Substance Abuse
"It's a Question of Accessibility and Acceptability"

Substance abuse is, without question, America's number one health care enemy. The numbers are startling, almost unbelievable. Between 8 and 10 percent of Americans - or one in nine people - are alcoholic. If prescription drug abuse and illegal drug use are factored in, between 10 and 15 percent of Americans are substance addicts. Fourteen percent of Americans will, at some time in their lives, be alcoholic - a prevalence of 24 percent of all men, but only 5 percent of women. About half of alcoholics become so by age 19.

The American Medical Association estimates that between 25 and 40 percent of U.S. hospital beds have patients who were admitted because of health problems directly related to alcohol abuse.

On average, people dying from a condition exacerbated by alcohol abuse have lost 26 years of an expected lifespan.

Half of the nation's automobile fatalities, or about 25,000 deaths, are caused by alcohol. And alcohol is implicated in half of all domestic disputes and a third of child molestations.

Although illicit "street" drugs may grab the local evening news headlines, drug abuse and addiction - including abuse of prescription medicines - pales in comparison to the abuse of alcohol in the U.S.

"It's a question of accessibility and acceptability," says Dr. Kenneth J. Krajewski, director of the substance abuse program at The University of Texas-Houston Harris County Psychiatric Center and associate professor of psychiatry and behavioral science at UT-Houston Medical School. "We have made alcohol not only accessible and easy to get, but we accept it as a part of the society. So we need more than just education about alcohol abuse. We need a concept of alcohol, a view of it," says Dr. Krajewski. "We need to come to the point where it is more fashionable to go to the gym than to happy hour."

While a definition of addiction may be helpful in understanding just what it is - Dr. Krajewski defines addiction as "the compulsive use of psycho-active chemicals that produce a duality in the biological, psycho-logical and social functioning of an ind

ividual" - an understanding of the terms "abuse" and "dependence" may be more enlightening. "Abuse is behavioral, and it involves a conscious choice," says Dr. Krajewski. "Dependence is a neurological state and involves the concept of tolerance, where more and more of the substance is needed for the desired effect."

While many people may think of alcohol abusers or people dependent on alcohol as skid-row types, staggering in the street or sleeping it off every morning, most alcoholics are functioning alcoholics. In truth they function with their illness just as diabetics function with their disease and people with heart disease function with theirs. "We can't measure the `occlusion' of an alcoholic's life as we can measure the occlusion in an artery," says Dr. Krajewski. "But we know that life is not as functional as it should and could be, and there are sure to be health consequences from the drinking."

Substance abuse can make an already-severe mental illness much more difficult to treat. Called dual-diagnosis, because the patient has both a mental health and substance abuse problem, this is a disorder that is growing in numbers each year. "Alcohol and/or drugs can really exacerbate a psychiatric illness, and make treatment very, very hard," says Dr. Krajewski. "People suffering from psychoses have a rate of substance abuse 5-10 times that of the general population. Sixty percent of people with bi-polar, or manic depression, abuse either alcohol or drugs. Half of people with depression do also, and about half of people with generalized anxiety do. So this is a troubling and widespread problem."

"Many alcoholics can function for a lengthy period of time because there are external controls in their lives," says Dr. James N. Flack, director of the psychiatry services at The Methodist Hospital and assistant professor of psychiatry and behavioral sciences at Baylor College of Medicine. "The man has to go to work five days a week, and that is somewhat of a control on his drinking. In the evenings and on weekends and vacations, that external control is not present, so the drinking may be intensified. Take away the external control of a job, for instance, as when this man retires, and you can expect some bad times."

Unlike opiate drugs, where tolerance is reached within a few weeks and more of the drug is needed for its sedative effect, tolerance to alcohol takes a long time. It may be years before the alcoholic reaches a point where tolerance is, in effect, a kind of dependence where withdrawal would create more biological problems than when the substance is in the body. "At this point of dependence, the person cannot function without the drug," says Dr. Flack. "So withdrawal would require medical intervention."

The first day of treatment for alcohol or drug addiction may be "the worst day of my life" for the patient, as Dr. Flack testifies many patients feel when they come into his program at Methodist. Typically, something negative has happened. In truth, a series of negative things have probably occurred over time, culminating in a major episode.

"We say, `Look, there are no guarantees that life is perfect, but we can guarantee that if you do not get alcohol out of your life, it will only get worse."

"When they come to our program, I tell them, `If you do not stop drinking, you will end up in one of three places: an institution, a jail or the morgue,'" says Dr. Krajewski.

"At this point, addiction means using alcohol or a drug when you don't really want to," says Dr. Flack. "It is the first step in recovery: realizing you are powerless against the alcohol or drug."

In the course of treatment, patients are encouraged to work to the point of allowing themselves, in their abstinence, to experience their family, work, spirituality and other positive things in their lives that have been neglected. "To rediscover the little miracles," says Dr. Flack.

Half of fully recovered alcoholics will remain sober. They face the challenges of creating a new social milieu for themselves. Drinking has been their recreation, and it has helped structure their day. Thankfully, most employers recognize that alcoholism is a disease and will work with their recovering employees. Having a job is a great salvation for the recovering alcoholic.

Of course the best way to treat alcoholism and drug addiction is prevention. "We are more effective as health care providers if we can prevent addiction from occurring," says Dr. Flack. Alcoholism and addiction run in families. Because there is a predisposition, Dr. Flack feels that some individuals need to make early choices about alcohol. "They need to say to themselves, `Ok, my system probably handles alcohol differently than most people, and it's likely I'll become addicted like other in my family have been.'

"It's important for young people to make this choice," says Dr. Flack. "They are difficult to treat when they begin drinking heavily because they have not yet suffered the losses of someone 50 years old or so - the DWIs, broken marriages, lost jobs."

Young people will drink to have a good time, to induce sensations. If mistakes are made, they will say they were, well, just mistakes. Meanwhile, a pattern is being established. In time, the alcoholic's life is organized around alcohol. Events where alcohol is not served will probably be avoided. People who do not drink will be avoided. The alcoholic will not drink to excess every time he drinks, but it can not be predicted when he will drink to excess.

Because young people can remain in good health despite the heavy drinking, they are more apt to deny the problem. Older drinkers will almost always score well below - 30-40 percent below - their non-alcoholic peers in health inventory questionnaires.

The alcoholic's family is in a difficult position. "Typically, the family is powerless," says Dr. Flack. "There's `tough love' and there's enabling. Most families, if they remain intact, will need to seek help."

"I still don't think we have come to the point where we think of alcohol as a major disease in the way we think of heart disease, cancer, diabetes or AIDS," says Dr. Krajewski. Considering the costs, the draining effects on America's health care system, the broken families and lost lives, many health care professionals who treat alcoholics and substance abusers are advocating for education efforts aimed at younger audiences - and the re-thinking of mass marketing of alcohol beverages.

---

©2006 Texas Medical Center

---

E-Mail: tmc-info@tmc.edu
URL: http://www.tmc.edu/tmcnews/01_15_00/page_11.html