Family Practice Grand Rounds Early Diagnosis and Treatment of Alcoholism Antonnette V. Graham, RN, MSW, David Sedlacek, PhD, Kenneth G. Reeb, MD, and Jay S. Thompson, MD Cleveland, Ohio ANTONNETTE V. GRAHAM, RN, MSW This patient is a very attractive, 34-year-old, single (Assistant Professor, Department of Family Med­ woman. She is currently employed as a school icine): Today we are going to discuss what many psychologist and is finishing her dissertation for people believe is the number-one health problem her doctorate in psychology. She lives alone in a in the United States—alcoholism.1 It is often felt middle-class suburb of a large northeastern city. that alcoholism affects the lives of more patients, She is the eldest of four children. Her father is a either because of their own drinking or because retired college administrator, and her mother is of the drinking of a family member, than any other currently employed as an executive secretary. disease. There is no family history of alcoholism. Miss Current prevalency estimates of alcoholism and Carr’s parents and siblings drink socially. On Miss alcohol-related problems indicate that in many pa­ Carr’s initial visit to the Family Practice Center, tients these problems go undetected by physicians her physical examination and laboratory values until they become manifested by severe physical were normal. sequelae. Current thinking among experts is that MRS. GRAHAM: Thank you, Miss Carr, for early intervention leads to better prognosis. No attending our Grand Rounds today. I’d like to longer is it felt that alcoholics must “ bottom out” focus today’s discussion on how alcohol has af­ before help can be effective. These changing stand­ fected your life—both while you were drinking and ards of medical care of patients with alcohol prob­ since you have stopped. Can you start by telling us lems require residency programs to train family about your drinking history? physicians for early detection of alcohol problems. MISS CARR: I had my first drink when I was 21 Residents’ education on alcoholism frequently years old. In fact, it was to celebrate my birthday. concentrates on inpatients with medical manifes­ 1 had never experimented with drinking during my tations of middle- or late-stage alcoholism.2 The teen years. I was the wholesome, cheerleader early diagnosis of alcoholism frequently must be type. Also, I was quite religious and felt drinking made on psychosocial and behavioral indicators was the wrong thing to do. of problems with alcohol, and physicians trained MRS. GRAHAM: What happened with your to attend to the late medical problems can easily first drink when you were 21? miss the early signs of alcoholism. MISS CARR: Well, I didn’t stop with one. I had The patient being presented today is unlike the five screwdrivers and became drunk! I was in col­ stereotypic alcoholic seen in the emergency room. lege and living at home, and I do remember having a hangover the next day. 1 spent that whole day in bed except when I was vomiting. After that, I began to drink regularly and to get drunk quite From the Department of Family Medicine, Case Western frequently. You’d think that with such a beginning Reserve University, Cleveland, Ohio. Requests for reprints I would never have touched alcohol again, but not should be sent to Mrs. Antonnette V. Graham, RN, MSW, Department of Family Medicine, University Hospitals of so. I noticed that I seemed to drink faster than my Cleveland, 2065 Adelbert Road, Cleveland, OH 44106. Continued on page 301 ® 1984 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 19, NO. 3: 297-313, 1984 297 Szioihydrochloride polythiazidc) Capsules For Oral Administration Thjj fixed combination drug is no! indicated lor initial therapy ot hypertension. Hypertension reguires therapy titrated to Hie individual patient. II the Usedcombination represents the dose so determined. Its use may b! more convenient m o a Et management. The trealmenl ot hypertension is not static, but must be re-evaluated as conditions in each patiSnt ALCOHOLISM warrant. ppTchTIOHS AMD USAGE: MINIZIDE (prazosin hydrochloride/polythiazidej is indicated m the treatment ot hypertension (See box CONTRAINDICATIONS: F.ENESE (polythiazidej is contraindicated in patients with anuria and in patients known to be sensitive tothia2,aes .,n nthpf sulfonamide derivatives. WARNINGS: MINIPRESS (prazosin hydrochloride) MlNlPRESS may cause syncope m lh sudden lossol consciousness in most cases Ih s Continued from page 297 iceiievedio be due loan excessive postural hypo ensiveelfecl, although occasionally ihe syncopal episode has Deen preceded Oyaboutm Levere tachycardia with heart rates of 120-160 beats per minute Syncopal episodes have usually occurred within 30 to 90 minutes of the n- Mldose ol the drug occasionally they have been reported m association with rapid dosage increases or the introduction ol another ant - hvoerlensivedrug intothe regimen ot a patient taking high doses of MINIPRESS The incidence ol syncopal episodes is approximately Ann aahents given an initial dose o 2 mg or greater Clinica trials conducted during the investigational phase ol this drug suggesl that syncopal ep sodes can be minimized by lim iting the initial dose ol the drug to 1 mg, by subsequently increasing thedosage slowly and by int o d X g friends. I could never sip a drink. About the time any additional anlihyperlensrve drugs into the patient s regimen w, h caution (see DOSAGE AND ADMINISTRATION) Hypolension ma, ieS S od in palienls given MINIPRESS w hoatealso receiving a bela-blocker such as propranolol. ' 1 moved out of my parents’ home and graduated il syncope occurs, the patient should be placed in the recumbent position and trealed supportively as necessary This adverse effect is seil-l'miting and in most cases does not recur afler the initial period ol therapy or during subsequenl dose titration from college, I got into some real heavy drinking. Palienls should always be started on ihe l-m g capsules ol MlNlPRESS The 2-mg and 5-mg capsules are not indicated lor initial therapy M ore common than loss ol consciousness are the symptoms often associated with lowering ol Ihe blood pressure namely dizziness i . lighineadedness The patient should be cautioned about these possible adverse etfecls and advised what measures lo lake should they Most of my friends were college dropouts or col­ develop. The palien! should also be cautioned to avoid situations where miury could result should syncope occur during the initiation ol lege graduates who had just "dropped out" of the ' RENEsItRENE^E should be used with caution in severe renal disease in patients with renal disease, thiazides may pieciodaleazolemia Cumutativeeftects of the drug may develop in patients with impaired renal function Thiazides should be used with caution in patients with impaired hepatic function or progressive liver disease since minor alterations of mainstream. I decided that 1 wanted to work with fluid and electrolyte balance may precipitate hepatic coma. Sensitivity reactions may occur in patients with a history of allergy or bronchial asthma my hands and became a carpenter’s apprentice. The possibility of exacerbation or activation of systemic lupus erythematosus has been reported Thiazides may be additive or potentiative of the action of other antihypertensive drugs Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs After a few months I realized this life wasn't Periodic determinations of serum electrolytes to detect possible electrolyte imbalance should be performed at appropriate intervals Ail patients receiving thiazide therapy should be observed for clinical signs of fluid or electrolyte imbalance namely hyponatremia hv- for me, and I entered graduate school in another pochloremic alkalosis, and hypokalemia Serum and urine electrolyte determinations are particularly important when the patien* is vomitina excessively or receiving parenteral fluids Medications such as digitalis may also influence serum electrolytes Warning signs irrespective ol town. cause, are: dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps muscular fatioue hvootension oliguria tachycardia, and gastrointestinal disturbances such as nausea and vomiting Hypokalemia may develop with thiazides as with any potent diuretic, especially with brisk diuresis, when severe cirrhosis is oresent or MRS. GRAHAM: What about your drinking during concomitant use of corticosteroids or ACTH interference with adequate oral electrolyte intake will also contribute to hypokalemia. Digitalis therapy may exaqqerate the metabolic ef­ then? fects of hypokalemia, especially with reference to myocardial activity Any chloride deficit is generally mild and usually does not require specific treatment except under extraordinary circumstances (as in he­ MISS CARR: For a while I gave it up and was a patic or renal disease). Dilutional hyponatremia may occur in edematous patients in hot weather, appropriate therapy is water restriction rather than administration of salt, except in rare instances when the hyponatremia is life-threatening In actual salt depletion appropriate re­ placement is the therapy of choice. model student. Then I discovered marijuana. 1 Hyperuricemia may occur or frank gout may be precipitated in certain patients receiving thiazide therapy. insulin requirements in diabetic patients may be either increased, decreased, or unchanged Latent diabetes mellitus may become manifest really liked the high I got with marijuana.