Alcohol dependence is an important and common public health problem. Some experts have concluded that alcohol dependence is present in 4% of the United States population. Alcohol use disorders are present in greater proportions than the typical primary care population among current cigarette smokers, emergency department visitors, and trauma settings.
While alcohol may be related to 100,000 preventable deaths per year, neuroscientists have made some very important discoveries about alcohol and alcohol dependence. Alcohol abuse and dependence are influenced heavily by genetic vulnerability, early abuse of alcohol, and cultural and environmental factors. Animals can be bred for alcohol preference and will avidly self-administer alcohol. These neurotransmitter, receptor, genomic, and neuropharmacologic studies have produced a good understanding of alcohol use, abuse, dependence, and withdrawal, and new treatments are being based on these findings.
According to the National Institute on Alcoholism and Alcohol Abuse, nearly 1 in every 13 US adults abuses alcohol or is alcoholic — that is, about 14 million US adults. Physicians have more prescription misuse and opioid abuse and dependence than appropriate controls but the same amount of alcohol use disorders. Adolescent use and binge use have remained major problems and targets for prevention activities. Drinking at a young age is known to increase the likelihood of developing alcohol problems later in life. It is reported that almost 30% of people ages 12 to 20 have reported drinking in the previous month, with nearly one-third of twelfth graders reporting that they have been drinking to get drunk. These figures have been stabilizing during the past few years.
While detoxification and abstinence with long-term Alcoholics Anonymous participation remains the treatment that most physicians choose for themselves and their colleagues, new treatments for alcoholism are being developed, tested, and administered. In this issue, we review the physician's role in alcohol use disorders, with specific attention to new treatments and special populations of patients.
In This Issue
We begin with an overview by Dr. Joseph Pagano and colleagues, “The Physician's Role in Recognition and Treatment of Alcohol Dependence and Comorbid Conditions.” Aspects of alcohol dependence are reviewed, including both the beneficial and toxic effects of alcohol, as well as withdrawal symptoms, screening, and diagnosis. Also examined are legal issues; comorbidity with other psychiatric illnesses, substance abuses, or HIV/AIDS; and potential benefits of alcohol consumption.
Understanding how patients become addicted will help us develop future cures. Dr. Joseph Volpicelli explores potential new treatments for alcohol dependence in the article “New Options for the Treatment of Alcohol Dependence.” Dr Volpicelli is a pioneer in this area and here presents an overview of medications and their use as adjuncts to other treatments in management of the patient with alcohol dependence and also those with other comorbid psychiatric disorders.
Next, we turn to two special populations, impaired physicians and adolescents. In “Double Trouble: Depression and Alcohol Abuse in the Adolescent Patient,” Dr. Jodi Star and colleagues look at the use of treatment of adolescents with alcohol use disorders with and without psychiatric illnesses. Comorbidity of depression and alcohol use disorders in children has a negative impact on the course, treatment, and outcomes of both syndromes. Taking a history and making a diagnosis is quite challenging in these patients.
Then, in “The Effects of Alcohol Use During Medical School,” my co-authors and I evaluate and report new data on medical school binge drinking and the effects of the impaired physician on the family, field, and society. While physicians have about the same rate of alcohol dependence as the general population, they are more likely to recover and return to work. Are there any prognostic indicators to help identify physicians at the greatest risk?
Finally, Dr. Michael Gossop's article “Alcohol in Suicide Attempts and Completions” examines the important links between alcohol use and suicide, as well as evidence as to the nature of this relationship. Alcohol abuse comorbid with depression remains a major underlying cause of suicide attempts.
Most diagnoses of alcohol dependence are made by law enforcement, life insurance physicals, emergency department or trauma visits, loved ones or family members. Few are made by physicians, who often attempt to make an alcohol abuse diagnosis using methods similar those used to evaluate cigarette use and pack-per-year history. Assessments and questions about attachment to alcohol are better early indicators than how much or how often. Drug testing should be used to confirm a diagnosis, establish drug-free outcomes, and identify common cooccurring tobacco and illicit drug disorders. All cigarette smokers, current prescription misusers, drug abusers, and patients with anxiety or mood symptomology should be screened for alcohol abuse — and vice versa.