Alcohol abuse: not touched, not poured

19. March 2013

Ethanol is and remains the number one drug of addiction among the people, being associated with high morbidity and mortality rates. Physicians can, using new strategies, help patients to find ways out of their addiction – or at least to reduce their consumption.

Experts estimate that more than 7% of all diseases and premature deaths are due to alcohol abuse. Year after year young people die as direct or indirect consequences of their addiction to alcohol. Young men between the ages of 15 and 29 years are particularly at risk. Frequent alcohol consumption can lead to dependence; many slide off into addiction without consciously perceiving it.

Successful, wealthy, alcoholic?

Adj. Professor Dr. Udo Schneider and Dr. Brit Schneider studied influencing factors in detail. Using data from the socio-economic panels (SOEP), a representative repeat survey, they arrived at interesting findings: the higher the level of education and income, the greater the risk of consuming alcohol regularly – among both women and men. Udo Schneider excludes their being a lack of information, it’s rather that beer and wine are socially accepted. To speak generally of alcohol dependence would be wrong. Observations made by U.S. scientist Elvin Morton Jellinek (1890-1963) show that this behaviour can lead to the so-called beta-type: those affected drink on social occasions, but otherwise remain inconspicuous. They also are not immune to having health consequences.

Deadly Drinks

Professor Ulrich John, Greifswald, Germany, has dealt specifically with the mortality rate of alcoholics. He examined 4,070 people aged between 18 and 64 years – and promptly found 153 with such an addiction. After 14 years, 149 of these patients made it to a follow-up. John found with alcohol-dependent women an elevated rate of mortality by a factor of 4.6, for men the mortality rate was 1.9-fold higher. Amazingly: patients who because of their addiction had received hospital treatment did not benefit in terms of life expectancy. Based on this finding, John Ulrich now calls for women to be placed more strongly in the focus and for therapy programs to be more critically reviewed.

Complex biology

The addiction itself is based on molecular effects. Ethanol inhibits NMDA receptors and stimulates GABA-A receptors, which explains the relaxing and fear-eliminating effects. Eventually adaptation occurs and patients consume increasing amounts in order to achieve the same effect. With withdrawal the control of the respective binding sites is missing. There are sometimes life-threatening symptoms such as seizures, anxiety, tachycardia and tremor – known as delirium tremens. Left untreated, up to one third of all patients would die from these symptoms. Detoxification thus takes place mostly in the hospital, with medical assistance via haloperidol, benzodiazepines, clomethiazole and clonidine. Once the first step is done, patients should be made to stabilise in the long term.

Stop the thirst

As a supplement to behavioral therapies and self-help groups, anti-craving substances reduce the desire for some high-percentage drink. Besides well-known drugs such as acamprosate, disulfiram (in Germany now no longer available) or naltrexone, in recent years another drug has created furore. The interest seen in a large part of the media in baclofen is inextricably linked to one name: Dr Olivier Ameisen, a cardiologist from France. He defeated his alcohol addiction using high doses of this muscle relaxant. After initial doubts – that it was perhaps just a matter of seeking publicity – science cast some light on the picture. A retrospective study of 181 patients, 132 of whom in the end provided evaluable data, verified Baclofen’s good results. At the start alcohol consumption measured 182 ± 92 grams per day. After one year, 78 people were abstinent, another 28 had significantly reduced their consumption. All study participants had received 129 ± 71 mg of the active substance per day. As a result, the French Medicines Agency ANSM (Agence nationale de sécurité du médicament et de produits de santé) gave the green light to baclofen for “case by case” use.

Success with the cuddle hormone

Oxytocin has interesting properties as well. Usually known as “cuddle hormone” and know for causing contractions, addiction patients also benefit from this neuropeptide. Researchers administered seven patients in a randomised, double blinded study with oxytocin while four patients received a placebo. All participants had consumed too much alcohol and, in trying to get rid of their addiction, complained of severe withdrawal symptoms. Under verum those affected required no or less lorazepam than people in the placebo group. Further work must follow in order to assess the long-term value of the peptide hormone.

Less is more

There is not always success in leading patients to abstinence. Therapists alternatively try at least to reduce the consumption of alcohol. Here the opioid receptor antagonist nalmefene comes into use. Patients are supposed to take the medication before they reach for a bottle – in order to reduce consumption. There are results for nalmefene available from several phase III trials. Before the start of the study the participants had more than six “heavy drinking days” (HDD), meaning at least 60 grams of ethanol per day (men), or 40 grams of ethanol (women) as a rule. In parallel to psychotherapy they received nalmefene or placebo. After one year of use under verum their consumption had reduced by as much as a significant 60 percent. Further, the European Medicines Agency EMA has spoken out for its approval. The target group is patients with high alcohol consumption for whom detoxification is not possible. Nalmefene might already be able to be prescribed as early as mid-2013.

Unpopular measures

Beyond medicine and pharmacy, there are law-based interventions which yet remain to be judged. Colleagues at the Centre for Addictions Research of British Columbia found that prices for alcoholic beverages play a central role. From 2002 to 2009 Canadian politicians made alcoholic beverages more expensive by ten percent by introducing minimum prices. Lo and behold – over the same time alcohol-related mortality decreased by 32 percent. Even heavy drinkers without any treatment curtailed their consumption.

As the state’s monopoly, with spirits having being sold only through its own stores, was finally dropped, private outlets arose. Mortality rates promptly increased again by two percent. Corresponding figures show that with measures applied against alcohol addiction, medicine, pharmacy and political policy need to act in concert.

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