ll just do what I want.”

The only thing we can say confidently about "healthy" drinking is "DON'T". Because generally speaking the possible harm due to drinking outweighs the possible health benefits.

Summy of Research on Healthy Drinking

When Alcohol Consumption becomes Physically Risky (follow these links to learn more about the research)

How alcohol works

Alcohol works on the GABA/Glutamate relaxation/arousal mechanism of the body initially resulting in sedation but when it wears off causing hyperarousal (hangover, withdrawal). It is the classic case of first drinking to feel good and then drinking not to feel bad. With continuous heavy drinking anyone can develop tolerance and withdrawal but it may only be people who have the right (or wrong) genes who progress in severity. It does seem though that with any substance, only a minority of users wind up with problems. Here is some information on genetics and SUDs

The Genetics of Alcoholism (follow this link for a good article on the physiologic basis of AUD)

Alcohol also affects the endorphin system and like all addictive substances finally causes dopamine release in the limbic system.The effect on the endorphin system (the mu opiate receptor) may explain why Naltrexone (Revia) is an effective medication for some (mostly male and mostly moderate to severe cases of AUD) heavy drinkers.

Harm Reduction

Principles of Harm Reduction (read this first)

Harm reduction approaches have largely been associated with researchers such as Stanton Peele who see heavy drinking as learned behavior and suggest that new temperate habits can be learned. Adherents of the medical model generally counsel abstinence. But this is one of those arguments (like nature vs nurture) that is unnecessary and the better answer is "both" harm reduction and abstinence depending on the person we are helping. If they can drink temperately we can work with them on that and if they can't, we will make progress towards learning that abstinence is the answer. One risk of an harm reduction approach is that really bad things (like an OUI) may happen while we are trying it. One risk of an abstinence only approach is that the client may get discouraged and give up completely.

Treatment Options

AA/Rational Recovery (an alternative to AA that doesn’t require belief in a Higher Power or attendance at meetings)

In Patient

Detox where there is tolerance and signs of withdrawal. Alcohol like benzodiazepines and barbiturates can have a life-threatening withdrawal syndrome including grand mal seizures. All heavy drinkers should be referred for medical evaluation prior to attempting alcohol cessation. With medication (such as Librium) alcohol dependent people can be safely detoxed.

Following detox the patient may spend additional time in therapy both individual and group and learning more about his/her disease.

A 28 day inpatient program was once the gold standard for alcohol treatment but managed care and lack of good empirical support have eliminated all but a few of these programs which tend to be very expensive and thus are only used by relatively affluent people.

Outpatient

Outpatient (weekly or more frequently for 8 to 12 weeks) and Intensive Outpatient (usualy 4 hours/day 4 days a week for 4 weeks). Both may include individual, group and family treatment and are covered by most insurances.

Generally managed care asks people to start with Outpatient and only progress to Intensive Outpatient if Outpatient fails.

Treatments include cognitive behavioral therapy and relapse prevention. The focus is learning how to live without the substance.

MHRT/Cs can work with recovering clients to reinforce what they are learning in treatment (for example how to cope with stress without drinking, how to deal with cravings by staying away from situations that provoke them, etc.)

Medications

• Revia. This is an opiate blocker that is also useful for AUD because it reduces craving. It can be administered in a once a month injection. It works with AUD because of the involvement of the endorphin system in alcohol addiction.
• Campral. This medication reduces glutamergic nervous activity and increases stress tolerance which is often a problem for months after the last drink and a cause of relapse
• Topomax and other mood stabilizers which are predominantly used for bipolar disorder also help with AUD perhaps by stabilizing various neurohumoral mediators including dopamine, epinephrine and GABA
• Klonopin and other gabanergic meds (benzodiazepines) which affect the alcoholic the same way that buprenorphine and methadone affect the opiate dependent person by supplying the same psychoactive substance in a more manageable way.
• Anti-depressants which may help by medicating co-occuring depression

Protocol #43 Medication Assisted Treatment from the Substance Abuse and Mental Health Services (read this in preparation for the next lesson!

Assessment

Lesson 7 Quiz

1. Compare and contrast the Judaeo/Christian view of alcohol to the Islamic view. Which part of the world has the lowest AUD rates? Why do you think rates are lower in some countries? (25 points)
2. What is a common problem with much research on the health benefits of moderate drinking? How could this problem be overcome? (25 points)
3. List a risk and a benefit for a harm reduction approach to drinking. Then list a risk and a benefit of an abstinence approach. (25 points)
4. List 4 treatment options for AUD and describe briefly how they work. (25 points)

Lesson 7 Discussion

Describe your own spirituality and what choices it leads you to make about use of substances. Reflect on what you have just written and list at least one potential problem with your approach.