Treatment Priorities

Establishing a trusting therapeutic relationship is integral to treating the alcoholic patient. A psychiatrist is in a strong position to develop a nonjudgmental, empathic relationship with alcoholic patients but, in addition, must be prepared to challenge denial and confront pathological behavior or regression. The physician's awareness of the continuing incentive to drink, mediated by chronic stimulation of dopamine-rich pathways in the mesocortical system, will assist him or her in tolerating relapses and encouraging the patient to learn from relapses rather than either the patient or the clinician succumbing to a sense of defeat. Alcoholism leads to impaired impulse control and an impaired priority system; that is, the salience or importance of alcohol has become dominant for the alcoholic patient, and the reversal of this priority is a slow, steady, day-by-day process.

Demoralization is always a potential factor, but it can be effectively countered by the doctor-patient relationship, combined with utilization of a support system such as Alcoholics Anonymous. The development of negative counter-transference on the part of the physician needs to be guarded against to the extent possible. Work with a sufficient number of alcoholic patients will demonstrate the heterogeniety of those who develop alcoholism and lead to the physician's ability to assist in recovery and witness the restoration of health, the reestablishment of effective work patterns, and the gratification of renewed relationships.

Detecting relapse is a treatment priority. The patient may report relapse, but often this is not the case. Family members, employers, or other collateral sources may provide information that suggests relapse. Observations made by the physician may indicate relapse. Biomarkers may be very useful in detecting relapse—for example, an increase of 30% or more in GGT above a previously obtained value is likely to reflect relapse (Anton, Lieber, & CDTect Study Group, 2002). CDT may rise before other signs of relapse are apparent. There are few sources of false-positive results. An elevation can be expected if alcohol is consumed for 2 weeks at a level of five drinks (60 grams) per day (Schmidt et al., 1997). Early detection of relapse offers the potential to prevent a return to harmful or dependent drinking, as well as an opportunity to identify "triggers" that render an individual susceptible to relapse.

Comorbidity with other psychiatric disorders is common in alcoholic patients. This potential multiplicity of clinical problems raises questions about what condition is treated first, which setting, and what modalities. Several guidelines can be offered.

1. The issues of acuity and safety must receive priority (Nace, 1995). A patient who presents as acutely suicidal would necessarily be placed in an inpatient setting capable of offering close or constant observation. An acutely delusional patient would require the intensity of an inpatient psychiatric unit as well. Addressing recovery issues would await psychotic stabilization.

2. Alcohol-related and co-occurring disorders should be treated in parallel or synchronously. For example, a suicidal patient requiring the protection of a locked psychiatric unit may also require detoxification, simultaneous with efforts to protect him or her from self-harm.

3. Sufficient time free of alcohol may clarify the issue of comorbidity. Alcohol-related anxiety and affective or psychotic disorders are expected to resolve in about 4 weeks, although clinical judgment is more appropriate than fixed time intervals in determining whether symptoms are alcohol-related or part of a comorbid condition. If symptoms abate as alcohol is withdrawn, the likelihood of a co-occurring disorder diminishes. If symptoms persist, or if new symptoms emerge in the absence of alcohol, a co-occurring disorder is likely.

tion and management. Panic attacks occurring in association with alcohol may require relief with alprazolam or other suitable drugs. Addressing acute symptoms pharmacologically does not imply that an additional dependence will be established, or that alcohol dependence will be prolonged.

5. Each disorder requires treatment. Severely depressed patients cannot be expected to respond to 12-step programs or rehabilitation efforts if they are not simultaneously receiving appropriate pharmacology and psychotherapy. Nor will a bipolar patient be likely to achieve stabilization if his or her alcoholism or alcohol abuse is not arrested. See Chapter 26, "Psychopharmacological Treatments," for the mechanism and utility of the agents used in alcohol use disorders, including disulfiram, naltrexone, and acamprosate, all recently approved for use in the United States.

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