Further Outpatient Care
Frequent follow-up is essential to support the patient in recovery. The most common mistake physicians make is assuming too soon that the patient is stable. Ask patients about attendance at AA meetings and about their relationships with their sponsors. Less than 20% of patients remain abstinent for a full year. Among patients who have been sober for 2 years, the relapse rate is 40%. Patients who have been sober for 5 years are likely to remain sober, but they are still at risk for relapse.
Warning signs for physicians that a patient has relapsed include missing appointments or attending AA meetings less frequently. Warn patients to avoid testing themselves, particularly early in sobriety. Encouraging involvement in exercise and other leisure activities also is helpful.
The key step for the patient is to realize that treatment does not end with sobriety. Recovery means that patients can handle the stresses of everyday life without alcohol. Therefore, the patient must develop and rehearse strategies to cope with high-risk situations.
Successful recovery requires the patient to be able to do the following:
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Learn to say no to drinking in social situations.
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Handle heavy-drinking friends who will try to undermine the patient's sobriety.
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Handle stress. (Patients should not ignore symptoms of anxiety.)
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Avoid boredom. (Prior to recovery, patients spent a great deal of time drinking or recovering from drinking. Upon abstinence, patients will have more free time.)
-
Learn to get along again with family and close friends. (Family problems often increase when drinking stops.)
-
Identify other situations that can lead to drinking and develop ways to cope with them.
Patients should have a list of phone numbers of people they can call when they are having a difficult time coping. Importantly, patients should write out the list and put it in a convenient location because sometimes during high-stress periods they may become emotionally and mentally disorientated, necessitating written instructions.
Patients should spend time thinking about circumstances during which they feel at highest risk for relapse. They should anticipate these situations and make a written list. Most persons with alcoholism can quickly list the circumstances and/or emotions that led them to drink.
Patients need to identify specific responses (thoughts as well as behaviors) to each of these high-risk situations. Encourage patients to be very specific when considering their responses. For example, ask patients exactly what they are going to say and do when asked at parties what they want to drink. Once patients have made the list, they should practice responses to their high-risk situations.
When patients have the urge to drink, there are several techniques that can be used to deal with the situation, including (1) self-distraction (i.e. getting involved with an alternate activity that they enjoy), (2) thought stopping (i.e. patients should not dwell on thoughts of drinking but should stop these thoughts), (3) reprogramming (ie, patients should avoid activities that remind them of drinking), and (4) use of social support structure. The most common cause of relapse is failure to use coping strategies.
If the patient has a relapse, find out what happened (make a diagnosis) in order to formulate a new treatment plan. Below is an outline for dealing with relapses. Insist that the patient be actively involved in devising solutions; do not attempt to solve the problem for the patient.
Make a diagnosis.
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How long had the patient been sober before relapse?
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What were the circumstances of the relapse?
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What was (were) the triggering event(s)?
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How does the patient feel about the relapse?
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What social support systems are available to the patient?
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Does the patient believe that he or she can quit again?
Institute a treatment plan.
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Determine what the patient thinks is appropriate treatment.
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Reinforce the patient's decision to seek help.
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Emphasize that complete abstinence is the only solution.
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Reframe the relapse as a learning opportunity.
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Provide support and empathy. For example, reassure the patient with encouragement such as "We can do this together."
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Have the patient come up with ways to avoid the triggering event or find alternative ways to deal with it.
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Rehearse what to do in high-risk situations, including making use of the patient's social support system.
A 2010 study investigated a 10-year comparison of public endorsement of treatment and prejudice of the diagnoses of schizophrenia, depression, and alcohol dependence. Regarding alcohol dependence, high proportions of respondents in this study endorsed treatment, with general increases in the proportion endorsing treatment from doctors and specific increases in the proportions endorsing treatment from psychiatrists (from 61% in 1996 to 79% in 2006). This study found that more of the public embraces a neurobiological understanding of mental illness, which translates into support for services but not necessarily into a decrease in stigma. [58]
Prognosis
The prognosis for alcoholism should not be considered hopeless. As many as 30% of persons with alcoholism stop drinking. Even a patient with cirrhosis might have a favorable prognosis if alcohol cessation is achieved.
Patient Education
For patient education resources, see the Mental Health Center, Infections Center, and Digestive Disorders Center. Also, see the patient education articles Alcoholism, Drug Dependence and Abuse, Alcohol Intoxication, Hepatitis B, Hepatitis C, and Cirrhosis.
Involving family in the patient’s treatment of alcoholism can be a vital step on the path toward recovery. At a minimum, the destructive behaviors that occurred before treatment should be addressed by the patient with his or her family members. This is an important acknowledgment by the patient as they begin to grapple with the significance of their previous alcohol-centered lifestyle. Family members may find support through Al Anon, a fellowship devoted to sharing experiences and learning from others how to achieve serenity when a loved one struggles with alcohol.
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Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Tables
Questions |
0 Points |
1 Point |
2 Points |
3 Points |
4 Points |
1. How often do you have a drink containing alcohol? |
Never |
Monthly or less |
2-4 times a month |
2-3 times a week |
4 or more times a week |
2. How many drinks containing alcohol do you have on a typical day when you are drinking? |
1 or 2 |
3 or 4 |
5 or 6 |
7-9 |
10 or more |
3. How often do you have 6 or more drinks on 1 occasion? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
4. How often during the past year have you found that you were not able to stop drinking once you had started? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
5. How often during the past year have you failed to do what was normally expected of you because of drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
7. How often during the past year have you had a feeling of guilt or remorse after drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
9. Have you or has someone else been injured as a result of your drinking? |
No |
|
Yes, but not in the past year |
|
Yes, during the past year |
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down? |
No |
|
Yes, but not in the past year |
|
Yes, during the past year |
Biomarker |
Sensitivity (%) |
Specificity (%) |
AST |
15-69 |
47-68 |
ALT |
18-58 |
50-57 |
GGT |
34-85 |
11-95 |
MCV |
34-89 |
26-95 |
CDT |
39-94 |
82-100 |
CDT + GGT |
90 † |
98 |
Alcohol |
0-100 |
0-100 |
EtG |
76-91 |
77-92 |
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors. [40, 6, 41, 43, 44] † The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated. [45] |
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