Because of the strong craving for alcohol and physical dependence of alcohol-dependent patients to the point that they cannot extricate themselves from it, they should generally abstain from alcohol under inpatient conditions except in mild cases, and they should also eliminate all sources of alcohol during hospitalization to ensure successful abstinence. The treatment of alcohol dependence is traditionally divided into two stages: acute treatment (or detoxification treatment) and recovery treatment.
1. Detoxification treatment
Detoxification, for patients with significant alcohol dependence, must be carried out not only under inpatient conditions, but also preferably in a closed ward in the early stages. This approach is designed to counteract the severe withdrawal syndrome that often occurs, and on the other hand to counteract the very difficult, painful and easy to return to drinking cravings during the early withdrawal phase. Abstinence from alcohol should be immediate and complete, while gradual reduction of alcohol will make it more difficult to quit. In the long term, abstinence from alcohol should also be absolute and should not be controlled, except for those with severe alcohol dependence and a combination of severe somatic disease or very poor physical condition, where a severe reaction to a single abstinence or the possibility of severe withdrawal symptoms may be considered for patients using gradual reduction of alcohol, and generally not for too long.
Patients treated during the detoxification period should initially undergo a comprehensive neurological and medical examination as in patients with somatic disease, with special attention to electrolytes, cardiac and circulatory function, and the combination of severe somatic disease should be treated promptly. Control of severe somatic withdrawal symptoms is the key to the detoxification period.
(1) Benzodiazepines.
Preferred benzodiazepines can better relieve and improve the symptoms of tremors, convulsions, anxiety, and even delirium tremens that occur during alcohol withdrawal. These drugs have a cross-dependent effect with alcohol, have a small effect on the cardiovascular system, are inherently safer, and rarely have the side effects of inhibiting breathing and lowering blood pressure, and the dosage is based on the principle of not causing withdrawal symptoms in patients. Commonly used drugs in China are diazepam (Valium), clorazepam (Librium), alprazolam (Jiajing Valium), etc. In recent years, clonazepam (clonazepam, rivotril) injection is also commonly used. In order to prevent the abuse and addiction of benzodiazepines, foreign countries advocate the reduction of 20% of the dose from the second day after the control of symptoms, generally 5 days to complete the reduction. In our clinical experience, the dosage is increased or decreased according to the symptoms, generally no more than 7 days, the patient’s withdrawal symptoms basically disappear, the drug can be gradually discontinued. It should be treated promptly and symptomatically for withdrawal symptoms and the somatic and neurological complications of chronic intoxication.
It is also reported in China that when withdrawal symptoms are obvious, symptomatic treatment with hydroxyzine (Antares) or chlorprothixene (Teldene), etc., generally 10-14 days for a course of treatment, can achieve satisfactory results. It has also been reported that propranolol (Tylenol) and colistin can reduce withdrawal symptoms.
(2) Supportive therapy.
Alcohol-dependent patients, especially severe chronic alcohol-dependent patients often take alcohol instead of meals, resulting in malnutrition and vitamin deficiency, especially B vitamin deficiency, so nutritional support therapy should be given. Large amounts of vitamin B and C. And timely supplementation to maintain water-electrolyte balance. The Institute of Mental Health of Peking University uses pro-brain metabolism to treat patients with alcohol dependence, which can reduce withdrawal symptoms and has good effects on improving the nutritional status of patients and improving memory.
(3) Insulin hypoglycemia treatment.
10% glucose 500ml added to insulin 10-20μ intravenous drip, and give a lot of vitamin B, niacin, etc. It is also effective in improving the nutrition and reducing the symptoms of alcohol-dependent patients.
(4) Psychotherapy.
①Supportive psychotherapy: alcohol-dependent patients are mostly unable to recognize the harmfulness of their alcoholism and often cannot take the initiative to seek medical help and fight against treatment; therefore, it is essential for doctors to help patients release the psychology of fighting against treatment as early as possible. This can improve the confidence to quit drinking. The doctor should explain to the patient the causes and hazards of alcoholism and the withdrawal symptoms that the patient is showing, so that the patient realizes that he is suffering from a disease and that there is no negligence and that he has the responsibility to receive treatment, and at the same time, make him realize the impact of drinking on his quality of life, on his family and on society. The patient’s cooperation is the key to successful treatment. Psychotherapy to achieve abstinence and consolidate the effect of abstinence.
(2) Behavioral therapy: Apomorphine and emetic root-alkaline aversion therapy can achieve significant results in nearly 70% of patients. After subcutaneous injection of apomorphine, the patient is asked to smell alcohol, and when the patient is nauseous and wants to vomit, the patient is immediately asked to drink a glass of wine, and so on once a day or once every other day, after 10-30 times in a row, the vomiting reflex to alcohol is formed. Withdrawal is achieved by creating an aversion to alcohol. Some people believe that the application of alcohol withdrawal sulfur is more effective. Withdrawal sulfur can reduce the activity of acetaldehyde dehydrogenase, and when the patient uses this drug and then drinks alcohol will cause the accumulation of acetaldehyde in the body to produce nausea, vomiting, flushing, palpitations, anxiety and other symptoms, making it aversion to drinking alcohol. Generally 5 days after 1 abstinence from alcohol can not drink, if a large amount of alcohol will produce acetaldehyde syndrome, taken orally once a day, can be used for 1 to 3 weeks.
(5) Anti-psychotic drug treatment.
For early withdrawal symptoms generally do not need to be treated with antipsychotic drugs, if there are obvious psychiatric symptoms and may affect the patient and the surrounding environment, small doses of antipsychotic drugs can be used, such as small doses of haloperidol, which can be discontinued immediately if the general symptoms disappear. For persistent alcoholic hallucinations and jealous delusions, small doses of antipsychotic drugs may be used continuously. It has been reported that when alcoholic hallucinations are not effective with antipsychotics, switching to benzodiazepines can be effective. For depressive symptoms antidepressants may be given. Diazepam (Valium) 10 mg intramuscularly or intravenously every 2-4 hours can be given for withdrawal symptoms of spastic seizures, and no further medication is needed for prevention after the seizure disappears. In delirium tremens state, efforts are made to quiet the patient and can be treated with room temperature artificial hibernation for 14 days as a course of treatment. Give fluid food without gastric stimulation and multivitamins, especially rich B vitamins, correct water-electrolyte imbalance, give diazepam (Valium) 30-60mg/d for restlessness, fear and spasms, and give small doses of antipsychotics if hallucinations and delusions become chronic, with the minimum dose to achieve the best efficacy for short-term use. Simultaneous treatment of comorbidities. For acute, obvious psychiatric symptoms, domestic often use small doses of haloperidol rapid injection treatment, the course of treatment is usually 1 to 2 weeks is appropriate.
(6) Comprehensive treatment.
Treatment of alcohol dependence is difficult to get satisfactory results only by a single method, often with 2 or more kinds of treatment at the same time, such as the use of alcohol withdrawal, supportive therapy, symptomatic treatment and other comprehensive treatment at the same time, in order to get better results.
2. Rehabilitation treatment
The main goal of rehabilitation treatment is to prevent relapse. Some data show that after alcohol-dependent patients quit drinking, their cravings can last for 2 to 3 years, and more than 50% of alcoholics return to drinking within 1 year after quitting. Therefore, for most patients, rehabilitation treatment includes the following 3 main components: (1) downplaying the patient’s craving for alcohol as the main cause of relapse of alcohol dependence; (2) trying to increase the patient’s motivation to quit drinking and keep it at a high level; and (3) helping the patient readjust to a life pattern in which he or she cannot drink alcohol.
(1) Downplaying the craving for alcohol.
(1) Use alcohol desensitizers: for example, disulfiram (abstinence sulfur), which is often applied starting 24h after the last 1 drink, at an initial dose of 0.25 or 0.5g, taken orally once a day, and can be used for 1 to 3 weeks. Disulfiram (abstinence sulfur) inhibits acetaldehyde dehydrogenase. Patients with this drug then drink alcohol, within a few minutes the body due to the aggregation of acetaldehyde produces nausea, vomiting, flushing, palpitations, anxiety, etc., making it aversion to drinking alcohol. Generally, you cannot drink alcohol about 5 days after taking one dose of disulfiram (abstinence from alcoholic sulfur). If you drink a lot of alcohol, you will have a serious acetaldehyde syndrome, which can be life-threatening and should always be remembered by the patient. Contraindications to taking this drug are coronary artery disease, cardiomyopathy, acute toxic state, acute psychosis, etc. Similar drugs have been reported abroad as calcium citrated calcium. Some domestic people use furazolidone to treat patients with alcohol addiction, the recent effect is good.
② Opiate antagonist naloxone: There are double-blind studies of naloxone treatment for alcohol withdrawal, which have confirmed that it can make alcohol-dependent patients less thirsty for alcohol, and the number of days of drinking is significantly reduced. In 1994, the U.S. FDA approved this drug for the treatment of alcohol dependence.
(3) The data of related studies found that selective 5-HT reuptake inhibitors are more closely related to drinking behavior. The mechanism may reduce the patient’s craving for alcohol, and several studies suggest that this drug can reduce the total amount of alcohol consumption by 15% to 20%. Currently there are five kinds of clinical applications: fluoxetine, fluvoxamine (fluvoxamine, fluvoxamine), paroxetine (paroxetine), sertraline (sertraline) and citalopram (citalopram). Their dosages are generally higher than antidepressant dosages. As reported abroad, fluoxetine commonly used amount is 60mg/d, while clinical observation 40mg/d has no significant effect.
④Gamma aminobutyric acid (GABA) receptor agonist: many existing studies have concluded that the GABA receptor agonist calcium peroxynivalenate is effective in the treatment of alcohol dependence. The commonly used dose is 1.3 g/d. The drug is safe and is now approved for marketing in France, the UK and other European countries.
The dopamine agonist bromocriptine has also been reported to reduce craving and alcohol consumption in alcohol-dependent patients. The commonly used dose of bromocriptine for the treatment of alcohol dependence is 7.5 mg/d.
Thiopride (Tebrile) is also a dopamine agonist. Some people treat alcohol-dependent patients with 300mg/d, which can make alcohol-dependent patients’ total drinking significantly reduce and increase the number of days to quit drinking.
(2) Psychotherapy.
(1) Counseling: Counseling can be done in an individual or group setting. The consequences of drinking, alcohol-related life problems, the possible evolution of the process in the future, and an explanation that only abstinence can lead to significant improvement are explored in the early stages of treatment. During the first few months of discharge, counseling is advocated abroad once a week. Counseling should focus on the patient’s daily life problems in order to help the patient improve the appropriate level of functioning, and intensive psychotherapy is needed for problems that may cause anxiety. At the same time, patients should be helped to establish a life pattern of not drinking alcohol, to develop plans for social and recreational activities that do not involve drinking alcohol, to help patients to cope with alcohol cravings, and to help get through the unfavorable state of possibly drinking again.
②Treating alcohol-dependent patients with Morita therapy: Most alcohol-dependent patients recognize that they must stop drinking but at the same time crave alcohol, which is very similar to the psychological conflict common in neurotic patients. Therefore, it is also applicable to Morita therapy. During the bed rest period of Morita therapy, patients can achieve a spiritual state of “relief from worries”, where they can look back on their lives and face themselves more fully. The basic principle of Morita therapy is to “let nature take its course” and to “frankly acknowledge the desire for alcohol and do what they need to do with that desire”. The work period of Morita therapy serves as a corrective action, allowing patients to experience “going with the flow” and “focusing on action” in practice.
(③) Alcohol withdrawal support activities: Alcohol-dependent patients are allowed to participate in various forms of withdrawal activities, such as therapy-based group therapy, which takes the form of a small group of about 10 alcohol-dependent people once a week for 2 hours/time, with the therapist giving explanations and guidance and the participants discussing freely to further promote motivation and determination to quit. There are also group therapy sessions led by alcoholics, such as those who have experience in sobriety, who pass on their personal experience and experience to the participants to increase the atmosphere of support, friendship and motivation to achieve the goal of continued sobriety.
④Family therapy: When dealing with alcohol abuse problems, it is important to focus not only on the abuser himself or herself, but also to pay more attention to the emotional needs of the whole family and its stability. Thus, some scholars believe that the problem of alcohol dependence is a problem of the whole family, i.e., most families exclude the sufferer from the family members. Therefore, it is important to educate family members to understand that alcohol abuse is a disease that cannot be cured by general treatment alone, and that family and social support is an important part of the process. Families should be taught new coping skills so that the family becomes a therapeutic environment in which the alcohol abuser is not isolated or rejected, but, on the contrary, is understood and has communication with each other. Love and unity in the family will eventually free the alcohol abuser from bondage and distress. In order for the family to learn and improve coping skills, the family is allowed to participate in activities related to counseling and sober living organizations, either alone or together with the abuser, to continuously learn and understand the abuser’s psychological state, to continuously encourage the abuser’s confidence and determination, and to help overcome crises in life, so that the alcohol abuser, like a normal person, can pick up his or her spirit, overcome difficulties, and continue to stop drinking.