Ty Johnston, PharmD Student
In our previous article, Alcohol Use Disorder: Stigma and Identification, we talked about how to identify someone that may be suffering from alcohol use disorder and provided practical tips on how to talk to someone about their illness. Today’s article is more personal as I share a patient’s experience. As a reminder, Alcohol Use Disorder (AUD) is an illness where a person has an addiction to alcohol that is causing them some degree of harm.
A Patient Suffering from AUD
Meet Melanie, a middle-aged single mother with two children. She has a successful career and works from home. I first met Melanie when she asked me a question about the risks of high blood pressure. My first impression of her was that she was a very kind, intelligent, and professional individual. I gladly answered all of her questions about blood pressure and began to ask her questions to assess her 10-year risk of having a heart attack. During routine assessments like this, it’s common to ask how much alcohol a person drinks to get a better sense of their overall health risk. When I first asked how much alcohol she was drinking, she said, “Oh… well, about one a day.” My first instinct was that she’s an average woman who enjoyed a glass of wine after a long day of work. But then I asked her what “one a day” truly meant. It turns out; she was drinking a bottle of wine every night.
She was drinking to the degree that was damaging her social, physical, and mental health. I asked Melanie more about her alcohol use, and she told me it had been going on for several years, but she never considered it a problem until one night when it led an altercation with her child. She noticed that it was starting to affect her work performance, relationships with her children, and all other aspects of her social life. She said through all these years she’d always refused to accept it as a problem and turned a blind eye to the consequences it was having on her and her family. Now that she was finally able to recognize her drinking for what it was- a detriment to her own and others’ health, she wanted nothing more than to repair the harm it was causing her family. But, she lacked the resources to help herself overcome it. Her life was revolving around her nightly bottle of wine, and she felt hopeless. The thing that really surprised me was her lack of awareness of the help available. When I asked her about her knowledge of the related health risks, treatment options, and if she ever discussed her struggles with her physician, it was as if I was speaking a different language. She admitted she was completely unaware any professional help was available and that she was embarrassed to discuss things with her doctor.
Melanie is the motivation behind this article, as there are so many medications and supports available to help with alcohol use despite many people being completely unaware of their existence. Although the medications may not fix the problem per se, they can greatly help someone overcome their battle with AUD. Before breaking down the medications, let’s first talk about the health risks of chronic alcohol overuse.
Physical Health Consequences of AUD1,2,3
- Wernicke Encephalopathy: Alcohol decreases the absorption of vitamin B1, also known as thiamine. Over long periods of alcohol overuse, people develop thiamine deficiency. This deficiency leads to Wernicke Encephalopathy. Symptoms include difficulty walking, restlessness, eye issues, and confusion. The condition can also lead to coma and death in about 20% of patients without adequate treatment. Although it occurs after long periods of alcohol overuse, the onset of the illness is abrupt. Therefore it’s essential to prevent the illness before it occurs, as there are no warning signs.
- Korsakoff Syndrome: Korsakoff Syndrome occurs in about 85% of survivors of Wernicke encephalopathy and is characterized by permanent brain damage. The majority of patients do not recover from the illness. Symptoms include psychosis, severe memory and emotional impairment. Korsakoff Syndrome is also known as Korsakoff dementia as the symptoms are very similar to classical age-related dementia.
- Mental health: Alcohol use disorder increases the risk of developing many mental health conditions including anxiety, depression, personality disorders, and psychosis.
- Alcoholic liver disease: Alcohol has detrimental effects on the liver and leads to varying degrees of liver damage. The most severe form of liver damage is cirrhosis which can lead to liver failure. When the liver fails to function optimally, it results in several complications. Notably, these include the build-up of toxic substances in the body, difficult-to-treat bacterial infections, internal bleeding, and kidney damage. Liver failure eventually can result in death.
- Withdrawal: After prolonged and heavy alcohol intake, your body becomes physically dependent. When someone is physically dependent and stops or reduces their alcohol intake, it can lead to alcohol withdrawal. Withdrawal symptoms typically develop within several hours to a few days and include insomnia, nausea, vomiting, hallucinations, agitation, anxiety, and seizures. Notably, alcohol is one of the very few addictive substances for which withdrawal can cause death.
- How it works: Naltrexone works by blocking the hormones that are normally released after consuming alcohol. Normally the release of these hormones results in the euphoric (or feeling good) effects of alcohol. Thus, the medication blocks those feelings and reduces one’s urge to drink.
- Benefits: The benefit of naltrexone is that it blunts the reinforcing effects of alcohol, reduces cravings, and reduces the perceived benefits of consuming alcohol. It’s usually the first and preferred treatment for AUD.
- Side effects: The common side effects of naltrexone are minor; such as stomach upset, fatigue, and dizziness. It’s important to know that naltrexone can reduce the effects of strong pain medications called opioids. It’s not a good option for people who also suffer from opioid dependence.
- How it works: The way acamprosate works is fairly complex and is related to the way alcohol acts in the body. Acamprosate appears to correct chemical imbalances in the brain that have been associated with alcohol overuse.
- Benefits: Like naltrexone, acamprosate reduces alcohol cravings. However, unlike naltrexone, it does not interfere with the pleasure obtained from consuming alcohol.
- Side effects: Acamprosate is quite well-tolerated (it has few side effects), but it can cause diarrhea and abdominal pain.
- How it works: When alcohol is consumed, it’s broken down in the body by an enzyme named acetaldehyde dehydrogenase. Disulfiram works to prevent the action of this enzyme, leading to the build-up of a toxic substance called acetaldehyde. High amounts of acetaldehyde result in severe and unpleasant flu-like symptoms, including severe nausea, vomiting, sweating, and flushing.
- Benefits: When a person is taking disulfiram and drinks alcohol they’ll be forced to endure the unpleasant effects of acetaldehyde. Therefore, it’s used to deter people from alcohol use.
- Side effects: Common side effects include a bad aftertaste, rash, and headache. However, if a person consumes high amounts of alcohol while on the medication there can be dangerous complications. Therefore, disulfiram is only used in people who are either very motivated to quit or don’t have access to large amounts of alcohol.
Medication is only one part of successfully overcoming an addiction to alcohol. Medications don’t work for everyone, but for some people, it can be an impactful way that helps them overcome their illness. Medication is most useful in addition to other forms of treatment like counseling and social support.
Importantly, there are different treatments available for alcohol withdrawal. If you think you’re at risk of withdrawal, because it can be fatal, it’s even more important to obtain help from a healthcare professional.
So what happened to Melanie? Well, our conversation dramatically changed from talking about the effects of diet on blood pressure to the long-term risks of overusing alcohol. We also discussed the available treatments, and I encouraged her to talk to a psychiatrist that specializes in the treatment of AUD.
Fast forward to now, and Melanie is now taking naltrexone, and although it wasn’t easy, she’s cut her alcohol intake down to one glass of wine per day from one bottle. She’s greatly improved her relationship with her children and is performing to full capacity at her job. Her story serves as a good reminder that the first step to overcoming any problem is to first identify the consequences of that problem and then find a way to change, whether it be through social support, medical help, or a change in mindset. Melanie is the epitome of my new favourite quote that I think can be applied to any aspect of life; “success is when you have the will and ability to sacrifice things you want now for what you want in the future.”
Persistent and heavy alcohol abuse can have a variety of long-term health complications. Although medications are not a cure for AUD, there are medications available that have been proven to reduce cravings, psychological dependence, and relapse rates. If you’re interested in seeking help about your problem with alcohol use, consult a healthcare professional that is experienced in treating AUD.
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- Dynamed Plus: Alcohol Use Disorder
- Dynamed Plus: Korsakoff Syndrome
- Dynamed Plus: Wernicke Encephalopathy