Dr. Qaadri

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Medical Post - Alcohol Dangers

Is Alcoholism on the rise in North America?
I believe that the incidence fluctuates back and forth. I am not aware that there’s a big increase recently. About ten percent of the North American population has the disease alcoholism, which is an extremely high number.

It is one of the significant triggers of heart disease, heart attacks, diabetes, and liver disease. People don’t realize how much cholesterol and fats they introduce into their bodies because regular drinking.

How do professionals in alcohol management define alcoholism—is it a behavioural definition, or do you refer to enzyme elevations?
It’s usually a combination of social as well as medical aspects. For example, a person will have a craving and desire to drink, and they will lose control to satisfy that desire. At the same time, they have a physical dependence, which means they will need to take higher and higher doses of the drug in order for them to feel good. And if they stop alcohol, they can go into withdrawal.

So there’s both a physical as well as a psychological component.

Regarding alcoholism, is there a gender bias?
Men do continue to have a higher rate of alcoholism, although it seems that women have tried to catch up.

What are the new developments regarding alcoholism and young people?
Alcohol is one of the easier drugs to get, so it is a particular worry in adolescents.

I was, for example, very concerned about the introduction of a device in the United States called AWOL. This means ‘Alcohol Without Liquid.’ So now you don’t actually have to drink the alcohol, you can use this nebulizer device, similar to what we might use for asthma, for example, and you can deliver straight drug. You can actually put any of the distilled spirits in it.

In this way, within a few minutes, you can actually absorb large quantities of alcohol because the surface area of the lung is so huge. So you get a very rapid rush, and that of course tends to intensify addiction. This also makes it very easy for a person to go over their limit without realizing it.

What are the common symptoms of alcohol dependence?
From the patient’s perspective, it can sneak up on you. You may not know that you’re becoming addicted.

There is the CAGE Questionnaire, which has basic questions such as, Have you ever felt that you should cut down on your drinking?—so that feeling like you’re drinking too much is one of the things to worry about. Another question is: Have people annoyed you by criticizing your drinking? If people are noticing and commenting on behavioural effects of your drinking, that is a strong indication that you may be drinking excessively.

Have you ever felt bad or guilty about your drinking? And then if you drink to rid yourself of that bad feeling, is another strong sign of an alcohol problem, as is Do you drink first thing in the morning? That is what some patients do to get rid of their hangover--their jitteriness, or nervous feeling. This aspect starts to show the physical dependence on alcohol.

A positive answer to just one of these questions indicates a strong possibility of alcoholism.

What happens neurochemically in alcohol dependence?
This is not fully understood, but we do know that alcohol functions as a membrane stabilizer. This alters neural conduction. That’s why, for example, someone who is intoxicated has poor reflexes, or is unable to do basic fine motor movements such as touching their nose—part of the sobriety test.

What the treatments for alcoholism?
For alcohol withdrawal, we have the usual medications, such as the benzodiazepines. These allow a person to go through their withdrawal with the least discomfort possible.
But once you’re past the medical withdrawal aspects, the treatment is complicated, multifaceted, and only partially successful.

There is no cure. In fact, once a person is diagnosed with alcoholism, they are taught that they have it forever. So the issue then becomes one of control.

For a patient with alcoholism never to drink again requires a very good support system: counselling, your family structure, healthcare, and community resources are all important.

What is the treatment protocol?
We have a short-term residential unit for alcoholic patients. Patients can come to us to undergo withdrawal in a controlled setting. Counselling begins while they are in-patients, and continues after discharge. This helps patients make the transition from the acute intoxication phase to being able to deal with the social and psychological aspects.

Why is it so dangerous to combine alcohol with prescription or OTC medications?
We are mostly worried about the additive effects of CNS depressants. Alcohol is a very potent central nervous system depressant. If you add that to another medication—for example, the classic Marilyn Monroe story in which she added barbiturates—you can lead to respiratory arrest.

What is the alcohol-acetominophen syndrome?
This refers to the alcoholic patient who takes acetominphen and then develops liver injury. Though this phenomenon certainly occurs, the question is at what dose, and what are the circumstances.

For example, it is well-known in animals and humans that regular drinking will induce the enzyme that metabolizes acetominophen. This is important, because then more of the metabolite that injures the liver is produced. But in a normal adult human, it would take about 15 grams of acetominophen to cause liver damage.

Does it take less than that dosage in alcoholic patients to cause liver damage?
This is an important question. We know that ten percent of the population has alcoholism. We also know that 20 percent of the population uses acetominophen each week. So there is concern about this potential interaction.

In our detox facility, we studied this question--if therapeutic doses of acetominphen might lead to liver injury in alcoholics…In patients who were receiving 4 grams of acetominophen, the maximum daily dose, we found that they did not develop liver enzyme elevations…This was published in The Archives of Internal Medicine.

Is A.A., Alcoholics Anonymous, of value?
I think it’s of great value. A patient’s support system is so important when they are trying to recover from alcoholism. Patients appreciate that they can go regularly to meetings where they can voice their concerns to other people who understand the issues and problems they are all going through.

Is the Gamma-GT enzyme more tracking of alcoholism?
It is. It’s just another intracellular enzyme of the liver cell. It is induced by alcohol, and is an indicator of current drinking. But there can be a lot of false positives as well as false negatives, so it’s not a test that is used tremendously in clinical medicine anymore.

What has been your experience in poison management?
One of the things we have an interest in is antidotes. For example, for rattlesnake bites, there is a rattlesnake anti-venom, which we helped develop and is now used in the United States.

Snake venom has three functions. It tries to digest the prey, so if you are bitten, you will get swelling and tenderness. It will also anticoagulate you, which is very interesting, and has even found commercial use in modified forms. It also has systemic toxins that help to depress cardiac function.

There are about 2500 snake bites in the US per year, and to benefit from the antidote, you need to receive it within a few hours.

What is your final message regarding the management of alcoholism?
The big message is to look for it, and not ignore the signs so that you can get the person into care that’s going to help them. The worse thing you can do, which is what a lot of families do, is just shy away from the topic and hide it.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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