Stop Alcohol Cravings

Alcohol Free Forever

This powerful guide walks you step-by-step through exactly what you need to do to free yourself from your alcohol addiction without going through AA meetings or expensive sessions. There are three main types of relaxation techniques you can practice when you feel upset and stressed. If you practice regularly, they will become part of your lifestyle and you may find yourself habitually more relaxed as a result. Part 2 will exercise Neuro Linguistic Programming to release thoughts and a technique of progressive muscle relaxation also negative situations. Because of the mind body connection, exercises to relax the body will also flow through the mind. Much of the stress we feel is because of our resistance to certain feelings or emotions. Alcohol Free Forever is a lifesaver ebook. This guide was extremely eye-opening and the daily emails make it extremely easy to quit and to establish a routine that did not involve alcohol. Read more...

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Ethnicity And Alcoholism

Ethnic minorities made up 29 of the U.S. population in 2000. Cultural attitudes exert a powerful influence on drinking behaviors and response to treatment. It has been shown that although cultural approval may increase the accessibility of alcohol, ritualistic use of the drug by the culture may help to inhibit abuse or dependence (Westermeyer, 1986). The lower rates of drinking problems among Italian Americans, Italians, and Jews have been explained by the traditional use of wine in these groups integration of drinking into family life and, in the Jewish drinkers, the religious significance attached to alcohol. However, even ethnic groups with ritualistic use patterns do not consistently show low incidences of alcoholism or alcoholic complications. For example, the French have relatively high rates of alcoholism and cirrhosis.

Medical Complications Of Alcoholism Gastrointestinal Tract and Pancreas

Secondary to vitamin deficiencies, alcoholics suffer from inflammation of the tongue (glossitis), inflammation of the mouth (stomatitis), caries, and perio-dontitis. A low-protein diet, associated with alcoholism, can lead to a zinc deficiency, which impairs the sense of taste and further curbs the appetite of the alcoholic. Parotid gland enlargement may be noted. Alcohol decreases gastric emptying and increases gastric secretion. As a result, the mucosal barrier of the gastrium is disrupted, allowing hydrogen ions to seep into the mucosa, which release histamine and may cause bleeding. Acute gastritis is characterized by vomiting (with or without hematemesis), anorexia, and epigastric pain. It remains unclear whether chronic alcohol abuse increases the risk of ulcer disease. The small intestine shows histological changes and contractual pattern changes even with adequate nutrition. Acute alcohol consumption impairs absorption of folate, vitamin B12, thiamine, and vitamin A, as well...

Uncomplicated Alcohol Withdrawal

This is the most frequent and benign type, usually occurring some 12-48 hours after alcohol intake is reduced, although it can develop as early as 6 hours after drinking has stopped. The essential features are a coarse tremor of the hands, tongue, and eyelids, together with at least one of the following If symptoms are mild, it is safe to recommend simple observation, but significant tremor and agitation will usually require sedation. The drugs of choice are long-acting benzodiazepines, which will not only treat alcohol withdrawal symptoms but will also prevent later complications (178). The starting dosages depend on the severity of the withdrawal, but 20 mg of chlordiazep-oxide, or 10 mg of diazepam, both given four times a day, will generally be appropriate (179). Usually the benzodiazepines should not be started until such time as the blood alcohol level has reached zero (180). However, detained persons with marked alcohol dependence may develop withdrawal symptoms before this...

Alcohol Withdrawal Delirium

The essential diagnostic feature of this disorder is a delirium that develops after recent cessation of or reduction in alcohol consumption. Traditionally referred to as delirium tremens, this withdrawal state typically begins 72-96 hours after the last drink, so it is uncommon within the normal span of detention in police custody. The delirium is characterized by impaired attention and memory, disorganized thinking, disorientation, reduced level of consciousness, perceptual disturbances, and agitation. Vivid, and often terrifying, hallucinations may occur. Usually these are visual, but other sensory modalities (e.g., auditory or tactile) may be involved. The disorder usually coexists with other features of alcohol withdrawal, for example, autonomic hyperac-tivity, which is usually severe. Alcohol withdrawal delirium is a medical emergency with a mortality rate of approx 5 . Once diagnosed, the detained person with delirium requires urgent hospitalization.

Complications of Alcohol Withdrawal

Several complications of alcohol withdrawal have been recognized, any one of which may be encountered when alcoholics are detained in police custody (176). Seizures are typically single and generalized. They usually occur between 6 and 48 hours after the last drink and although in themselves are not life threatening, their importance lies in the fact that about one-third of those with seizures will go on to develop alcohol withdrawal delirium. This is an infrequent disorder that tends to occur at about the age of 40 years in those who have been drinking heavily for more than 10 years. The essential features are vivid and persistent hallucinations, which develop shortly (usually within 48 hours) after cessation of alcohol intake. The hallucinations may be auditory or visual, and their content is usually unpleasant and disturbing. The disorder may last several weeks or months and is quite different from the fleeting hallucinations observed in other forms of alcohol withdrawal. The...

Heavy Alcohol Consumption

For most adults, occasional moderate alcohol drinking (one to two drinks per day) is not harmful, and may have health benefits. Moderate alcohol drinking can increase the HDL-cholesterol level in the blood, decrease risk of blood clots, and reduce risk of heart attack.1 However, regular heavy drinking (more than three to four drinks per day) is a health hazard. (A drink is considered a 180-ml glass of wine, 360-ml glass of beer, or 30-45 ml of spirits.) Heavy drinking increases risk of high blood pressure, stroke, liver disease, im mune weakness, and cancer.2,3 Moreover, about one in ten people who drink alcohol become physically addicted.


The effect of chronic alcoholism on lumbar spine BMD was evaluated in 76 Caucasian men using DPA (Lunar DP3) (24). The average age of the subjects was 47 years. Of the 76 men, 22 had spine BMD measurements more than 2 SD below the young-adult mean BMD for healthy men. As a group, the alcoholic subjects had significantly lower spine BMDs than a group of 62 healthy men who served as controls. Of the alcoholic subjects,

Alcohol Dependence

Alcohol abuse and dependence is a major risk factor for serious health, social, and economic problems (167). Early identification of those who are dependent on alcohol increases the possibility of successful treatment, and brief intervention by the forensic physician seems both feasible and acceptable (124,168). Although not yet validated in police custody, brief interventions show a high acceptance among drinkers in licensed premises (169). However, obtaining accurate and reliable information about a person's drinking habits can be extremely difficult because heavy drinkers tend to underestimate or deliberately lie about their alcohol consumption (170). Use of the Alcohol Use Disorders Identification Test identifies persons whose alcohol consumption has become harmful or hazardous to health (171) self-report questionnaires, such as the Michigan Alcohol Screening Test (172,173) and CAGE (174,175) may help to identify those with alcohol dependency and should prevent the doctor falling...

Alcohol Withdrawal

Many alcoholics develop symptoms of withdrawal when in custody. Their acquired tolerance to and physical dependence on alcohol is a manifestation of compensatory neuropsychological changes that offset the drug's CNS depressant effects. When alcohol intake is abruptly stopped on incarceration, the compensatory changes give rise to signs and symptoms of withdrawal (176). The severity of the symptoms depends mainly on the amount and duration of alcohol intake, although other factors, such as concurrent withdrawal from other drugs, like benzodiazepines, may contribute to the clinical picture (177). Alcohol withdrawal may present as a mild picture of uncomplicated alcohol withdrawal or as the more severe syndrome of alcohol withdrawal delirium (DSM-IV criteria).

Preface and Acknowledgments

Claims of genetic factors in behavior have been slower to develop. Indeed, genetic research on mental illness, for example, often has been characterized by false premises, unreplicated claims, and retracted papers. There are many reasons for this, including the difficulty of establishing diagnostic criteria, complex modes of inheritance, multiple gene interactions, difficulty in measuring end points, problems of methodology, and the uncertain effects of environment. These research problems are intensified for nonpathological behavioral factors. Nevertheless, assertions of a genetic link to thrill seeking, aggression, nurturing, aging, the development of language and social skills in women, handedness, and food preferences all have been announced recently. Sexual orientation, alcoholism and other addictive behavior, and intelligence have surfaced to varying degrees as well. Our individual and collective responses to

Serotonin transporter polymorphisms

Reduced binding of imipramine and paroxetine to brain and platelet SERTs in patients with depression and suicide victims indicates that altered SERT function might contribute to aberrant behaviors. Two polymorphic regions have been identified in the SERT promoter and implicated in anxiety, mood disorders, alcohol abuse, and in various neuropsychiatric disorders.21 Thus, studies are emerging to support the notion that impaired regulation might contribute to human disease conditions such as those seen in human variants of the SERT coding region.

Vitamin B1 or Thiamine

The active form of thiamine, thiamine pyrophosphate, is a coenzyme involved in energy metabolism reactions the requirement for thiamine is therefore related to energy expenditure 56 . Patients at risk for vitamin B1 deficiency include alcoholics, those on chronic peritoneal dialysis, those re-fed after starvation, and thiamine-deplet-ed persons who are given glucose 64 . The RDA of vitamin B1 is 1.1 mg per day for women over 50 years and 1.2 mg per day for men over 50 years (Table 3) 54 . Patients at high risk, such as alcoholics, may benefit from supplementation 54 . Excessive amounts of ingested thiamine are rapidly cleared by the kidneys. No evidence exists of thi-amine toxicity by oral administration 50 .

Alcohol dehydrogenases

But the prototypic reaction is the oxidation of ethanol to acetaldehyde, during which they transfer the pro-R hydrogen from NADH to substrate. Globally, these enzymes constitute part of the medium-chain dehydrogenase reductase superfamily.70 In humans, five classes (classes I-V) of ADHs are known members of different classes share less than 70 amino-acid sequence identity within a species.71 Three genes found within the human class 1 enzymes - ADH1, ADH2, and ADH3 are expressed in most adult tissue, with the exception of brain, kidney, and placenta. The absence of ADH1 enzymes, the most efficient ethanol-metabolizing enzymes among the ADH family, in the placenta and brain argues against a substantial contribution of this enzyme in local ethanol developmental central nervous system toxicity. On the other hand, polymorphisms in the human ADH2 gene have been associated with alcoholism.72

Rates Of Hiv Infection Among People With Substance Use Disorders

The extent to which addiction fuels IDU is the most obvious link between psychiatric disorders and HIV transmission. Kral et al. (1998) estimated an overall HIV infection rate among U.S. IDUs of 13 , with wide geographic variability between cities in the East (where rates exceed 40 ) and in the Midwest and West (where rates generally are under 5 ). Yet many studies of this population did not obtain AOD use disorder diagnoses, so summarizing across studies to generalize rates of HIV infection for specific diagnostic groups is methodologically problematic. People discharged from general hospitals who had documented AOD use disorders were twice as likely to be HIV infected as those without AOD use disorders (Stoskopf et al., 2001). Studies of people admitted to treatment for primary alcohol abuse or dependence reported HIV infection rates of 5 to 10.3 (Avins et al., 1994 Mahler et al., 1994 Woods et al., 2000), and these rates are 10 to 20 times higher than those among the general...

Assessing Suicidality in the Elderly

Studies have found that most older people who commit suicide consult their primary health care providers within days or months of their deaths, so all health care personnel must be alert to the possibility of suicide in older adults. Screening for suicidal ideation is best accomplished as part of a general diagnostic interview conducted by a health professional with whom the individual has ongoing close rapport. Areas to cover include current sources of stress, such as recent losses signs and symptoms of depression vague somatic complaints or complaints of severe, unremitting pain family and personal history of mental health problems, including depression, alcoholism, or substance abuse and past suicide attempts. If answers to these questions raise concern about suicidality, direct questions should be asked to assess the severity of suicidal thoughts and any possible plan that may involve injury to self or others. Whenever possible, family members should be interviewed for suicide...

Synopsis Of The Novel

All throughout the human life span Controllers decide what is best for the common good, but from time to time things go wrong. The Alpha-Plus psychologist Bernard, a loner mocked for his Gamma-like appearance, is different. During his embryonic stage, the Controllers put too much alcohol in his blood-surrogate. Bernard and another misfit, the poet Helmholtz, become friends. Bernard attends the quasi-religious Solidarity Service where the president is the minister, the T is the cross, and everyone else leaves feeling reperfected. Unlike Len-ina, the woman Bernard likes, he refuses to join in the orgy. Lenina has been conditioned with the feelings and desires of her lower class and cannot understand Bernard's nasty desire to express his individuality. They plan to vacation on a New Mexico Indian Reservation, an outpost not worth civilizing. Long ago the Director had taken a pneumatic Beta-Minus woman there who was lost and did not return with him. Bernard fears being banned for his...

Lipoatrophy Associated with Multiple Symmetric Lipomatosis Launois Bensaude Syndrome or Madelung Collar

In a series of 69 patients, the male to female ratio was 7 1. MSL appears in adulthood (range 29-65 years), has a slowly progressive course, and is an autosomal dominant inherited disorder that primarily affects adipose tissue. Previous observations suggested lipomatous cells as brown-adipose-tissue-derived cells 46, 47 . Almost all patients have a high alcohol intake, usually red wine, suggesting a specific role for ethanol or

Personality Disorders

The assumption that alcoholism and personality traits are linked in some fashion has a long history. Earlier editions of the DSM (DSM-I and DSM-II) classified alcoholism along with personality disorders. By 1980, with publication of DSM-III, substance use disorders (including alcoholism) were understood as entities independent of the personality disorders. Generally, antisocial personality disorder (APD) is the most prevalent personality disorder associated with alcoholism when samples from public treatment centers are studied, and borderline personality disorder (BPD) is the most common disorder in studies from private treatment facilities. In a private psychiatric hospital sample, 57 of substance-abusing patients met DSM-III-R criteria for a personality disorder with BPD being the most commonly occurring personality disorder (Nace, Davis, & Gaspari, 1991). Personality disorder occurs more commonly in alcoholics than in the general population. A prospective long-term study of a...

Pharmacology Of Alcohol

The principal route of metabolism of alcohol is through the ADH pathway, which eliminates approximately one drink (13 g of alcohol) per hour. The major product is the toxic substance acetaldehyde. Acetaldehyde is further broken down to acetic acid via the enzyme aldehyde dehydrogenase (ALDH), and subsequently goes through the citric acid cycle to become carbon dioxide and water. Both ADH and ALDH possess several distinct isoenzymes that may reflect a genetic predisposition to alcoholism. Another pathway for oxidation, the microsomal ethanol-oxidizing system (MEOS), is induced by chronic ingestion of alcohol. An increase in the activity of the MEOS pathway can increase the rate of elimination by 50-70 . The MEOS may be responsible for the increased metabolic tolerance seen in chronic alcoholics for other hypnotic sedative drugs, as well as for alcohol. One action of ethanol is the disruption of the phospholipid molecular chain in the nerve cell membrane. The result is an increased...

Alcohol Induced Persisting Dementia

This disorder develops in approximately 9 of alcoholics (Evert & Oscar-Berman, 1995) and consists of memory impairment combined with aphasia, apraxia, agnosia, and impairment in executive functions, such as planning, organizing, sequencing, and abstracting. These deficits are not part of a delirium and persist beyond intoxication and withdrawal. The dementia is caused by the direct effects of alcohol, as well as by vitamin deficiencies. Models of cognitive impairment in alcoholics include premature aging, which means that alcohol accelerates the aging process, and or that vulnerability to alcohol-induced brain damage is magnified in people over the age of 50 the right-hemisphere model, which is derived from the evidence that nonverbal skills (reading maps, block design tests, etc.) are more profoundly impaired in alcoholics than left-hemisphere tasks (language functions) and the diffuse brain dysfunction model, which proposes that chronic alcoholism leads to widespread brain damage...

Alcohol Induced Sleep Disorder

Alcohol consumed at bedtime may decrease the time required to fall asleep but typically disrupts the second half of the sleep cycle, resulting in subsequent daytime fatigue and sleepiness. Even a moderate dose of alcohol consumed within 6 hours prior to bedtime can increase wakefulness during the second half of sleep (Vitiello, 1997). Alcohol use prior to bedtime will also aggravate obstructive sleep apnea, and heavy drinkers or those with alcoholism are at increased risk for sleep apnea. Patients with severe obstructive sleep apnea are at a fivefold increased risk for fatigue-related traffic crashes if they consume two or more drinks per day compared to obstructive sleep apnea patients who consume little or no alcohol (Bassetti & Aldrich, 1996). In alcoholics, heavy drinking eventually leads to increased time required to fall asleep, frequent awakenings, and a decrease in subjective quality of sleep. Slow-wave sleep is interrupted, and during periods of withdrawal there is pronounced...

Immunogenetic markers as determinants of outcome and fibrogenesis in alcoholic liver disease

Alcoholic liver disease (ALD) progresses to liver cirrhosis in less than 10 of heavy drinkers. This clinical variability, and disappointing results from studies of genes involved in alcohol metabolism, has led to considerations that cirrhosis, fatty liver and alcoholic hepatitis are determined to some degree by genetic factors which regulate the immune system. An immune hypothesis for alcoholic cirrhosis has been suggested, although there is some evidence for a dose response. Twin studies suggest that genes do play a role in determining progression beyond simple alcoholic steatohepatitis, and candidate associations have been sought either with HLA or with other immunoregulatory genes. More recently, attention has focused on the cytokine genes. Ongoing studies at the Centre for Liver Research in Newcastle, UK, have linked TNF-238 and IL-10-627with alcoholic cirrhosis but not with alcoholic hepatitis 36, 37 . The IL-10 gene promoter encodes three SNPs which have been linked with...

TB and Isoniazid INH Epidemiology

TB is epidemic among high-risk populations of Asian, African, and Eastern European immigrants Native Americans and Inuits alcoholics prisoners homeless refugees intravenous drug users (IVDUs), and HIV AIDS patients. Approximately 2 billion people worldwide are infected with TB, with 10 million new cases per year, and 1 million deaths per year. Isonicotinyl hydrazide (INH) or isoniazid is among the most common causes of drug-induced seizures in the United States. INH toxic risk factors rapid acetylators of INH the elderly or malnourished alcoholics patients with preexisting liver disease synergistic drug toxicity INH and concomitant rifampin or pyr-azinamide antituberculosis treatment.

Musculoskeletal System

The development of osteoporosis in middle-age men is uncommon except in male alcoholics, where decreased bone mass has been documented (Turner, 2000). In women, improvement in bone mass has been shown with moderate alcohol use, especially in postmenopausal women (Laitinen et al., 1993).

Etiologies of Hypoglycemia

Pathophysiological Endocrinopathy (Addison's disease, Sheehan's syndrome) neoplasms (insulinomas, multiple endocrine adenomatosis MEA type I) liver disease (alcoholism, cirrhosis) chronic renal failure (CRF) and hemodialy-sis miscellaneous (AIDS, autoimmune diseases, pregnancy).

Differential Diagnosis

Smokers with psychiatric illness such as schizophrenia, alcoholism, and depression also have an extremely difficult time quitting smoking (Glassman, 1993 American Psychiatric Association, 1996), and for smokers who succeed in quitting, negative affect and stress play a major role in smoking relapse (Shiffman, 1986).

Micronutrient Metabolism

Deficiencies of water-soluble vitamins, including vitamin C, and the B complex compounds, are particularly common in cirrhotic patients with active alcoholism. Similarly, low plasma concentration of fat-soluble vitamins (A, E, D, and K) may occur in patients with cirrhosis of any aetiology 72 . Abnormalities in vitamin activation, conversion, release, and transport by carrier molecules all result from hepatocellular injury. Low serum levels of some trace elements, such as zinc and selenium, have also been detected in cirrhotic patients 73 . In most patients with liver cirrhosis, while micronutrient deficiencies are clinically silent, the biological antioxidant effects of micronutrients are notably impaired.

Alcohol and Sedatives

The lifetime prevalence of alcohol dependence in the United States is in the range of 14.1 (Kessler et al., 1997), while binge alcohol use and heavy alcohol use within the past month have been reported as 22.8 and 6.9 , respectively (SAMSHA, 2005). Even higher rates are seen among gay men, regardless of their serostatus (Ferrando et al., 1998 Stall et al., 2001). Alcohol is rapidly absorbed from the duodenum with blood alcohol concentrations of 100-200 mg , causing impaired motor function and judgment concentrations of200-400 mg lead to stupor and coma. Alcohol activates GABA receptors, inhibits NMDA receptors, and has additional effects on 5-HT3, nico-tinic, and opioid receptors. It is metabolized by alcohol dehyrogenase at a constant rate of 100 mg kg hour. Medical complications of alcohol dependence are listed in Table 8.3. Problems such as anemia, peripheral neuropathy, and dementia are of particular concern in HIV patients, who are already predisposed to these complications. More...

Treatment And Management Of Substance Use Disorders

After medical stabilization and detoxification, the goals of treatment should include maintenance of abstinence when possible and rapid treatment of relapse. Substance abuse treatment is usually provided on an outpatient basis, though treatment communities afford a higher level of care for those with a more severe and refractory SUD. Adjunctive anticraving agents may be used by HIV-positive patients with severe addictive disorders to aid in abstinence. Disulfu-ram, acamprosate, and naltrexone have all been used to curb alcohol craving. Methadone maintenance therapy has been shown to be effective in managing abstinence from opiates, and recently buprenorphine has been approved for the office management of opiate dependence.

Alcohol and Fitness for Interview

Alcohol withdrawal states and the complications of alcohol withdrawal can impair cognitive functioning and affect a suspect's ability to both cope with interrogative pressure and provide reliable testimony. Even the after effects of alcohol, or hangover, impair critical task performance, such as aircraft operation, and can impair judgment (71). Research evidence has also suggested that alcohol withdrawal can increase a suspect's suggestibility, although it is not totally clear whether this is a direct result of the alcohol withdrawal or is secondary effect of its treatment (72).

Legal Ideas of Responsibility

The Court in Robinson did not clearly explain the reasons for its holding, and consequently, a variety of subsequent defendants raised the defense that they should not be punished for their diseases. In Powell v. Texas (1968), a man was convicted of being drunk in a public place. The U.S. Supreme Court distinguished this situation from the Robinson case. The Court noted that medical experts did not agree about whether alcoholism was a disease. Powell had not been punished for the mere status of being a chronic alcoholic he had engaged in a particular act being in public while drunk. The Court also indicated that since there are no adequate treatments, facilities, or manpower to aid alcoholics, the use of the criminal process as a means of dealing with the public aspects of problem drinking could be seen as rational. The Court found no constitutional requirement that punishment be rehabilitative or therapeutic (Powell v. Texas 1968).26

Substance Induced Persisting Dementia

Certain substances with central nervous system activity can produce both intoxication, during which cognitive impairment severe enough to otherwise qualify as dementia may be present, and dementia per se, which persists for months or years after the substance use is terminated (see Table 5-6). Alcohol is perhaps the classic example of such a substance. Some patients with a diagnosis of alcoholic dementia have Korsakoff's syndrome, which is a pure amnesia due to damage to the mammillary bodies, dorsomedial nucleus of the thalamus, and periaqueductal gray matter, with varying amounts of cortical atrophy and ventricular enlargement. The syndrome is caused by thiamine deficiency, usually in the context of severe and prolonged alcohol intake, and has been reported to be responsive to cholinesterase inhibitors (Cochrane et al. 2005) in case reports but not in a placebo-controlled, single-blind study of malnutrition-related disease (Sahin et al. 2002). Other cases of alcoholic dementia are...

The Social Implications of the Use of Behavioral Genetics in the Criminal Justice System

The use of genetic information by the criminal justice system can stigmatize the relatives of the individuals using those defenses, as well as unrelated third parties who have the same genotype. When Stephen Mobley claimed that a genetic propensity toward violence ran in his family (see Curriden 1994), his father, a multimillionaire businessman, was embarrassed by the publicity given to their family history (Verkraik 1995). Such a defense may also stigmatize the ethnic group to which the individual belongs. Consider John Baker, the California lawyer who avoided disbarment by claiming that he was genetically predisposed to alcoholism. That defense was developed by Baker's lawyer after Baker mentioned that his father had American Indian blood.67 Its acceptance in this case may fuel the stereotype that Native Americans are prone to alcoholism.

Transmission of Infectious Agents

Exposure to Infected Body Fluids As you learned in Chapter 9, AIDS is caused by exposure to infected blood. Hepatitis is another disease caused by contact with infected blood. There are at least six different hepatitis viruses, but the most dangerous is the virus known as hepatitis C. Exposure to hepatitis C leads to chronic liver diseases such as cirrhosis (irreversible, potentially fatal scarring of the liver), liver cancer, and liver failure. Hepatitis C ranks second to alcoholism as a major cause of liver disease and is the leading reason for liver transplants in the United States.

Vitamin B1 Thiamine Deficiency

Thiamine pyrophosphate (TPP) is an important cofactor of the enzyme transketolase, which is involved in glucose metabolism. Deficiency develops in various clinical settings malnutrition, malabsorption syndromes, chronic gastritis, gastrointestinal malignancies, persistent vomiting, and prolonged intravenous feeding without vitamin supplement. Alcoholics are at particular risk for the disease because of malnutrition moreover, alcohol interferes with the metabolism, absorption, and storage of thiamine.

Vitamin B12 Cobalamine Deficiency

Wernicke-Korsakoff encephalopathy in a 48-year-old man, a heavy drinker. A. Transverse section at thalamus level shows brownish discoloration of the mammillary bodies and fresh petechiae in the floor of the third ventricle. Macrosections show (B) hypercellularity in mammillary bodies due to proliferated astrocytes and macrophages (Cresyl-violet), and (C) demyelination of stria medullaris and pallor of myelin in the thalami (Weil stain). D. Mammillary body contains macrophages and proliferated astrocytes (HE). Wernicke-Korsakoff encephalopathy in a 48-year-old man, a heavy drinker. A. Transverse section at thalamus level shows brownish discoloration of the mammillary bodies and fresh petechiae in the floor of the third ventricle. Macrosections show (B) hypercellularity in mammillary bodies due to proliferated astrocytes and macrophages (Cresyl-violet), and (C) demyelination of stria medullaris and pallor of myelin in the thalami (Weil stain). D. Mammillary body contains macrophages and...

Associated Psychiatric Conditions

Besides intoxication and withdrawal, the major mental syndromes associated with alcohol abuse and dependence in the elderly are cognitive impairment and depression. Cognitive impairment severe enough to meet DSM-IV-TR criteria for dementia is common in active elderly drinkers but typically resolves during the first few weeks of abstinence as the acute effects of intoxication, poor nutrition, compromised liver function, and alcohol-induced mood changes diminish. The proper diagnosis of cognitive deficits that persist in the sober elderly alcoholic person may be challenging, but in clinical practice, these deficits are often attributed to varying combinations of age-associated memory impairment, Korsakoff-type amnesia (i.e., isolated short-term mem-

Treatment Brief Counseling and Psychotherapy

Simple advice and counseling provided by primary care physicians have been shown to be effective in reducing problem drinking among high-risk (i.e., heavy-drinking) older adults (Fleming et al. 1999). In this study, two 10- to 15-minute counseling sessions resulted in a 34 reduction in 7-day alcohol use, 74 reduction in mean number of binge-drinking episodes, and 62 reduction in the percentage of patients drinking more than 21 drinks per week in the intervention group compared with the control group. The research literature generally suggests that treatment of established alcohol abuse and dependence in the elderly follows principles appropriate for young and middle-aged adults and depends on the severity of the problem, the financial and social resources of the patient, and the patient's motivation. Combinations of individual and group counseling, treatment of associated physical and mental conditions, and referral to outpatient, partial hospital, and inpatient programs can be...

Newer Sedative and Hypnotic Agents

In recent years, a variety of alternatives to the benzodiazepines have become available to treat both anxiety and insomnia. Buspirone (Buspar) has been shown to reduce anxiety in generalized anxiety disorders, but it does not suppress panic attacks, and is not used as a primary treatment of obsessive-compulsive disorder. Buspirone is not abused by alcoholics and drug addicts, and it does not produce withdrawal symptoms on abrupt discontinuation. Like the antidepressants, buspirone requires several weeks of daily dosing to produce antianxiety effects, which are less dramatic from patients' point of view than are the effects produced by the benzodiazepines (Sussman & Stein, 2002). The antidepressants as a class have been shown to possess antipanic and antianxiety effects opening a new range of uses for these medicines in the treatment of anxiety disorders. The selective serotonin reuptake inhibitors (SSRIs) have emerged as the first-line treatment for many anxiety disorders (Davidson,...

Population Based Studies

When considered in community samples, the presence of an SUD diagnosis elevates lifetime risks of additional SUD diagnoses (Regier et al., 1990). This is true with most classes of abused drugs. For example, the risk for a nonalcohol SUD is elevated among both males and females with alcohol dependence. In the National Comorbidity Survey (NCS), more than 40 of individuals with a DSM-III-R alcohol dependence had, excluding nicotine dependence, co-occurring drug abuse or dependence (Kessler et al., 1997). Between 13 and 18 of those with alcohol abuse will also have a co-occurring lifetime drug use disorder (NCS Kessler et al., 1997). Lifetime drug use disorder was also present in 21.5 of subjects (odds ratio OR 7.1) with an alcohol use disorder identified in the Epidemiologic Catchment Area survey (ECA Regier et al., 1990). In addition, among individuals with a nonalcohol substance use disorder in the ECA study, 47.3 also had a lifetime alcohol use disorder. Excluding nicotine

Personality Correlates

In community samples, 28.6 of individuals with a current alcohol use disorder have at least one personality disorder, and 47.7 of those with a current drug use disorder have at least one personality disorder (Grant et al., 2004). Furthermore, of individuals with at least one personality disorder, 16.4 had a current alcohol use disorder and 6.5 had a current drug use disorder. Personality disorders are associated with poorer treatment outcome for patients with alcohol dependence and those with drug dependence (Helzer & Pryzbeck, 1988 Rounsaville, Dolinsky, Babor, & Meyer, 1987). In various treatment settings, patients with SUDs screened with standard instruments meet criteria for personality disorders, with 57-73 having at least one personality disorder diagnosis, and 35-50 having at least two personality disorder diagnoses (Kleinman et al., 1990 Kranzler, Satel, & Apter, 1994 Marlowe et al., 1995 Rounsaville et al., 1998 Skinstad & Swain, 2001). Personality disorder diagnoses are...

Neuropsychological Impact Of Multiple Substance Use Disorders

As compared with non-polysubstance-using drug abusers, those with multiple SUDs demonstrate the greatest degree of chronic neuropsychological impairment and recover the least function with long-term abstinence (Beatty et al., 1997 Medina, Shear, Schafer, Armstrong, & Dyer, 2003). This may be due in part to the increased cumulative exposure of the brain to drugs and alcohol Multiple substance users tend to use as much of a particular substance (e.g., alcohol or cocaine) as those who use only alcohol or cocaine (Selby & Azrin, 1998). Selby and Azrin (1998) conducted a comprehensive neuropsychological battery with 355 prison inmates classified by DSM-IV criteria into four groups those with alcohol use disorders, cocaine use disorders, multiple SUDs, and no history of SUD. The multiple SUDs and the alcohol groups demonstrated significant impairment on most measures compared to the cocaine or no-drug groups, but the multiple SUDs group performed worse than the cocaine alone, alcohol alone...

Universal Precautions In Pain Medicine

As we begin to gain an understanding of the prevalence of substance-use disorders within the chronic pain population, it has become clear that no one behavior is pathognomonic of addiction. With this in mind, the importance of carefully inquiring into drug and alcohol histories in all patients becomes evident. This information is vital to any clinician treating complex medical and psychological problems. Alcoholism, for example, is a disease that intrudes into many aspects of the care of affected patients seeking medical treatment. Unresponsive hypertension, intractable mood disorders, difficult interpersonal relations, and poor sleep are all part of the life of an untreated alcoholic. While the use of potent medications including opioids in such cases is likely to be more complicated than in a similar patient who is not afflicted with this disorder, the need for the treating health-care professional to explore issues related to drugs and alcohol is not because of a choice to...

Diagnosing Psychiatric Disorders In Patients With Substance Use Disorders

Is independent of substance use or related to intoxication or withdrawal. For example, when examining a patient who has a long history of alcohol dependence and depressive symptoms, it can be difficult to determine whether the depressive symptoms result from the direct pharmacological effects of alcohol, the many losses experienced as a result of the alcohol use, feelings of discouragement about the inability to stop drinking, or an independent mood disorder. Other etiologies, such as metabolic disturbances, head trauma, and personality disorders, must also be considered in the differential diagnosis of depressive symptoms in alcohol-dependent patients (Jaffe & Ciraulo, 1986). Given these considerations, one could ideally establish diagnostic rules to assist in determining whether a psychiatric syndrome is due to substance use or represents a separate and independent disorder. For example, some clinicians may establish a rule that a patient must be abstinent from alcohol and drugs for...

Treatment Of Dually Diagnosed Patients A Heterogeneous Population

An additional consideration is that not all patients are similar in terms of insight regarding their SUD, nor are they similarly ready to address it. Thus, patients who are undecided whether or not to address their substance use may do better in a group focused on resolving that issue, as opposed to a group in which all participants are actively engaged in treatment and making lifestyle changes to support sobriety. We know of no studies, however, that have tested this idea empirically. It is possible, for example, that having a mix of patient severity levels in one group allows patients the opportunity to learn from those further along in their recovery. This is a central principle of Alcoholics Anonymous (AA), and appears to have strong anecdotal support. Treatments that focus on particular dual diagnoses (e.g., bipolar SUD patients) also have not been directly compared to more general thematic groups (e.g., dual diagnosis groups that are more general, encompassing a wide variety of...

Sequential Parallel and Integrated Treatment Models

In sequential treatment, the more acute condition is treated first, followed by the less acute co-occurring disorder. The same staff may treat both disorders, or the less acute disorder may be treated after transfer to a different program or facility. For example, a manic patient with a cocaine use disorder needs mood stabilization before initiating substance abuse treatment. Conversely, a patient with major depression and alcohol withdrawal delirium is not in a position to discuss treatment adherence to antidepressant medication. Instead, this issue is best addressed when the patient is more stable. Although sequential treatment has the advantage of providing an increased level of attention to the more acute disorder, a typical disadvantage of this model is that patients are often

Other Psychiatric Populations

In non-SPMI populations, integrated treatment models have also been developed for other patient subpopulations with psychiatric disorders and SUDs such as bipolar disorder (Weiss et al., 2000), personality disorders (Ball, 1998 Linehan et al., 2002), and anxiety disorders such as PTSD (Brady, Dansky, Back, Foa, & Carroll, 2001 Najavits, Weiss, Shaw, & Muenz, 1998), obsessive-compulsive disorder (Fals-Stewart &Schafer, 1992), and social phobia (Randall, Thomas, & Thevos, 2001). With the exception of social phobia, for which integrated CBT for social phobia and alcohol use disorders has yielded worse anxiety and drinking outcomes compared to group CBT geared toward alcohol relapse prevention alone (Randall et al., 2001), preliminary evidence suggests that these new treatments are generating some positive results.

Dementia Due to Huntingtons Disease

Dementias, individuals with Huntington's disease are often well aware of their deteriorating mentation. This may be a factor in the high rates of suicide and alcoholism associated with this condition. Although attempts have been made to increase ACh and GABA concentrations in these individuals, such pharmacological interventions have been unsuccessful, and the dementia is untreatable. Genetic counseling is indicated.

Selfhelp Groups And Dually Diagnosed Individuals

Despite the fact that self-help groups are both free of charge and geographically accessible (Kurtz, 1997), many dually diagnosed patients do not attend these meetings (Noordsy, Schwab, Fox, & Drake, 1996). Some clinicians may be reluctant to recommend self-help groups to dually diagnosed patients because of concerns that self-help group members might express negative attitudes toward psychotropic medication (Humphreys, 1997). However, recent research indicates that, while this sometimes occurs (Noordsy et al., 1996), it is not prevalent (Meissen, Powell, Wituk, Girrens, & Arteaga, 1999). Moreover, official AA literature states that psychiatric medication, when legitimately prescribed, is appropriate (Alcoholics Anonymous, 1984). When educating patients about the interaction between psychiatric symptoms, drug and alcohol use, and medications, clinicians should inform patients that while some self-help group members may criticize the use of medications, this contradicts official AA...

Pharmacotherapy For Dually Diagnosed Patients

During the past decade, the literature regarding when to prescribe pharmacotherapy for dually diagnosed patients has changed considerably. Previous consensus in the field reflected reluctance to prescribe psychotropic medications in these populations. However, this consensus was based on earlier, methodologically flawed studies. For example, older studies examining the use of antidepressants in alcoholics often did not use standardized methods to assess the depressed population, had inadequate dosing or duration of antidepressants, and sometimes measured mood or drinking outcomes, but not both (Ciraulo & Jaffe, 1981). More recent studies have demonstrated that phar-macotherapy can improve outcomes for the psychiatric disorder and sometimes for the SUD as well (Greenfield et al., 1998 Schubiner et al., 2002). Still, it is important also to incorporate psychosocial treatments directed at improving substance use outcomes when treating dually diagnosed patients. The literature on...

Substance Induced Persisting Dementia Diagnosis

In instances in which the features of dementia result from central nervous system effects of a medication, toxin, or drug of abuse (including alcohol), the diagnosis of dementia due to the persisting effects of a substance should be made. The most common dementias in this category are those associated with alcohol abuse, accounting for about 10 of all dementias. The diagnosis of alcohol persisting dementia requires that the cognitive changes persist after the cessation of alcohol use and are not the result of changes in mentation associated amnestic episodes (blackouts), or Wernicke-Korsakoff syndrome. In addition to various nutritional deficiencies and the toxic effects of alcohol itself, alcohol abusers are more prone to develop dementia as a result of head trauma and chronic hepatic encephalopathy. Severe alcohol dependence is the third leading cause of dementia. Alcohol-induced dementia is a relatively late occurrence, generally following 15 to 20 years of heavy drinking. Dementia...

Metabolic Complications

Hyperglycaemia, hypercapnia, electrolyte abnormalities, and re-feeding syndrome are metabolic complications that can occur with enteral feeding. Complications are seen more often in diabetics and in patients receiving formulas with high caloric density. In diabetics, the use of hyperosmolar formulas can lead to hyperosmolar nonketotic coma. High carbohydrate concentrations may increase respiratory quotients and increase carbon dioxide production. Re-feeding syndrome is characterised by dehydration, hypernatraemia, hyper-chloraemia, and azotaemia. Its most common cause is the use of high-protein formulas with low water intake. This syndrome is seen among severely malnourished patients, such as alcoholics, when potassium and phosphorus requirements are high because of the intracellular shift that occurs when nutrients are replenished.

Pharmacotherapy Targeting Substance Dependence in Dually Diagnosed Populations

Although pharmacotherapies aimed specifically at decreasing alcohol or drug use (e.g., naltrexone, disulfiram) can be efficacious in improving SUD outcomes in non-dually-diagnosed populations, the literature on the use of these medications in dually diagnosed populations is quite thin. Concerns that disulfiram may cause or exacerbate psychosis (Mueser, Noordsy, Fox, & Wolfe, 2003) have contributed to a reluctance to prescribe it in patients with SPMI (Kingsbury & Salzman, 1990). While there have been no controlled studies of disulfiram in populations with alcohol dependence and SPMI, there have been a few published case reports (Brenner, Karper, & Krystal, 1994) and case series (Kofoed, Kania, Walsh, & Atkinson, 1986 Mueser et al., 2003) describing its tolerability and potential benefit for improving alcohol outcomes and hospital-ization rates for those who remain in treatment. Additionally, there is preliminary evidence that naltrexone may improve drinking outcomes in patients with...

Pathological Gambling and Other Behavioral Addictions

Data further support a relationship between behavioral and drug addictions For example, high rates of PG and SUDs have been reported during adolescence and young adulthood (Chambers & Potenza, 2003) the telescoping phenomenon (reflecting the rapid rate of progression from initial to problematic behavioral engagement in women as compared with men) initially described for alcoholism has been applied to PG (Potenza et al., 2001) and similar typologies to those defining groups with alcoholism have been proposed for PG (Lesieur, 2000 Potenza, Steinberg, McLaughlin, Rounsaville, & O'Malley, 2000). Emerging biological data, such as those identifying common genetic contributions to alcohol use and gambling disorders (Slutske et al., 2000) and common brain activity changes underlying gambling urges and cocaine cravings (Potenza et al., 2002), provide further support for a shared relationship between PG and SUDs. between gambling and alcohol use disorders (Cunningham-Williams, Cottier, Compton,...

Selected Amnestic Disorders

Blackouts are periods of amnesia for events that occur during heavy drinking. Typically, a person awakens the morning after consumption and does not remember what happened the night before. Unlike delirium tremens, which is related to chronicity of alcohol abuse, blackouts are more a measure of the amount of alcohol consumed at any one time. Thus, blackouts are common in binge pattern drinkers and may occur the first time a person ingests a large amount of alcohol. Blackouts are generally transient phenomena, Korsakoff's Syndrome. Korsakoff's syndrome is an amnestic disorder caused by thiamine deficiency. Although generally associated with alcohol abuse, it can occur in other malnourished states such as marasmus, gastric carcinoma, and HIV spectrum disease. This syndrome is usually associated with Wernicke's en-cephalopathy, which involves ophthalmoplegia, ataxia, and confusion. Korsakoff's syndrome is often associated with a neuropathy and occurs in about 85 of untreated...

Alcohol Assessment Questionnaires

Do you feel you are a normal drinker 2. Do friends or relatives think you're a normal drinker 3. Have you ever attended a meeting of Alcoholics Anonymous 7. Have you ever had DTs, sever shaking, heard voices or seen things that weren't there after heavy drinking From Pokomy, A., D., Miller, B. A., Kaplan, H. B. The Brief MAST a shorten version of the Michigan Alcoholism Screening Test. Am. J. Psychiat. 131 1121-1123, 1974. Two or more positive responses sensitive indicator of alcohol dependence. From Mayfield, D., McLeod, G. and Hall, P. The CAGE Questionnaire Validation of a New Alcoholism Screening Instrument. Am. J. Psychiatry. 131 1121-1123, 1974. A score of 8 produces the highest sensitivity a score of ten or more results in higher specificity. In general high scores on the first three items in the absence of elevated scores on the remaining items suggest hazardous alcohol use. Elevated scores on items 4 through 6 imply the emergence of alcohol dependence. High scores on the...

Natural history of HCV infection

Recently, a new form of HCV infection called occult HCV infection'' has been described in patients with abnormal liver function tests of unknown etiology (patients were anti-HCV and serum HCV-RNA negative, did not have markers of HBV infection and did not have clinical or biochemical evidences of autoimmunity, genetic or metabolic disorders, alcohol intake or drug toxicity). By analyzing liver biopsies from 100 patients with the above mentioned characteristics, Castillo et al. (2004) found HCV-RNA in the liver of 57 of the cases. Furthermore, the negative HCV-RNA strand was detected in 48 out of the 57 cases (84.2 ), indicating that the virus was replicating in the liver of patients with occult HCV infection. The clinical importance of this finding lays in the fact that the percentage of patients with occult HCV infection who had necroinflammation and fibrosis in the liver biopsy was statistically higher than that of patients without detectable HCV-RNA in liver. In fact, 5 of patients...

Postmortem Brain Studies

The reciprocal changes in the levels and activity of Gaq 11 in BD occipital cortex also appear to uniquely distinguish this disorder from Alzheimer's disease (79a), schizophrenia (44), alcoholism (44), and major depression (80), in which the activity of Gaq 11 is either increased or decreased in the absence of changes in Gaq 11 and PLC-P1levels. It is also noteworthy that the largest differences in Gas levels and forskolin-stimulated adenylyl cyclase activity were observed in the occipital cortex of BD subjects (10,11). Given the substantial evidence of crossregulation between cAMP and PPI signaling pathways, the possibility that the observed differences in Gaq 11 and PLC-p1 levels may reflect the consequences of relatively greater disturbances in cAMP signaling in this brain region in BD cannot be excluded.

Intracranial Hemorrhages

In subdural hematoma (SDH), the hematoma forms between the inner surface of the dura and the arachnoid, generally in the fronto-parietal regions, but it may cover the entire hemisphere. It results from tearing of the veins at the point where they enter the superior sagittal sinus (bridging veins). Here, unsupported by the brain parenchyma, they are prone to tearing by motions of the brain that occur in blows to the head, falls, and traffic accidents. SDH is a common finding in physically abused children (shaken baby syndrome). Importantly, it can result from minor injuries and, in about 20 of cases, no clinical evidence of injury exists. Alcoholism, hematologic disorders, anticoagulant therapy, ventricular shunting, and old age predispose to SDH.

Micronutrients Alcohol

Alcohol can cause widespread cell damage and fat peroxidation in the liver.8 Supplements may help protect against oxidative damage. Vitamin C may help detoxify alcohol9 May help reduce damage to the liver and lessen symptoms related to alcohol withdrawal in heavy drinkers12 B vitamins are poorly absorbed and their activation is impaired by alcohol. Most heavy drinkers are deficient in many B vitamins Deficiency is very common in heavy drinkers and can produce heart and neuromuscular problems The main enzymes that detoxify alcohol are dependent on zinc, thus zinc deficiency impairs abilityto breakdown alcohol, increasing potential

Integration Of Psychotherapy And Pharmacotherapy For Dually Diagnosed Patients

Long-term therapy with benzodiazepines despite alcohol dependence disorder. Am J Addict, J (4), 288-293. Aharonovich, E., Nguyen, H. T., & Nunes, E. V. (2001). Anger and depressive states among treatment-seeking drug abusers Testing the psychopharmacological specificity hypothesis. Am J Addict, J0(4), 327-334. Albanese, M. J., Bartel, R. L., Bruno, R. F., Morgenbesser, M. W., & Schatzberg, A. F. (1994). Comparison of measures used to determine substance abuse in an inpatient psychiatric population. Am J Psychiatry, J5J (7), 1077-1078. Alcoholics Anonymous. (1984). The AA member Medications and other drugs Brochure . New York Alcoholics Anonymous World Services. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC Author. Ball, S. A. (1998). Manualized treatment...

Recreational Drugs and the Nervous System

Drugs affect each of us differently because of differences in overall metabolism, weight, and gender. The gender difference is clearly illustrated by the way alcohol consumption affects males and females. Impaired judgment, slurred speech, unsteady gait, slower reaction times, uncontrollable emotions. Chronic alcohol abuse leads to loss of intellectual ability and liver damage. Alcohol kills nerve cells that cannot be regenerated. As nerve cells die, the brain actually gets smaller. The frontal lobes, where judgment, thought, and reason are centered, are the first to die.

Risk Factors Related to Affect Dysregulation

Alcohol and drug use are well-known risk factors for sexual assault, especially among adolescents (Gidycz, Hanson, & Layman, 1995 Koss & Dinero, 1989 Greene, Navarro, & Gidycz, 1995 Muelenhard & Linton, 1987). In addition, drug and alcohol abuse are highly prevalent among individuals with childhood sexual abuse (Browne & Finkelhor, 1986 Polusny & Follette, 1995). Recent data suggest that alcohol consumption is a risk factor for sexual assault as well as a consequence of childhood abuse. However, it seems that although alcohol consumption is a consequence of childhood sexual abuse, it becomes an independent and additional risk factor for later assault. In a study of navy recruits, Merrill et al. (1999) found that childhood sexual abuse, alcohol problems, and number of sexual partners were distinct and independent predictors of adult rape. Similarly, Messman-Moore and Long (2002) found that childhood sexual abuse, alcohol-related diagnoses, and substance-related diagnoses each predicted...

The Scientific Evidence

As an example, take the case of alcoholism. Several past and ongoing studies have explored whether there is a genetic component to alcoholism. Assume there is such a component in some cases of alcoholism. Does that mean that, as a society, we will be more or less tolerant of alcoholics, more or less inclined to mandate genetic testing for such an allele or alleles, or more or less likely to embrace the disease model of alcoholism On the one hand, it could be argued that the genetic component vitiates the moral taint from individuals with alcoholism. On the other hand, the genetic, heritable nature of the disorder may increase the stigma associated with alcoholism it may increase the pressure for genetic screening for the mutation it may contribute to individuals feeling a sense of resignation and a reluctance to enter treatment and it may lead to disdain for individuals who, despite knowledge that they have the mutation, proceed to drink nonetheless. Research to find an association...

Treatment Considerations

F., Hofmann, M., DelBoca, F. K., Hesselbrock, V., Meyer, R. E, Dolinsky, Z. S., & Rounsaville, B. (1992). Types of alcoholics I. Evidence for an empirically derived typology based on indicators of vulnerability and severity. Arch Gen Psychiatry, 49, 599-608. Beatty, W. W., Blanco, C. R., Hames, K. A., &Nixon, S. J. (1997). Spatial cognition in alcoholics Influence of concurrent abuse of other drugs. Drug Alcohol Depend, 44, Bondi, M. W., Drake, A. I., & Grant, I. (1998). Verbal learning and memory in alcohol abusers and polysubstance abusers with concurrent alcohol abuse. J Int Neuropsy-chol Soc, 4, 319-328. Brook, D. W., Brook, J. S., Zhang, C., Cohen, P., & Whiteman, M. (2002). Drug use and the risk of major depressive disorder, alcohol dependence, and substance use disorders. Arch Gen Psychiatry, 59, 1039-1044. Caetano, R., & Weisner, C. (1995). The association between DSM-III-R alcohol dependence, psychological distress and drug use. Addiction, 90, 351-359. Cloninger, C....

Diagnosis of insomnia

In an attempt to document hyperarousal in patients suffering from insomnia, functional neuroimaging methods, assessing regional cerebral glucose metabolism were used 38 . Evidently, subjectively disturbed sleep was associated with greater brain metabolism. Thus, it is possible that the inability to fall asleep is related to a failure of arousal mechanisms to decline in activity from waking to sleep states. This may be an explanation why there is an association between chronic insomnia and alcohol dependence 39 . Perhaps some individuals with hyperarousal and failure in their mechanisms to control it, try self-treatment methods through alcohol consumption.

Substance Withdrawal Delirium

Some varieties of drug withdrawal, although uncomfortable, are not life threatening (e.g., opioid withdrawal). Others such as alcohol withdrawal delirium are potentially fatal. Withdrawal delirium is much more common among individuals who are hospitalized than among individuals living in the community. The incidence of delirium tremens, for example, is found in 1 of all alcoholics, but in 5 of hospitalized alcohol abusers. Improvement of the delirium occurs when the offending agent is reintroduced or a cross-sensitive drug (e.g., a benzodiazepine for alcohol withdrawal) is employed.

Cardiovascular System

It is well established that alcoholic heart muscle disease is a complication of long-term alcoholism and not malnutrition or other possible causes of dilated cardiomyopathy. In a dose-dependent fashion, left ventricular systolic function declines, implicating alcohol in at least 30 of all dilated cardiomyopathies (Lee & Regan, 2002). The contractility of heart muscle is decreased through Transient hypertension is noted in nearly 50 of alcoholics undergoing detoxification and is related to quantity of drinking and severity of other withdrawal symptoms. Epidemiological studies have demonstrated that alcohol elevates blood pressure independently of age, body weight, or cigarette smoking (Klatsky, Friedman, & Armstrong, 1986). A 10-year follow-up study found even moderate intake of alcohol (60 grams day) is associated with increased risk of ischemic and hemorrhagic stroke. Mechanisms involved include alcohol-induced hypertension, coagulation disorders, atrial fibrillation, and reduction...

Cognitive Behavioral and Nonpharmacological Treatments

Cocaine disorders have proven to be refractory to both psychological and pharmacological treatment. Consequently, considerable energy has been directed toward developing and testing the efficacy of new psychotherapeutic approaches in the treatment of cocaine use disorders. Many of these therapies have been adapted from ones originally developed to treat alcoholism. One approach that has received attention is cognitive-behavioral relapse prevention (Marlatt & Gordon, 1985). Relapse prevention strives to teach the addict how to recognize high-risk situations and deal with these using cognitive strategies that have been well rehearsed. Relapse prevention recognizes that with a chronic disorder such as addiction, relapses and remissions are expected. When a relapse occurs, more intense treatment and cognitive restructuring are necessary to help prevent a slip from escalating. Reminding patients of their prior progress, focusing on making the slip an isolated event, and maximizing the...

Trends In Treatment And Prevention

From the time of Benjamin Rush, two central treatment methods were established, based on the psychiatric treatment methods of the late 1700s (1) asylum in a supportive environment away from drink and companion drinkers and (2) moral treatment, consisting of a civil, respectful consideration for the recovering person (Johnson & Westermeyer, 2000). Both methods persist today and remain as two standard treatment strategies. They were not and are not inevitably successful. Consequently, other methods have been tried. One of these methods was the substitution of one drug for another. For example, laudanum (combined alcohol and opiates) was once prescribed for alcoholism. Morphine, and later heroin, was recommended for opium addiction during the mid-1800s. This approach is not extinct, as exemplified by the frequent recommendation in the 1970s that alcoholics substitute cannabis smoking for alcohol. Currently, methadone is used for chronic opiate addicts who have failed attempts at...

Metabolism of Alcohol

Once absorbed, alcohol is eliminated at a fairly constant rate, with 90 being metabolized in the liver and the remainder excreted unchanged in urine, breath, and sweat. The rate of elimination in moderate drinkers may vary between 10 and 20 mg 100 mL blood h, with a mean of 15 mg 100 mL blood h. Chronic alcoholics undergoing detoxification have elimination rates of 19 mg 100 mL blood h or even higher (17). This increased rate of alcohol burnoff is believed to be a consequence of increased activity of hepatic microsomal enzymes (P450IIE).

Fields Of Expertise Within Toxicology

Cirrhosis of the liver is one of the most well-known adverse effects of chronic alcohol abuse. The cholesterol-lowering, life-prolonging statin drugs must be monitored routinely for hepatotoxicity and rhabdomyolosis. A Google search on the terms statins, hepatotoxicity, and review produced over 22,000 hits indicating this is a very active field of interest.

Rates Of Psychiatric Disorders Among People Living With Hiv Infection

The landmark HIV Cost and Services Utilization Study (HCSUS) found that a large, nationally representative probability sample of adults receiving medical care for HIV in the United States in early 1996 (N 2,864 2,017 men, 847 women) reported major depression (36 ), anxiety disorder (16 ), and drug dependence (12 ) (Bing et al., 2001 Galvan et al., 2002), as well as heavy drinking at a rate (8 ) almost twice that found in the general population and high rates of drug use (50 ). The HCSUS study remains the most comprehensive view we have of the prevalence of psychiatric disorders among people living with HIV AIDS, though the study was not designed as a diagnostic assessment of psychiatric disorders among people with HIV AIDS and so rates of psychosis, bipolar disorder, alcohol abuse or dependence, and substance abuse, among others, were not obtained. Disorders of alcohol and other drug (AOD) abuse are differentiated from dependence in the Diagnostic and Statistical Manual of Mental...

Chronic APAP Poisoning

Chronic Because APAP is a phenacetin metabolite, renal papillary necrosis and nephrotic syndrome are possible chronic analgesic nephropathy. In addition, patients at risk of increased NAPQI production as a result of CYP40 enzyme induction (from INH, rifampin, most anti-convulsants, ethanol) or reduced glu-tathione stores (alcoholism, HIV AIDS, malnutrition, starvation) are at increased risk of hepatotoxicity from APAP.

Utility of Event Related Potentials in Substance Abuse Research

Because many of the illnesses believed to have genetic components are characterized by some type of abnormal brain function, it has been postulated that abnormalities in latency, amplitude or topography of ERP components could serve as markers of genetic vulnerabilities. To date, most of the data supporting this notion in substance abuse is in the area of alcoholism. The P300 is a good candidate as a biological marker because there is ample evidence to indicate that its generation is genetically determined (Begleiter et al., 1998) and a number of studies have found that young children with a family history of alcoholism have significantly reduced P300 amplitudes before ever being exposed to alcohol compared with children without such a history (Begleiter et al., 1984, 1987 Porjesz and Begleiter, 1990). In addition, findings of reduced P300 amplitudes in chronic (Porjesz et al., 1980) and recovering (Porjesz et al., 1987) alcoholics further support the notion that that P300 amplitude...

Risk Factors and Cancer

Alcohol and tobacco smoking are the main cause of cancers of the upper respiratory and gastrointestinal tracts. Alcohol by itself plays a role in liver cancer (cirrhosis) and possibly in a proportion of colon and breast cancer.36 Poverty is associated with increased exposure to tobacco smoke, alcoholism, poor nutrition, and certain infectious agents. Thus, poverty can act as a carcinogen, which suggests that fighting cancer also requires fighting poverty.

Preparation for Quitting

Difficulty concentrating, increased appetite and weight gain). For most individuals, these symptoms peak within a few days of quitting and dissipate within 1 or 2 weeks. (4) The physician can help the patient identify high-risk or dangerous situations. These are events, internal states, or activities that increase the risk of smoking or relapse due to their past association with smoking (e.g. negative emotional states, being around other smokers, drinking alcohol). These situations should be avoided early on, if possible. (5) The physician can help the patient select cognitive and behavioural coping skills to use when she experiences an urge (or craving ) for cigarettes. Examples of cognitive coping skills are reminding him herself reasons for quitting telling him herself that urge will pass and repeating the phrase, Smoking is not an option. Behavioural coping skills include leaving the situation, engaging in some distracting activity, taking deep breaths, and seeking social support.

Sedatives Hypnotics and Benzodiazepines

The sedatives and the hypnotics, especially the benzodiazepines, are widely used in medical practice in the treatment of anxiety, insomnia, epilepsy, and for several other indications (Baldessarini, 2001). The combination of abuse by alcoholics and drug addicts, and the withdrawal symptoms on discontinuation leads to the view that these are addictive drugs (DuPont, 2000 Juergens & Cowley, 2003). The pharmacology and the epidemiology of sedatives and hypnotics are reviewed in this chapter, which focuses on the needs of the clinician.

Social And Selfhelp Movements

Abstinence-oriented social movements first appeared among organized religions (Johnson & Westermeyer, 2000). Certain South Asian sects, arising from early Persian religions and Hinduism, abstained from alcohol over two millennia ago. Buddhist clergy were forbidden to drink alcoholic beverages, and pious Buddhist laity were urged to refrain from drinking, or at least to drink moderately. Early on, Moslems were urged not to drink tradition has it that Mohammed himself established abstinence for his followers. Abstinence-oriented Christian sects evolved in England and then in Central Europe at about the time of the gin epidemic. Religiomania has long served as a cure for dipsomania and narcotomania. Opium addicts in Asia have gone to Buddhist monasteries in the hope that worship, meditation, or clerical asceticism would cure them, which it sometimes did (Westermeyer, 1982). Many Latin Americans and Native Americans with high rates of alcoholism have abandoned Catholicism and Anglicanism...

Patterns of Psychoactive Substance

Socially sanctioned, episodic psychoactive substance use may involve heavy use, with marked intoxication or drunkenness (Bunzel, 1940). In a low-technology environment, this pattern may cause few problems, although psychotomimetic drugs such as cannabis can cause toxic psychosis (Chopra & Smith, 1974). In a high-technology environment, with modern methods of transportation and industrial machinery, intoxication even at mild traditional levels may be life threatening (Stull, 1972). Binge-type alcohol problems include delirium tremens, fights, sexually transmitted disease, and falls.

Cultural and Social Change

The low rates of alcoholism among Asian peoples, who presumably find the reaction aversive and hence drink little although rates are increasing across much of Asia (Ohmori, Koyama, et al., 1986). 2. The high rates of alcoholism among certain Native American groups, who presumably must drink through their flushing reaction to experience other alcohol effects. In addition to religion as a preventive measure, religion has also served as a therapy for psychoactive substance abuse. Native Americans and Latin Americans, plagued with high rates of alcoholism, have joined fundamentalist Christian sects as a means of garnering social support while resisting peer pressures to drink (Mariz, 1991). Many Native Americans have joined the Native American Church, in which peyote is a sacramental substance but alcohol is proscribed (Albaugh & Anderson, 1974).

Identification Of Problems Among Longterm Benzodiazepine Users

Some critics of benzodiazepines, including Stefan Borg and Curtis Carlson of St. Goran's Hospital in Stockholm, Sweden (Allgulander, Borg, & Vikander, 1984), have expressed concerns about the possibility that benzodiazepine use may lead to alcohol problems in patients without a prior history of alcohol abuse, especially in women. The simple advice to a long-term medical user of a benzodiazepine is not to use alcohol, or to use alcohol only occasionally and never more than one or two drinks in 24 hours. Most anxious patients who do not have a prior history of addiction either do not use alcohol at all or use it only in small amounts. The Benzodiazepine Checklist helps the physician, the patient, and the patient's family identify any problems (including alcohol abuse) at early stages, thus facilitating constructive interventions.

Alcohol Induced Sexual Dysfunction

Alcohol consumption has been found to have a negative relationship to physiological arousal in women. Although women state that they felt more aroused, the physical responses tend to be depressed when alcohol is consumed. Inhibition of ovulation, decrease in gonadal mass, and infertility may follow chronic heavy alcohol use. In males, erectile dysfunction may occur transiently with alcohol use, especially at blood alcohol levels above 50 mg 100 ml. Decreased libido, erectile dysfunction, and gonadal atrophy are reported in chronic alcoholics (Adler, 1992). Chronic male alcoholics, even without liver dysfunction, commonly demonstrate primary hypogonadism, as evidenced by decreased sperm count and motility, and altered sperm morphology. Increases in luteinizing hormone and a decrease in the free androgen index were reported in noncirrhotic males and related to lifetime quantity of ethanol intake (Villalta et al., 1977). However, a controlled study of abstinent alcohol males selected for...

Major Depressive Disorder

Major depression is one of the most common mood disorders in HIV-seropositive individuals, and it was the earliest reported mood disturbance of HIV. Rates of depression in HIV have varied widely across studies due to differing sample populations, which are difficult to compare as they share little else in common other than their HIV serostatus. The landmark HIV Cost and Services Utilization Study (HCSUS) identified high rates of drug use (50 ), major depression (36 ), anxiety disorder (16 ), and heavy drinking (12 ) among a large representative sample of adults receiving care for HIV in early 1996 (Bing et al., 2001 Galvan et al., 2002). The HCSUS study remains the most well-designed and comprehensive study of the prevalence of psychiatric disorders in an HIV-infected population, although other studies provide snapshots of the high rates of comorbid psychiatric disease in this population (Winiarski et al., 2005). Depression is the most common reason for psychiatric referral among...

Distinguishing Medical And Nonmedical Use Of Benzodiazepines

Is the substance used to treat a diagnosed medical problem, such as anxiety or insomnia, or is it used to get high (or to treat the complications of nonmedical use of other drugs) Typical medical use of a benzodiazepine or other controlled substance occurs without the use of multiple nonmedical drugs, whereas nonmedical use of the benzodiazepines is usually polydrug abuse. Although alcoholics and drug addicts sometimes use the language of medicine to describe their reasons for using controlled substances nonmedically, self-administration or self-medication of an intoxicating substance outside the ordinary practice boundaries of medical care is a hallmark of drug abuse (DuPont, 1998).

Table 89 Factors to consider before prescribing potentially addictive substances for elderly patients

Dependence been used if appropriate (e.g., buspirone hydrochloride for anxiety or nonopioid analgesics for pain) Is the drug yielding an acceptable therapeutic response with use of appropriate doses (often lower in elderly than in younger patients), and, if not, have the diagnosis and treatment been reconsidered Has the patient had other drug or alcohol dependence or abuse problems in the past

What is the role of nutritional factors in the susceptibility to COPD

It is possible that smokers who develop COPD have dietary deficiencies in the nutritional elements mentioned above. However, this hypothesis is not supported by longitudinal studies 68 and would not explain the whole problem, since there are so many confounding factors between diet and cigarette smoking (alcohol intake, etc.).

To Drugs Of Abuse In 5ht1b Ko Mice

There are a number of genetic arguments suggesting that common genes are involved in differential responsiveness to different categories of drugs such as alcohol, opiates, and psychostimulants. Several inbred strains of rodents such as the Fischer and Lewis rats and the C57BL 6 and DBA 2 mice differ in their responses to alcohol, opiates, and psychostimulants. Lewis rats self-administer cocaine, opiates, and alcohol at higher rates than Fischer rats (47-49). Lewis rats also display greater conditioned place preference to these drugs and increased locomotor response to repeated cocaine injections (47,50). Similarly, the C57BL 6 mice self-administer more cocaine, alcohol, and opiates in an oral self-administration paradigm when compared to the DBA 2 mice (51-53). The analysis of a panel of 26 recombinant inbred strains has revealed that the differential responses to drugs of abuse of the C57BL 6 and DBA 2 strains are due to several QTLs, including one containing the gene encoding the...

Psychiatric Comorbidity And Sequelae

More than one-half of all cocaine abusers meet criteria for a current psychiatric diagnosis and nearly three-fourths for a lifetime psychiatric diagnosis (Ziedonis, Rayford, Bryant, Kendall, & Rounsaville, 1994). The most common comor-bid psychiatric diagnoses among cocaine abusers include alcohol dependence, affective disorders, anxiety disorders, and antisocial personality disorder (Kleinman et al., 1990 Marlowe, Husband, Lamb, & Kirby, 1995 Mirin, Weiss, Griffin, & Michael, 1991 Rounsaville et al., 1991 Weiss, Mirin, Griffin, Gunderson, & Hufford, 1993). For most cocaine users, co-occurring psychiatric disorders (including agoraphobia, alcohol abuse, alcohol dependence, depression, posttraumatic stress disorder (PTSD), simple phobia, and social phobia) precede cocaine use (Abraham & Fava, 1999 Shaffer &Eber, 2002). The most frequent co-occurring substance use disorder is alcoholism 29 of cocaine abusers have a current alcoholism diagnosis, and 62 a lifetime alcoholism diagnosis...

Psychiatric Disorders 601411 Schizophrenia

Modafinil can alleviate excessive daytime sleepiness without these adverse effects and does not induce tolerance, indicating a lower abuse potential. Both TCAs and SSRIs are effective in treating this aspect of narcolepsy. OSA is typically treated by lifestyle changes such as weight loss and decreased alcohol consumption. Patients may also be placed on a nasal continuous positive airway pressure (CPAP) device. CPAP acts to keep the airway open during the night thus avoiding the apneic episodes. Modafinil is also approved for use in OSA patients with EDS. Current approved treatments for substance abuse are directed at decreasing craving and preventing relapse. These include methadone and buprenorphine treatment for heroin addiction, and naltrexone for the treatment of alcohol abuse. Currently no drug is approved for the treatment of cocaine addiction, although several, including disulfiram and modafinil, have shown promise in randomized control trials. Notably, none of these compounds...

Optic Neuropathies of Malnutrition Definition

An optic neuropathy of malnutrition is one caused by a dietary deficiency. In the developed parts of the world, this is most commonly a deficiency of vitamin Bi2. Such cases are uncommon, and are most often caused by macrocytic anemia. Vitamin Bi2 and folate levels are easily measured. Other risk factors for malnutrition include intestinal bypass or gastric stapling for weight loss and the hepatic cirrhosis of alcoholism. Treatment should include intramuscular injections of high doses of hydroxycobolamine.

Mechanisms of Malnutrition in Chronic Pancreatitis

Muscle Loss Malnutrition Exam

Other factors may contribute to malnutrition in patients with chronic pancreatitis. Increased resting energy expenditure, small-bowel bacterial overgrowth, severe alcoholism, and poor control of associated diabetes may have a role. Hebuterne et al. reported that the measured REE was significantly higher than the predicted energy expenditure in underweight patients with chronic pancreatitis but not in control groups 85 . Therefore, weight loss accompanied by hypermetabolism should be taken into consideration in patients with chronic pancreatitis. Small-bowel bacterial overgrowth deconjugates bile salt, impairing micelle formation. Almost 40 of patients with chronic pancreatitis have co-existent small-bowel The absorption of fat-soluble vitamins (A, E, and K) is usually preserved 84, 88, 89 in patients with chronic pancreatitis, and, although vitamin D is not significantly reduced, osteopaenia and osteoporosis are much more common than previously thought 90 . Deficiencies of...

Genetic And Family Studies

Much of the evidence for the heritability of the general and specific vulnerability for SUD is taken from studies of familial aggregation. Bierut and colleagues (1998) compared siblings of probands with alcohol dependence and those of a control group for the presence of lifetime SUDs. Siblings of alcoholic probands were not only more likely to have a lifetime alcohol use disorder, but they also had an increased risk of cannabis, cocaine, and nicotine dependence. Fifty percent of the alcohol-dependent siblings of alcohol-dependent probands had an additional diagnosis of cannabis and or cocaine dependence. What is compelling with respect to understanding the risk for multiple substance dependence is that the siblings of cannabis-dependent probands had an increased risk of cannabis dependence, siblings of cocaine-dependent probands had an increased risk for cocaine dependence, and siblings of habitual smokers were at higher risk for nicotine dependence (Bierut et al., 1998). In another...

History Of Substance Abuse Treatment

Modern treatment approaches have their origins in methods developed by Benjamin Rush, a physician from the Revolutionary War era, who is often credited as the father of American psychiatry. Rush developed a categorization of drinkers and alcoholics. He further prescribed treatment that consisted of a period of asylum from responsibilities and from access to alcohol, to take place in a family-like setting, in a milieu of respect, consideration, and social support. As Rush's concepts were extrapolated to the growing American society, large state-supported institutions were developed although some smaller, private asylums or sanitoria for alcoholics have persisted up to the current time (Johnson & Westermeyer, 2000). Medical treatments can interact constructively with cultural factors. For example, taking disulfiram can serve as an excuse for Native American alcoholics to resist peer pressures to drink (Savard, 1968). Ethnic similarity between patients and staff appears to be more...

Historical Context

In Virginia, Carrie Buck was an institutionalized 18-year-old unwed mother whose mother and child were also feebleminded. She was forcibly sterilized under Virginia's 1924 eugenics law. Her case was appealed to the Supreme Court, claiming that the plaintiff, under the Fourteenth Amendment, was denied due process and equal protection of the laws. However, Supreme Court Justice Oliver Wendell Holmes in Buck v. Bell (1927) upheld the state eugenics law, declaring three generations of imbeciles are enough. With this precedent, over the next 40 years 60,000 people nationwide were sterilized for other types of unacceptable behaviors or conditions, such as alcoholism, promiscuity, criminal acts, epilepsy, and running away from home. In an attempt to make restitution, several governors have formally apologized to their states' eugenics victims.

Testing Programs in Occupational Settings

The five substances routinely tested for include marijuana, cocaine, amphetamines, opiates, and PCP. Other drugs, such as alcohol, may be added to the panel if suspected by the employer from objective evidence (i.e., slurred speech, alcohol on the breath). Keeping with the Rule of Fives, there are five situations in which drug testing is conducted (1) preemployment, (2) random, (3) postaccident, (4) probable cause, and (5) return to work follow-up. The employer may request testing for additional substances in the case of postaccident, reasonable suspicion, and return-to-work situations. In order to undergo this additional testing, the employee must be notified via an official Employee Drug Policy document. Recognizing the high prevalence of alcohol abuse, ethanol testing was mandated in a 1994 amendment. There are separate regulations for alcohol testing, including not requiring MRO participation. The program is designed always to give the employee the benefit of the doubt, and the...

Descriptive Approaches

In patients with alcohol dependence or substance dependence (Caetano & Weisner, 1995), the majority of whom use substances simultaneously (Staines, Magura, Foote, Deluca, &Kosanke, 2001). Longitudinal studies in community samples are able to discriminate between simultaneous and concurrent polydrug use, but a differential impact upon subsequent health outcomes including psychological distress, physical symptoms, and services utilization has not been identified (Earleywine & Newcomb, 1997).

Diagnosis of mci

It is necessary to evaluate an MCI case with the same accuracy one would bring to the diagnosis of a patient with dementia. This means that all potential medical, psychiatric or neurological causes of cognitive impairment must be considered before making a diagnosis. In fact, although MCI concept was introduced intending the very early stage of AD pathology, in medical practice the exact etiology is rarely known with certainty. Before a neurodegenerative disorder such as AD can be considered as the underlying mechanism, it is essential to rule out cognitive dysfunction caused by systemic medical disorders, endocrinological abnormalities, nutritional deficiencies, alcohol abuse or other toxic or metabolic factors. The occurrence of cerebral infarcts, subdural haematoma or hydrocephalus must be excluded as well. The presence of these conditions can be assessed through an accurate anamnesis, a neurological examination, basic laboratory investigations, neuroimaging and a careful...

Posterior Pituitary

A 74-yr-old male first presented in 1990 for evaluation of recurrent syncope. He had six episodes of syncope since 1979, and these were usually associated with stressful events, recent alcohol intake, or rapid standing. Neurologic evaluation, including electroencephalogram (EEG) and head computed tomography (CT), were unrevealing, and he was diagnosed with vasovagal syncope. Subsequent cardiac evaluation with Holter monitoring and tilt table testing also supported a diagnosis of vasovagal syncope. At his initial presentation in 1990, he was found to have serum sodium 130 mEq L, potassium 4.1 mEq L, blood urea nitrogen 13 mg dL, and serum creatinine 1.1 mg dL. On review of his past medical records, it was apparent that his hyponatremia was longstanding, with serum sodium concentrations ranging from 128-134 mEq L over the past 20 yr. He was on no medications. Further evaluation revealed a random urine osmolality of 717 mOsm kg H2O and a urine sodium of 71 mEq L when his serum sodium was...


Chronic overdose Chronic renal failure (CRF) in the elderly and alcoholics bleeding and cognitive dysfunction and dementia in elderly. Constellation of side effects Gastrointestinal, renal, hypersensitivity reactions, (acetic acids and phenylbutazone piroxicam propionic acid) pulmonary, CNS, hematologic, drug-drug interactions.

Beat The Battle With The Bottle

Beat The Battle With The Bottle

Alcoholism is something that can't be formed in easy terms. Alcoholism as a whole refers to the circumstance whereby there's an obsession in man to keep ingesting beverages with alcohol content which is injurious to health. The circumstance of alcoholism doesn't let the person addicted have any command over ingestion despite being cognizant of the damaging consequences ensuing from it.

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