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RF_MH_2_A_SUDHA

clinical psychologist.
.-.soiMitajk Professor
*
Peyshiotry, ."lenta Psychiatry,

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Jobs’s ftsdioal

Over the last two decades, consumption of alcohol has been Increasing

on a global settle. In some third world countries the increase is mor® rapid

titan in others. If the steady rise in the per capita consumption of alcohol
is continued for another generation, these countries will attain or exceed the

present level of consumption in the developed world. It noy also lead to a

higher incidence of alcohol related problems and prove to be a substantial
drain on already scarce economic and social resources. Such alarmlag possibilities
snake it imperative that strategies be developed for the management and prevention
of alcohol dependence. In this context, the different sociocultural status of

those countries become^ significant so far as the choice of methods of treatment
is concerned. Th® vast majority of the Indian population does not approve of

alcohol consumption as an acceptable social behaviour. However, the increase
in alcohol consumption and its acceptability is readily manifest in the

urban, industrialised section of the society, probably due to a shift from the
traditional values of a joint family to the modern values of the nuclear- family

and the resultant lack of aocal support systems. If this change is considered

as a significant one, then the inclusion of family intervention as an adjunct
to the other modes of management becomes important. Wheras previously alcoholics

wore taken to be homeless, jobless, physically ravaged individuals with eagre
psychological resources, it is now clear that the ’end stage’ alcoholic is not

representative of the patient population that abuses alcohol. A significant
proportion of the slooholic population continues to function is witMn intact

and stable family ayeterea.
The family has only recently been viewed as a possible focus of

intervention by professionals. Clinical interest has focussed on disturbed

comsunication and structural patterns within the family, several theories of
family functioning, pathology and therapeutic change have been dsvelcpod, and

certain core concepts have gained widespread acceptance# drawing from tec
concepts of the general systems theory, the family u;ay be viewed at a primary

Organizational unit
*

Individuals thus represent the component parts of this unit.

The emphasis is on the patterns of interrelationships between the component parts,

hence the focus on interactional behaviour, structural patterning within the

family an^the balance or stability of the system as a whole. Any single piece

of behaviour in the family has to be understood first in terms of how all th©
individuals are contributing to make the behaviour possible, and secondly, bow the
behaviour is affecting all the individuals in the family. Pathology becomes

redefined as a structural or functional imbalance in the family, rather than as
difficulties being experienced by any single individual in the family.
Families tend to establish a sense of stability and Lave mechanisms

io resist any change. This stability does not necessarily imply a healthy state
of affairs. The family right for example, include as part of this stabilisation,

a form of psychopathology such as chronic alcohol abuse. An extension of this
concept implies that on individual might, through his or her symptom expression,

be -stabilizing the level of functioning of other family members. It may thus be
more prefitable to view tbe whole family, rather than the individual alone, as the
basic unit of pathology. The behaviour- of each spouse may be rigidly controlled

by the other. As a result, any effort by one io alter the typical role behaviour
threatens the family equilibrium and provokes renewed efforts by the others to
maintain the status quo.

Within on alcoholic
s
*

family of origin, there is frequently a lack of

eonntruotilre pressure for change, either because the alcoholism is accepted or

because the alcoholic is viewed as helpless and discounted as a person. These
influences fi-on the family of origin are carried over into the alcoholic’s current

nuclear family, and are especially evident in the husband - wife interation. Often
the alcoholic marriage can be viewed a© a strug gle for control. The nonalcoholic

spouse may appear overly responsible and dominant, and osrurse an ’overfanciioaal’

role in contract to the alcoholic spouse who underfunctionn. The alcoholic's
drinking txy be viewed as neutralizing the overfunctioner’s apparent control in

the relationship. The overfunctioner may further perpetuate the drinking by s
exhibiting anxiety, criticizing and attempting to forbid the drinking, thereby

initiating another round of ’counter-control
*

drinking behaviour by the alcoholic

souse. The overfunctioning apouse may alno perpetuate the drinking cycle by
indirectly na. reinforcing the drinking. The spouse r.rjy support the drinking a

behaviour by hiding it from public gaze er at times by evta bringing alcohol for
the .aartner. Thus each npov.se contributes to the drinking behaviour ur.d eaco has

some needs satisfied by it. However, both spouses also needs that arc; set met by
the drinking behaviour and hence the relationship remains ocnfli.otusl
*

The cfeered

fears of separation oftan keep the couple from risking honost, angry confrontations
regarding their conflicting views and th^y continue in a highly competitive

relationship. The alcoholic repeatedly tries to control the aituaticn and yet
avoids responsibility through subtle, passive-dependent techniques. The epoas®
tries for control by being forceful, active, blunt and dosdneering. Neither

achieves deninance, bu
* the fight continues indefinitely.
The male alcoholic gives up his role as a father-, ether roles are

also rapidly abandoned and takev, over by other family members. Bie rife may

encourage an older son to take over the reaponsibUitics abdicated by the father,
thuo placing the sou in a position of overt competition with tha father, is the
nonalcoholic members take over the full management of the family functioning, the

alcoholic is relegated to child status, which perpetuates his drinking. In the

immediate situation of the alcoholic family, the children are also severely
victimised. They have growth and development problems, school and learning problems
develop emotional problems and may exhibit significant behaviour dysfunction.

Further, the Mildren are subject to groso neglect and abuse. The raadly of

acohollo »„,iclw M„

interpersonal contacts.

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*

Treated alcoholic patients frequently relapse into fora®? linking
rotara u ttel» ia.rai.ting
,;Mly Jiveoi

sobriety brings with it the desired goals of behavioural stabilization,
it often carries with it seemingly undesirable aspects such as lack of

familiarity with new patterns of the marital relationship ana now deaanjds
for in’&a-jcy. Such a model could explain the appearance of significant
depression in a nonalcoholic spouse when the alcoholic stops drinking
*
In fact, many families seek help, not-because of the alcohol problem,

but because of severe problems in family communication, parent-child
conflict5 sexual difficulties and the like. linen the drinking is under

control and the underlying marital and family problems surface, the
alcoholic may resume drinking to cover then up, or the couple may

become too threatened and terminate therapy.
there io continuing debate over the structural component

of the therapeutic situation ir. alcoholism, for example, who should

th© therapy ba addressed, co. However, family therapy techniques have
been used with increasing enthusiasm. In recognition of this trend,
the second special report to the U.S Congress on alcohol and health

(1974} called family therapy the most notable current advance in the
area of psychotherapy of alcoholism
*
Cnee attention is focussed on
the families of alcoholics, it becomes obvious that th? relationship
between the alcoholic and his' family is not a asensiy one-way relationship.
The family also affects the alcoholic and his illness. The family

can either help or interfere with the treatmsat process
*

Communication,

coth verbal and nonverbal, is viewed as reflecting the basic structural
and interactional pattern governing the family’s behaviour, sad HwsksKO

therefore frequently becomes the primary focus of attention in therapy.

The marital partners go through an initial resistance in which each attempts
to pin the rap on the ether ae the/trouble maker in the marriage,
followed by a period of insight into their own roles in the maintenance

of the naritai ’homecctosis'. for this reason it increases the likelihood

that the drinking problem io acknowledged ao a problem and also stimulates the
motivation for change. The goal of communication centered therapy is to correct

discrepancies in communication styles. This is achieved by having messages
clearly Hfeited, earifying meanings and assumptions and permitting feedback.
The therapist acts as or. objective governor of communication who teaches
people to speak dearly and directly in a structured, protected situation.
When working with couples where alcohol is part of the relational

system, it is useful to identify one or more functions that alcohol is serving

fcr the couple and to make this the focus of intervention. Focussing on the
marital interaction can allay some of th-.? guilt and anxiety of the alcoholic
place responsibility for the situation on both spouses. Thus tlio emphasis is

on an alcohol related problem rather than on labelling one family member as
an alcoholic. Joint admission of the spouses to the hospital not only gives
the staff an opportunity to observe the couple’s interaction, provide feed­

back to the couple and integrate the spouse into the therapeutic milieu,
but also facilitates the couple in learning new ways of adaptive sober

behaviour.
Multiple family therapy is the treatment of several families

simultaneously through the vehicle of group meetings led by a therapist.
It uses the group setting and group processes to assist the couples in

examining tli&ir marital interactions and the relationship between those
patterns of interactions and drinking behaviour. It is unique in contempoi’ary
society in that families expose themselves to one another and try to exercise
significant effects on one another’s way of life. In the process the tech­

nique reduces premature dropouts, acts as a preventive mental health measure

for other family members, builds an extended good family subculture and

creates and supports structural family changes that facilitate abstinence.
In the first few sober days of an alcoholic he is so ne.dy that his resistance
to tho group is low and he has the best acceptability of the •roup
*
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Treatment: Emerging Trends in Research and Practice
During the past decade, several Issues sur­
rounding the treatment of alcoholism have
been subject to controversy. Does the unitary
disease concept permit reliable diagnosis for
the purposes of early detection and treatment
planning? Is treatment effective and, if so,
can the costs of treatment be contained? Are
there distinct subgroups of alcoholic persons?
Can treatment efficacy be Improved by
matching individual patients to specific types
of treatment? Should abstinence be the sin­
gular goal of treatment or can some problem
drinkers engage in nonabuslve drinking? If
some can, how can these Individuals be iden­
tified? The issues raised by these questions
imply much about the theoretical and prac­
tical challenges facing the treatment field.
This chapter will focus on the state of the
art of alcoholism treatment, giving special
attention to developments not covered In the
Fourth Special Report (USDHHS 1981). These
developments Include innovations in diagnosis,
improved procedures for screening and early
intervention, new findings on the costs and
benefits of treatment, a continuing debate on
the use and viability of controlled drinking
therapies, and emerging models of treatment
efficacy. An encouraging development In re­
cent years has been the enhanced investment
in research and clinical training In the alcoliollsm field, and the concomitant emergence
of a multidisciplinary research community
actively Involved in the problems of treating
alcoholism. As the quality and sophistication
of clinical research Improve, it is likely that
many of the unanswered questions will be
solved.

Recent Advances in Diagnosis
and Nomenclature
Diagnosis, the process of identifying and
labeling specific disease conditions, uses pre­
cise attributes, or diagnostic criteria, to

classify a sick person as having a disease. The
importance of diagnostic criteria derives from
their usefulness') in making clinical-decisions;
estimating disease prevalence, understanding
etiology, and planning treatment. While the
diagnosis of alcoholism may seem straight­
forward, to the concerned layperson, It Is. in
fact a complex process.
Limitations in current diagnostic procedures
were recently reviewed by McIntosh (1982),
who compared data collected in 31 studies of
the prevalence of alcohol-related problems in
general hospital populations. Variations in the
use of diagnostic criteria, as well as lack of
conceptual precision in differentiating alcohol
dependence from related disabilities, have led
to widely differing prevalence estimates of
the number of alcoholic patients, in spite of
the fact that these patients were in hospitals,
most individuals with drinking problems had
neither been diagnosed as such nor received
appropriate treatment for their alcohol
problems.
The traditional unitary disease concept of
alcoholism has been challenged by the obser­
vation that there may be. multiple patterns of
dysfunctional alcohol, use, which result . in
multiple kinds of disability. A corollary of the
unitary disease concept, has been the assump­
tion that alcoholics. could be clearly differ­
entiated from nonalcoholics on. the basis of
their distinctive disease characteristics.
Known as the binary classification rule, this
assumption has led to the search for universal
and singular rcrlterlalappUcable to all alco­
holics. This ,dl'chdtdmouk approach'’;, has not
been particularly helpful to programs inter­
ested in early intervention (namely, secondary
prevention), nor has it been useful In differ­
entiating prognoses within patient, samples in
ways that could clarify Important questions
about treatment efficacy. An alternative ap­
proach (Marlatt 1981) characterizes alcohol
dependence 'along a continuum of severity,
with no clear demarcation between 1 the be­
ginning of alcoholism and the end of social

C. drinking. An advantage of this approach Is that
early detection may be improved when levels
of risk have been established.
An important development in the area of
diagnosis has been the publication in ,1980 of
the third edition of the Diagnostic and Sta­
tistical Manual of Mental Disorders (American
Psychiatric Association 1980), better known as
DSM-IH. As a major revision of the manner in
which various disorders, including .alcoholism,
are diagnosed and classified, . DSM-lil intro­
duced several Innovations designed to address
problems in earlier ciasslflcatory. systems
(Spitzer et al. 1980). in-contrast to previous
editions of DSM, alcoholism is now included
within the separate category of substance use
disorders rather than as a subcategory of
personality disorder. Reflecting a trend
toward Increased semantic precision, the term
''alcohol dependence" is used In preference to
the more generic "alcoholism." In addition, a
separate category of "alcohol abuse" is added
to permit greater differentiation. As deline­
ated In table i, alcohol dependence Is dif­
ferentiated from alcohol abuse by the pres­
ence of tolerance or withdrawal symptoms.
Both diagnoses Include a pattern of patho­
logical use or Impairment In social or occupa­
tional functioning due to alcohol. Modeled
after diagnostic procedures Initially developed
for research purpos » (Pelghner et al. 1.972),
these criteria provide a systematic, stand­
ardized approach to diagnostic decision making.
DSM-lil permits evaluation of the IndivlduaPs condition In terms of five Independent
dimensions or axes. Axis I describes the major
clinical syndromes, including substance use
disorders, while Axis II is reserved for con­
comitant personality disorders. Axis HI
classifies physical disorders and conditions, a
number of which can be coded as alcoholinduced, including alcohol Intoxication, alcohol
withdrawal, alcohol withdrawal delirium, al­
cohol hallucinosis, alcohol amnestic disorder,
and dementia associated with alcoholism. Axis
IV draws attention to the severity of psycho­
social stress (e.g., occupational, interpersonal,
physical) that may modify the course of the
current disorder. Finally, Axis V permits the.'1,
clinician to Indicate the patient's highest level .
of adaptive functioning during the past year in
terms of social relations, occupational func­
tioning, and use of leisure time.
Preliminary evaluations of DSM-lil suggest
that It provides reliable and valid Identifi­
cation of alcoholics in clinical settings, but
that It may be less useful In detecting alco­
holics who are not Institutionalized (Mulford

and Fitzgerald 198It Helzer et al. 1981; Hesselbrock et al. 1982). Thus, while the DSM-lil
alcohol-related diagnoses contain many in­
novative features, the usefulness of this ap­
proach for. early identification, epidemio­
logical surveys, and treatment planning re­
mains to be evaluated.
The recent development and successful field
testing of two standardized Interview sched­
ules, the Schedule of Affective Disorders
(Weissman et al. 1980) and the Diagnostic in­
terview Schedule (Helzer et aL 1981), rep­
resent . a major advance in clinical diagnosis
and psychiatric epidemiology...Both schedules
provide objective, standardized procedures for
diagnosing. alcoholism and other clinical syn­
dromes using DSMrlH criteria, v As these in­
struments are usecT with greater frequency to
study clinical and population samples, they
promise to advance . basic knowledge about
alcoholism and Its relationships to psychiatric
syndromes and personality disorders. Data
from household surveys using the Diagnostic
Interview Schedule in three National Institute
of Mental Health Epidemiology Catchment
Areas suggest that,, at some time during their
Ilves, one In seven, adults 18 years of age or
older met criteria for alcohol abuse or alcohol
dependence.
A related development In the area of alco’•olism diagnosis is the international program
on diagnosis and classification sponsored
Jointly by the U.S. Alcohol, Drug Abuse, and
Mental Health Administration (ADAMHA) and
the World Health Organization (WHO 1982).
The purpose of this project Is to recommend
improvements in sections of the International
Classification of Diseases (ICD) dealing with
alcoholism, drug abuse, and mental health. The
first phase was devoted to a systematic exam­
ination of concepts and nomenclature per­
taining to alcohol and drug abuse (Edwards et
al. 1981); Of particular interest to the alco­
holism treatment field Is the emerging set of
concepts, definitions, and criteria that may
well provide the basis for the next revision of
ICD. Central to the WHO approach to alco­
holism is the concept of a dependence syn- -7
drome that ..is distinguished from alcohol- —
related disabilities (Edwards et &L 1976, 1981). T
As outlined, in table >2, the dependence syndrome . Is an Interrelated cluster of cognitive, r
behavioral, . and physiological symptoms. £
Alcohol-related, disabilities, on the other hand, .
consist of those physical, psychological, and
Social dysfunctions that follow directly or
Indirectly from excessive drinking and
dependence.

u alcohol dependence syndrome
Table 2 Constituent elemehts of th.

Table 1. DSM in criteria for alcohol abuse and alcohol dependence

' interpretatlon/example,

Diagnostic criteria for alcohol abuse

Diagnostic criteria for alcohol dependence

A, Pattern of pathological alcohol uses need
for daily use of alcohol for adequate
functioning, inability to cut down or stop
drinking, repeated efforts to control or
reduce excess drinking by "going on the
wagon" (periods of temporary abstinence)
or restricting drinking to certain times of
the day, binges (remaining intoxicated
throughout the day for at least 2 days),
occasional consumption of a fifth of spirits
(or its equivalent in wine or beer), amnesic
periods for events occurring while intox­
icated (blackouts), continuation of drinking
despite a serious physical disorder that the
individual knows is exacerbated by alcohol
use, drinking of nonbeverage alcohol.

A. Pattern of pathological alcohol uses need
for daily • use of alcohol for adequate
functioning, inability to cut down or stop
drinking, repeated efforts to control or
reduce excess drinking by "going on the
wagon" (periods of temporary abstinence)
or restricting drinking to certain times of,
the day, binges (remaining intoxicated
throughout the day for at-least 2 days),
occasional consumption of a fifth of spirits
(or its equivalent In wine or beer), amnesic
periods for . events occurring while Intox­
icated (blackouts), continuation of. drinking
despite a serious physical disorder that the
Individual knows is exacerbated by alcohol
use, drinking of nonbeverage alcohol.

Narrowing of th. drinking repertoire

B. Impairment In social or occupational
functioning due to alcohol use! violence
while intoxicated, absence from work, loss
of job, legal difficulties (e.g., arrest for
intoxicated behavloi
*,
traffic accidents
while intoxicated), arguments or diffi­
culties with family or friends because of
excessive alcohol t-e.

B. Impairment In social or occupational
functioning due to alcohol use: violence
while Intoxicated, absence from work, loss
of job, legal difficulties (e.g., arrest for
intoxicated behavior, traffic accidents
while intoxicated), arguments or diffi­
culties with family or friends because of
excessive alcohol use.

Compulsion to drink

C. Duration of disturbance of at least 1 month.

C. Tolerance: need for markedly increased
amounts of alcohol to achieve the desired
effect, or markedly diminished effect with
regular use of the same amount.

Either tolerance or withdrawal:

D. Withdrawal: development of alcohol with­
drawal (e.g., morning "shakes" and malaise
relieved by drinking) after cessation of dr
reduction in drinking.

Source: American Psychiatric Association 1980.

phasizlng that both dependence and alcoholrelated disabilities exist In degrees rather than
in an ail-or-none state.
In the brief period since ft was first intro­
duced, the dependence syndrome construct has
received considerable attention from re­
searchers and clinicians. A number of in­
struments have been developed to assess its
usefulness (Stockwell et al. 1979| Skinner and

According to the WHO dependence model, a
complete description of an individual's alco­
hol-related pathology must Include statements
concerning the' nature and severity of de­
pendence, the kinds and degrees of disability,
and the personal and environmental factors
that Influence the drinking problem. The WHO
model departs significantly from DSM-I1I and
the older binary classification schemes by em-

Elements

continuous dally consumption.

Salience of drlnk^eeklng behavior
Increased tolerance to alcohol .

Repeated withdrawal symptom,

^a™f?effit £rWs ^,‘l££e.

Relief drinking .
weuTrmp^X^l'over ’qwn-

tlty and frequency of Intake.
Readdiction liability

The syndrome tend, to be rapidly
when drinking I, recommenced after a period
of abstinence.

Source! Adapted from Edwards et ai. 1976, 1981.

Allen 1982j Hesselbrock et al. 1983). Research
in both experimental and clinical settings
suggests that the severity of dependence can
correlate positively with attendance at a
treatment clinic(Skinner and Alien 1982),
cravings for alcohol after a. "priming
*
1 drink
(Kaplan et al. 1983), and failure to control
drinking following relapse (Orford et al. 1976)
Polich et al. ,1981). While further research is
needed, the dependence syndrome construct
shows considerable promise for early detec­
tion, diagnosis, and treatment planning.
Differential Assessment
Both DSM-HI and , the, WHO dependence
model represent a general movement toward
differential .assessment as evidenced by the
use of multiple criteria to provide a compre­
hensive evaluation for treatment planning.
Ideally, specificity of diagnosis should lead to

specificity of treatment, an Important goal in
the delivery of treatment services for three
essential reasons: (1) economy of cost, (2)
avoidance of inappropriate or ineffective
treatment,. and (3) increased efficacy. Sur­
prisingly, outside the area of personality as­
sessment, little Interest has existed until re­
cently in differential assessment of the alco­
holic person. This.is due in part to assumptions
about the unitary nature of alcoholism, and in
part to the limited ,methods available to eval­
uate
alcoholics.
Recent
advances in evaluation methodology
(Meyer, et ai. 1981) have stimulated research
in this area,, and a number of assessment pro­
cedures Have been, developed.; In addition to
those already discussed, several investigators
(Skinner and Allen. 1982) have demonstrated
the usefulness of assessing drinking patterns
and alcohol-related problems In an effort to
identify individual differences related to

103
102

treatment outcome. Other instruments have
been developed rec- itly to provide differ­
ential assessment rf tages of alcoholism
(Mulford 1980), client liabilities .associated
with poor treatment response (Costello and
BaiUargeon 1981), severity of addictionrelated problems (McLellan et al. 1980), and
stability of the male alcoholic's marital sit­
uation (O'Farrell et al. 1981). With the bur­
geoning application of computer technology to
individual testing and statistical data analyses,
the benefits of differential assessment may
well become routine in clinical settings.

Screening and Early Detection
of Alcoholism
Consonant with recent conceptual devel­
opments in the diagnosis of alcoholism, there
has been increasing interest in the develop­
ment of a simple and accurate screening pro­
cedure that could facilitate early identifi­
cation of alcohol dependence. Clearly, early
casefinding can improve the effectiveness of
treatment and reduce its costs. Research on
early identification has progressed on two
relatively independent planes: (1) the search
for biochemical markers for alcoholism and (2)
the elucidation of psychosocial Indicators.
Biochemical Markers

The accumulation of research findings, some
of which have already been noted, in previous
chapters of this report, suggests that several
laboratory tests may be useful in the early
detection of alcohol abuse. Serum gamma­
glutamyl transpeptidase (GGTP) has been
suggested as an indicator of heavy alcohol
consumption among problem drinkers (Reyes
and Miller 1980). Although its usefulness may
be affected by concurrent liver pathology,
drug use, and individual differences among
heavy drinkers (Garvin et al. 1981), its dis­
criminative ability is enhanced considerably
when Interpreted In conjunction with mean
corpuscular volume (MCV) and other tests
(Mayfield and Johnston 1980; Chick et al.
1981). That routine blood chemistries may be a
useful adjunct for detecting alcoholism is
suggested by the results of several studies
(Ryback et al. 1980, 1982) that have found
that the profiles of 25 biochemical tests dif­
ferentiated between known alcoholics and
nonalcoholics with a high degree of accuracy.

I no

Psychosocial, Clinical, and
k ombined Assessments
Because some psychosocial symptoms (e.g.,
escape drinking, concern about a drinking
problem, alcohol-related accidents) may ap­
pear relatively early in the alcoholic's drinking
career, their, assessment by means of inter­
views or self-administered questionnaires has
received increasing attention by researchers
Interested in screening and early diagnosis
(Skinner et al. 1981).
Clearly, the most Investigated self-admin­
istered diagnostic instrument continues to be
the Michigan Alcoholism Screening Test
(MAST). Consisting of 25 true/false state­
ments describing the typical medical, social,
and behavioral problems associated with ex­
cessive drinking, the MAST has demonstrated
a considerable degree of validity In distin­
guishing between known groups of male alco­
holics and male nonalcoholics (Brady et al.
1982). Concurrent with validation of the MAST
has been the development of a variety of
similar screening Instruments (Brown and
Lyons 1981; Skinner et al. 1981). These tests
are rapid, Inexpensive, and relatively accurate
when used under proper conditions. Their
simplicity, or gender specificity, however,
may limit their usefulness for general popu­
lation screening, particularly as the. obvious
Intent of the questions leaves them vulnerable
to deliberate falsification or unconscious
d-nlal.
Recognizing that psychosocial tests have
limitations when used in isolation, investi­
gators have begun to use clinical, laboratory,
and psychosocial tests In combination. The
results of one study (Skinner et al. 1980) un­
derscore the advantages of this approach. Us­
ing the Munich. Alcoholism Test, a new In­
strument that .combines clinical signs and
symptoms (as identified by the physician) with
self-report Information provided by the pa­
tient, it was found that the two types of In­
dicators occurred with relative independence
of each other. Psychosocial problems predom­
inated In the younger patients, while clinical
signs and symptoms were more frequent in the
older drinkers.

From Screening to Early Intervention
Developments'In several countries indicate
that concerted efforts are now underway to
link new screening technologies to low-cost
early Intervention strategies. Building on
previous research (Edwards et al. 1977), which

suggested that one session of advice can be as
effective as conventional treatment for some
alcoholics, a pilot program is currently being
evaluated In Scotland to determine the ef­
fectiveness of a brief Intervention with prob­
lem drinkers identified In a general hospital
setting (Chick et al. 1982). Preliminary results
of a 1-year followup indicate that a single
35-mlnute counseling session may reduce
drinking and its consequences in a significant
proportion of newly Identified problemdrinkers.
In Sweden, an early Intervention program
was conducted with middle-aged heavy
drinkers identified by means of elevated GGTP
values (Krlstenson 1982). Individuals randomly
assigned to a control group received advice to
limit their alcohol consumption. Those as­
signed to an intervention group were repeat­
edly encouraged to drink less and, In addition,
received feedback about their GGTP levels.
Compared with the controls, the Intervention
group showed significant reductions In ab­
senteeism, hospitalizations, and mortality up
to 6 years after the Initial screening.
In France, screening tor problem drinking
and alcohol dependence is conducted routinely
in Industry, health care settings, and the
courts. Individuals Identified by means of a
simple clinical exam (the Le Go grid method)
and biochemical tests (GGTP and MCV) are
referred to a nationwide system of more than
130 early intervention clinics. While the ef­
fectiveness of these clinics has not been
studied systematically, the program demon­
strates that, from a public health perspective
(Babor et aL 1983), early Intervention In a
large population Is now feasible.

Job-Based Interventions

emphasis away from the sole identification of
alcohol problems to Include any employee
problem that adversely affects performance
(Roman 1981). In the more recently developed
employee assistance programs, the role of
supervisor as dlagnostldan has been deempha­
sized in favor of the more traditional roles of
supervising performance and focusing on un­
acceptable changes In performance as the
basis for intervention and referral.
One recent itudy investigated how the
threat of disciplinary action affects treatment
outcome (Freedberg and Johnston 1980). Men
who chose to'enter treatment as an alterna­
tive to disciplinary action were compared with
others who sought treatment voluntarily. Both
groups were simitar, with respect to lob func­
tioning and drinking behavior after 1 year, a
findinc that denotes the disciplinary process as
a useful ,way >tO engage employees in treat­
ment. Moberg et aL (1982) report followup
data on several hundred inpatients from an
abstinence-oriented industrial program. Fortysix percent were abstinent 3 months after
treatment, while 37 percent were abstinent
after 9 months. About 20 percent were
drinking moderately at each followup, but
those listed as moderate drinkers at 3 months
had a high relapse rate 9 months after treat­
ment. Although social support and employer
Involvement had a positive Influence on out­
come, type of referral (voluntary vs. coercive)
made little difference.
Despite increasing Interest in the evaluation
of occupational programs, the relative lack of
studies in this area, together with limited ac­
cess to the worksite, have made It difficult to
assess the overall contribution of these pro­
grams to improved Job performance and re­
duced health care costs.

The process by which problem-drinking em­
ployees within a work organization are Iden­
tified and engaged in treatment has been the
subject of much discussion (Googins and Kurtz
1980; Roman 1982). Initially, It was advocated
that supervisors and managers be trained to
Identify impaired Job performance, and then to
confront the employee to determine the nec­
essary corrective action. Supervisors have
been found to be Inconsistent in confronting
their problem-drinking employees (Kurtz et al.
1980), depending on their own attitudes about
alcohol use and abuse and their perceptions of
the union’s support for the program (Beyer et
al. 1980). With the Impressive expansion of
, .jb-based employee assistance programs dur­
ing the past decade, there has been a shift in

Alcoholism Treatment- Program.
and Therapeutic Approaches
The treatment system that emerged fol­
lowing the Second World
Is varied, com­
plex, end still In the process ot development.
Many of Its programmatic components (e.g.,
detoxification (facilities, Inpatient hospital and
residential .. programs, halfway houses, .nd
outpatient clinics), and the therapeutic approache. employed In these components, have
only recently begun to receive systematic re­
search attention. What Is the most appropriate
setting for treatment? What are the mori ef­
ficacious therapeutic approaches? What Is the
10>

optimal reimbursement policy for medicare,
medicaid, and private insurance carriers?

settings. Moreover, while the proponents of
social setting detoxification contend that It
will facilitate referrals to long-term treat­
ment, insufficient evidence exists to conclude
that this type of referral will occur more ef­
The management of acute alcohol intoxi­
ficiently In either social or medical settings.
cation and the concomitant alcohol withdrawal
What Is clear from the experience of non­
syndrome Is commonly referred to as detoxi­
hospital detoxification programs Is that medi­
fication. In the late 1960s, specialized detox­
cally oriented inpatient detoxification may not
ification facilities were developed to address
be necessary for the majority of referrals who
the needs of the public inebriate! these fa­
are not severely dependent and who are
cilities expanded rapidly following widespread
otherwise In good health (Dlesenhaus 1982).
adoption by the States of the 1974 Uniform
With the increasing availability of ambulatory
Alcoholism and Intoxication Treatment Act
and inpatient social setting detoxification,
decriminalizing public intoxication. At first
careful study of the nature and role of detox­
these facilities were closely associated with
ification In the rehabilitation process would
hospital emergency services, but in recent
seem warranted. The long-range Implications
years several alternatives to hospital-based
of this trend need to be considered.
detoxification have emerged. A recent survey
The high rate of relapse among detoxified
of State Alcoholism Authorities (Den Hartog
patients Is another major concern to service
1982) indicated a threefold increase In the
providers. Although it may be unrealistic to
number of States operating or purchasing nonexpect an Initial care component to accom­
hospltal-based detoxification since 1975. The
plish much more than detoxification end re­
most controversial of these alternatives has
ferral, at present a small proportion of the
been "social setting" detoxification, In which
public inebriate population utilizes a dispro­
the use of drugs such as diazepam and chlor­
portionate share of detoxification resources.
diazepoxide Is avoided in the management of
Further, these patients often refuse recom­
withdrawal in favor of a supportive social
mended referrals to intermediate care facil­
climate designed to engage the patient in
ities. One study of a predominantly skid row
further treatment.
population (Fagan and Mauss 1978) found that
Because
the
'ifferent
detoxification
'ewer than one-third •’.ccepted their recom­
methods have not b
*en assessed directly In
mended treatment referral after detoxifica­
controlled comparisons, little Is known about
tion. Another study (Richman and Smart 1981)
the relative merits of various approaches In
found that the probability of further referral
relieving the distress associated with alcohol
was lowest in those patients having a history
* withdrawal, preventing the risks of medical
of multiple detoxlficatlons. Two possible so­
complications, and facilitating the process of
lutions to the problem of "resource absorption"
referral to long-term treatment. The need for
by detoxification repeaters have been sug­
hospltai-based, medical detoxification, as well
gested. The first is the greater availability of
as the referral to social setting facilities, de­
comprehensive services to the skid row popu­
pends on the patient's physical condition, nu­
lation! the second is the use of legal coercion
tritional status, severity of alcohol depend­
to motivate the public inebriate to enter and
ence, And overall medical evaluation.
remain in treatment (Fagan and Mauss 1978).
The growth of social setting detoxification
has resulted from Its lower cost, the changing
Benefits of Treatment
attitudes about the use of sedatives and
tranquilizers In withdrawal management, and
The rapid growth of insurance coverage for
evidence indicating that a significant number
alcoholism treatment has been predicated In
of patients do not experience serious ■ medical
part on the assumption that su^h treatment is
complications during withdrawal (Dlesenhaus
cost-beneficial, Le., the I mg--erm costs to
1982). A recent review of the published lit­
both the individual and society will be re­
erature in the United States, Canada, and
duced. Alcoholics and their families have been
Europe (Den Hartog 1982) concluded that de­
found to use a disproportionate amount of In­
toxification could occur humanely, safely, and
patient and outpatient medical serr!“’C for a
efficiently In nonhospital settings. These re­
wide variety of physical problems related to
ports need to be substantiated by systematic
excessive drinking (Roghmann et al. J98lj
re-earch, since it Is not clear what proportion
Putnam 1982a). Reflecting an Increased con­
of alcoholics require detoxification in hospital
cern with the implications of treatment re-

Detoxification

106

imbursement policy, a number of new studies
have used the Improved methods of cost­
effectiveness and cost-benefit analysis to
show that cost savings can be accrued over a
period of time (Swint and Melson 1977). The
first major review of research conducted
during the 1970s (Jones and Vlschl 1979) found
surprising consistency across 12 studies. De­
spite some methodological problems, these
studies indicated significant reductions In
medical care use and expenditures related to
various kinds of alcoholism treatment,
amounting to a 40-percent median reduction In
sick days and accident benefits. Additional
studies since that time have confirmed this
conclusion (Saxe et aL 1983).
Substantiating these findings Is a recently
conducted study of State employees of Cali­
fornia in which 90 families with an alcoholic
member, all enrolled In Blue Cross/Blue
Shield, were followed for a period of 3 years.
Results Indicated that the total medical care
costs per family member decreased sub­
stantially over time once the alcoholic mem­
ber entered treatment (Holder and Hailan
1981).
These studies have been conducted predom­
inantly within health maintenance organiza­
tions (HMDs), primarily because alcoholics are
relatively easy to track within these compre­
hensive health programs. A major study of
alcoholism treatment In HMOs recently com­
pleted by the Group Health Association of
America (Plotnick et al. 1982) compared the
utilization of four HMD outpatient alcoholic
treatment programs by alcoholic persons from
2 years before entering treatment to 48
months after treatment. The study revealed
significant reductions in general health care
use for the alcoholic persons and their family
members. In another HMO study (Forsythe et
aL 1982), treated alcoholics were compared
with nonalcoholics over a 4-year period. Al­
though the cost differential between the two
groups was substantial during the entire study
periods, there was a significant decline in al­
coholics' demand for services following referral to treatment.
Focusing on the illnesses that may preclpitate alcoholics' referral to treatment, Put­
nam (1982a) found that alcoholics manifested
a high number of physical and emotional ill­
nesses. Problems most likely to be associated
with the alcoholics' hospitalizations entailed
psychosocial difficulties such as anxiety, de­
pression, and marital discord, as well as ac­
cidents, drug overdoses, and violence. In many
cases, the alcoholics were found to be seeking

I

'

'

Inappropriate care and receiving Inappropriate
treatment, since the alcoholism underlying
their illness was often not properly diagnosed.
In a related study of the same HMO (Putnam
1982b), alcoholics who received outpatient
alcoholism treatment were compared with
alcoholics who were Identified but refused to
accept treatment. An examination of the
utilization rates for medical care services
before and after referral to treatment re­
vealed that both groups showed a higher level
of service use in’ the 4-month period prior to
referral. Those who accepted alcoholism
treatment, however, Showed a progressive
decrease in use of services during the subse­
quent period, while those who refused treat­
ment Increased their demand for services ap­
proximately 15 months after the attempted
referral. This increase Is related to a high In­
cidence of problems associated with accidents,
drug overdoses, and violence, and highlights
the importance of appropriate diagnosis and
treatment to reduce both the human and the
social costs of alcoholism.
Finally, a significant non-HMO-based study
(Holder and Hailan 1981) followed the families
of 90 State employees In California for a
period of 5 years. Each family had an alcoholic
member and all were enrolled In Blue Cross/
Blue Shield. The study Indicated that total
n odical care costs pet family member de­
creased substantially over time once the al­
coholic family member entered treatment. At
the end of the study, inpatient costs per per­
son per month of both the comparison families
(N=83) and the alcoholic, families (N^90) were
similar, and outpatient costs of the compari­
son families were actually higher.
Although many of the studies of alcoholics'
use of health services are limited In scope,
methodology, and populations Investigated, the
evidence suggests that!,(l) alcoholics and their
families Initially use more health care services
than nonalcoholicsi (2) this elevated demand
can be reduced substantially by treatment for
alcoholism! and (3) the benefits of alcoholism
treatment deafly outweigh its costs.
Treatment Settings

Studies comparing the effectiveness of in­
patient programs with outpatient and day
hospital treatment are important because of
the potential for improved cost-effectiveness
and the appeal these approaches may have for
alcoholics who reject inpatient or residential
care, in one study (Longabaugh et aL iri press),
patients participating in a day hospital pro107

gra'm (while returning home at night) were
given the same behavioral treatment program
that hospitalized inpatients were receiving. At
6-month followup, both groups were compa­
rable on measures of drinking behavior, need
for rehospitalizations, and social and occupa­
tional functioning. The partial hospitalization
group was superior on measures of psycho­
logical well-being. Given the lesser cost of
partial hospitalization, the authors conclude
that this form of ’ treatment is more costeffective. In another study, comparable find­
ings are reported after 1-year followup of 100
patients who were randomly assigned either to
a day clinic or (o an inpatient facility offering
a similar treatment program /McLachlan and
Stein 1982). These results support the con­
clusion that the two types of treatment set­
ting may be equally effective.
Studies comparing the results of inpatient
and outpatient programs have generally not
shown significant differences in the effects of
treatment setting (see review by Cole et al.
1981). However, it seems likely that day hos­
pital and outpatient treatment programs will
prove to be substantially less effective for
certain groups of patients, and Spicer et al.
(1981) caution that conclusions regarding equal
effectiveness should be limited to clients who
are appropriate for each type of program.
Many studies comparing outpatient with in­
patient treatment have not controlled for the
possibility that patients choosing outpatient
settings are less severely dependent? Inpatient
treatment seems Indicated when motivation is
weak to continue treatment, when patients are
psychotic, depressed, or suicidal, and when
- complicating physical disabilities are present.
Other factors which may also influence the
choice of treatment setting Include patients'
social stability and the number and severity of
their symptoms, as well as the ability of pro­
grams to respond to individual needs (Cole et
aL 19111 Spicer et aL 1981). Research Is
needed’to identify the characteristics of pa­
tients most likely to benefit from an outpa­
tient program, followed by treatment-match­
ing studies to test the validity of the Identi­
fied patient types. An additional obstacle to
the substitution of residential . treatment by
outpatient treatment is the high rate of client
attrition usually encountered in the outpatient
setting.

Malching CUeals with Programs

Considerable selection takes place on the
part of both the client and the referral agent

In the natural process of identifying alcoholics i
and referring them to treatment (Pattison and
Kaufman 1981; Beckman and Kocei 1982), De­
spite the increasing variety of programs, set- ■
tings, and treatment modalities, many alco- ,
holies do not have the opportunity to find an
informal match between their own specific /
needs and the type of treatment available.
This is particularly true of special needs pop­
ulations, such as women, ethnic minorities, the :
multidisabled, the elderly, and skid row alco- '
holies. For these groups, access to treatment
and successful rehabilitation are often Imped­
ed by cultural barriers, financial constraints,
and program design characteristics. Since
considerable attention has already been given j
to the needs of these groups in the Fourth
Special Report (USDHHS 1981) and other
sources (Dlesenhaus 1982; NIAAA 1982), this ,
section will provide a brief update on the is­
sues common to all special needs populations.
Because middle-aged white men represent •
the typical clientele of most treatment fa- ,
ciilties, programs often are not designed with
the needs of other groups In mind. These
groups may thus be reluctant to seek help be- |
cause of a number of structural and group-- ;
specific barriers that restrict access to ap­
propriate facilities. For example, a survey of |
53 California treatment facilities (Beckman .
and Kocei 1982) suggested that women alco­
holics were less likely to enter programs :j
jacking child care services, professional staff, J
and aftercare programs. However, Institute j
experience in providing services for women i
reveals that many women do not utilize child
care services even when provided. Other bar- :
riers to treatment for some groups are lan­
guage differences and composition of treat­
ment staff. Minority staff members represent
only a small proportion of the Nation's alco­
holism treatment personnel (NIAAA 1980). Yet
another barrier may be financial constraints. ;
.Women and minorities tend to be overrep­
resented in publicly funded facilities and un- |
derrepresented in private ones (NIAAA 1980).
Without programs' sensitivity to the needs of
these populations, many Individuals may fail to
seek treatment until their alcoholism has 1
reached a severe stage of development.
With the growing recognition that utilize- ;j
tlon rates may be Improved by removing bar- .,j
riers to access, greater attention is now being -4
given to special population groups in the design of treatment programs. Some facilities J
seeking to attract Hispanic and Native Amer- -1
lean clients are using folk medicine and native
healing approaches as alternatives or adjuncts JS

to traditional medical and psychiatric treat­
ments. Counselors and other treatment staff
members are being matched to the sex and
ethnic background of their clients. Also, con­
veniently located, community-based programs,
at times staffed and planned in collaboration
with special population groups, are appearing
more frequently (NIAAA 1982).
What is uncertain, at this time, is the im­
pact the ADM block grant program will have
on treatment programs. Of particular Interest
will be the differential rates of service use
across States, by both the general population
and special population groups. As these pro­
grams become available to special population
groups, research will need to move from pro­
gram descriptions to actual evaluation studies
In which programs designed for special popu­
lation groups are compared with more tradi­
tional approaches.
One exception to the trend to develop ser­
vices for special population groups and sub­
types of alcoholic persons has been the small
number of combined programs serving both
alcoholics and drug dependent persons. Al­
though combined treatment for alcoholics and
drug abusers has not been widely adopted, the
feasibility of such programs may have im­
portant Implications for the planning of future
treatment services, given the Increased tend­
ency for patients to present multiple abuse or
addiction patterns at the time of treatment
(Sokolow et al. 1981).

Therapeutic Approaches
Several diverse treatments are often de­
livered within the context of alcoholism ser­
vices, depending on the resources and needs of
clients, as well as the specific training or
orientation of the staff. In many cases, a
combination of therapeutic interventions is
provided to all clients, under the assumption
• that multiple treatments stand a good chance
of meeting at least some of each client's
needs. As the alcoholism treatment system has
grown in size and complexity, evaluating in­
dividual therapeutic approaches In isolation
from one another has become more difficult.
Many studies reported in the literature involve
adding a treatment of interest to a facility's
standard therapeutic program, or are descrip­
tive evaluations rather than clinical trials
comparing one or several treatments with the
. absence of treatment. Studies discussed here
genprdly cr.plqytd ?n experimental method­

ology, as firm conclusions about efficacy can
be made only through systematic comparisons.
Behavior Therapy
Behavioral elements most frequently applied
in treatment programs include social skills and
assertiveness training, contingency manage­
ment, deep muscle relaxation, self-control
training, and cognitive restructuring (Miller
and Mastria 1977). Despite their widespread
adoption, these methods have not been subject
to systematic evaluation with random assign­
ment of large numbers of patients to various
treatment conditions.
Aversion therapy.—This approach to treat­
ment grew from Pavlpvlan conditioning
theory, which predicts that the sight, smell,
and taste of alcohol will acquire aversive
properties if repeatedly paired with noxious
stimuli. A thorough review of the research in
this area (Miller and Hester 1980) concluded
that emetic (nausea producing) aversive con­
ditioning can be effective lor employed, mar­
ried, well-motivated alcoholics, but that the
effectiveness of electrical aversion is doubt­
ful. These conclusions are supported by recent
work (Cannon et al. 1981) comparing these two
aversion procedures when used in addition to a
standard treatment program. Patients exposed
to emetic conditioning exhibited significantly
greater improvement after 6 months than pa­
tients exposed to conditioning with electric
shock, but the advantage after 1 year was not
significant.
Work has also proceeded on covert sensi­
tization, a procedure in which imagined scenes
of alcohol ingestion are paired with nausea
induced by verbal suggestion. This method may
overcome some of the practical disadvantages
of emetically based aversion therapy. Some
recent studies have offered support for this
procedure. One study found that patients re­
ceiving covert sensitization remained ab­
stinent longer and demonstrated better psy­
chosocial adjustment than patients In control
groups (Elkins 1980). In a related study, pa­
tients receiving covert sensitization in a
standard inpatient treatment program showed
greater improvement over a 4-year period
than patients who received insight-oriented
therapy (Olson et al. 1981).
Extinction,—Recent experiments have shown
that alcohol-related stimuli (such as the sight
or smell of an alcoholic beverage) can induce
both physiological changes and altered
behavior in alcoholic patients (Kaplan et aL
1983; Pomerleau et aL 1983). Because condi-

109
108

tn summary, the Issues surrounding moder­
alcolwl abuse rather than alcoholism. Similar
fl •, nonprobtem drinking as a, viable treatment
semantic problems clv.-d the meaning of mod­
option for nonalcoholic problem drinkers arc
eration. Several studies (Armor et al. J07?;
not likely to be completely resolved until
Moos et ah 1981) have included amounts of up
progress t)as been made in those areas most
to 5 ounces of absolute alcohol per day within
relevant to. this controversy::improved nomen­
their definitions of moderate drinking. While
clature, more precise diagnostic criteria, new
many patients were drinking far below this
techniques for differential assessment, earlier
limit, the use of such a high cutoff point would
treatment interventions,., better, matching of
tend to Inflate estimates of the proportion of
client needs to specific treatments, and im­
moderate drinkers. Furthermore, to the extent
proved , research methodologies. It should be
that cognitive impairment and other alcoholclear that while continued .exploration and
related disabilities may result from consuming
assessment of a variety of. Treatment options
these amounts (Wilkinson and Sanchez-Craig
and goals for nonalcoholic and/or..prealcolvdic
1981). this liberal, definition of moderation
persons are appropriate ' endeavors, . the con-<
may be questioned in terms of its health
sensus of clinical opinion is that , the most
implications.
t
The controversies generated by such studies
appropriate „ goal for... alcoholic • -persons is
abstinence.
•
« .
as the Rand reports.(Armor et al,. 1978; Poilch
et ah 1981) illustrate the : need , to apply
sophisticated and systematic research method­
ology to explorations of the following ques­
Alcoholics Anonymous
.
<
tions: In the small number of alcoholic sub­
jects who have reportedly established a pat-.
With nearly JO years of service to alcoholic
tern of moderate drinking, how stable Is that
pattern over time? How much is this drinking
persons and their .families, the fellowship of
Alcoholics .Anonymous (AA) has not been the
pattern altered by stress, anxiety reactions,
subject of systematic ; research to study ns
and environmental factors, such as media ad­
vertising and the cost of alcoholic beverages?
long-term and short-term Efficacy. To this
end, Glaser and Ogborne (1982)' reviewed the
What are the risks of resuming drinking com­
clinical and- research, literature, and have
pared with abstinence in this group? What are
proposed a number of research questions and
the characteristics of patients who have de­
designs to highlight the most effective ele­
veloped moderate drinking patterns in terms
ments of the AA program and describe those
of age, sex, socioeconomic level, marital
persons for. whom AA participation is the
status, and drinking history?,.To what extent
p.eferred approach.
does the existence of a belief in. moderate
Efforts to Identify patients, who are best
drinking Increase the risk of relapse in alco­
suited to the. AA approach .have thus far
holic patients?
sought to identify characteristics of those, who Despite questions raised about treatment
have become actively ..Involved In the AA-.
goals for alcoholic persons, research has nev­
program (e.g., Boscarlnov 1980; O'Leary et al.
ertheless proceeded on the effects of teaching
1980). Some common characteristics have
moderation to socially stable problem drinkers
(Heather and Robertson 1981). Ponierleau et
been identified, including'need for structure
al. (1978) have demonstrated that behavioral
and for. affiliation with,a group. As yet, no
consistent profile has emerged to-characterize
treatment can be used effectively for teaching
moderation to middle-income nonalcoholic
successful AA members In terms of degree of
problem drinkers, while others have explored
impairment,. social stability, or emotional
some dimensions of teaching nonproblem al­
disruption. ..This state of a/fairs has been at
*
cohol consumption skills. Effective elements
tributed to- Inconsistencies of findings among
of treatment that have been identified include
studies, differing focuses of attention across
modeling and repeated practice of a clearly
studies, and . methodologicalinadequacies
delineated pattern of moderation (Strickler et
(Ogborne and Glaser 1981). «
.
al. 1981), and empathy on the part of thera- .
Alcoholics Anonymous .is a .major voluntary
resource in the treatment of alcoholism, with .
pists (Miller et al. 1980). These, must be
viewed as suggestive findings, since the results ;a reported,, membership of 4?6,000 In the
of these treatment studies have yet to be con­
United .States and Canada in 1980. The most.
firmed with various subgroups of problem
comprehensive information-, on membership..
drinkers, In natural environment .settings, or
comes from, the organization Itself (Alcoholics
with studies of long-term outcomes.
Anonymous 1981). The triennial sample sur111

veys conducted since 1968 profile character­
istics and trends of the membership. For ex­
ample, membership has increased from
170,000 in 1968 to 476,000 in 1980; the pro­
portion of women increased from 22 percent In
1968 to 31 percent in 1980; the proportion of
people 30 and under has increased to 14.7
percent In 1980 from 11.3 percent in 1977
when this trend toward younger membership
was first noted; and the proportion who state
counseling agencies and treatment facilities as
Important in their attending their first A A
meeting increased from 19 percent in 1977 to
26 percent in 1980. {Of those members be­
ginning A A since the 1977 survey, 33 percent
indicate counseling and treatment referrals
wc< c most responsible for first attendance.)

Dynamic Psychotherapy and Group Therapy
Numerous descriptions of the application of
•namic psychotherapy to the treatment of
alcoholism exist (Bean and Zinberg 1981; Zimberg 1982), but almost no outcome studies
evaluating’ this approach to treatment have
been conducted. In recent years, psychother­
apeutic approaches have given way to, or have
been combined with, behavlorally oriented
treatment In many settings. Some clinicians
have argued against the use of psychotherapy
on the grounds that it inay strip patients of
defense mechanisms that could be used in the
service of sobriety (Wallace 1978), and that it
makes demands that alcoholics are unready to
meet in the early phases of recovery (Valliant
1981). Nevertheless, there are indications that
psychodynamically oriented group psycho­
therapy may in fact be preferred for certain
subgroups of alcoholic persons (Kissin 1977).
A considerable body of literature describes
group therapy techniques in the treatment of
alcoholism (e.g., Vannicelli 1982), but with
only a few evaluative * studies to support its
efficacy. A recent study by Oekand 3ackson
(1980) compared group with Individual therapy,
each of these approaches being used to provide
social skills training to some patients and
traditional- supportive therapy to others. Sig­
nificant improvement was found only in pa­
tients given social skills training, with greater
improvement in those trained in a group set­
ting than among those treated individually.
Given the potential cost-effectiveness of
group therapy, as weir as its ’widespread use,
these findings should be followed up with
comprehensive evaluative studies.

Family Treatment
The accumulating evidence documenting the
deleterious effects of alcoholism t-n • lamlliet’
has prompted heightened Interest in family.
treatment of alcoholism, as described in'some’:
detail in the Fourth Special Report (USDHHS
1981). Although the therapeutic value of fam-'
ily treatment is well documented and heralded’
for many related problem behaviors (Stanton
and Todd 1982), its unique contribution arid
efficacy with alcoholism treatment remain to
be fully demonstrated and evaluated (Steinglass 1979; Pattison and Kaufman 1981). Pre­
liminary results from a study comparing--de-.
grees of spouse involvement In outpatient al­
coholism treatment indicate certain advan^j
tages for marital therapy,- but 18-month’ out­
come data have not yet been reported
(McCrady and Noel 1982).' Considerable work
in evaluating family therapy with alcoholic
families is needed, especially efforts Io match
specific treatment' to the problems presented
by different families.

Pharmacotherapy
The value of pharmacological agents such as
disulfiram (Antabuse) as a deterrent to
drinking and various patient factors associated
with favorable outcome is of continuing re­
search Interest. In recent work, Fuller and
Roth (1979) randomly assigned 128 men to
receive either a standard dose of disulfiram, a
pharmacologically inactive ' dose, or a daily dose of the vitamin riboflavin. The standard
dose of dlsulfiram was more effective than
*
riboflavin in ' producing abstinence ■ after ! ■
year, although differences were small (Fuller
and Williford 1980).
’ One aspect
*of
treatment with disulfiram haa
been patient noncompliance, that is, the pa-1
tlent's unwillingness to continue regular inges­
tion. Azrln ct al. (1982) studied compliance- '.
enhancement procedures with patients in a .
rural outpatient clinic. A behavioral "dlsul^-'
firam assurance" program, involving five ses­
sions of stimulus control training, role playing,''
and communication skills training, was highly:
effective in promoting abstinence In marrietrU
clients, but had little effect on single clients. J
However, the addition of behavior therapy
(training in’ drink refusal, social skills, and:
muscle relaxation, and' counseling in recrel?
*
.

Don activities and job-finding) was sufficient
to produce nearly complete abstinence for
tingle clients. These are Intriguing results,
eg>eclally since they were obtained in rela­
tively few sessions and with only monthly
followup contacts thereafter..
Another study tested the effects of a com­
pliance-enhancement procedure In an • Indus­
trial setting (Robichaud et al. 1979) and dem«mtrated the effectiveness of closely super­
vised Ingestion of dlsulfiram for reducing abmteelsm, but only during the treatment
period. The • findings 1 regarding dlsulfiram
ihould be regarded as preliminary, but they do
suggest that dlsulfiram may have a useful role
in treatment If compliance can be ensured.
Future studies of compliance with broader
tinges of clients‘arc’needed and may be fa­
cilitated by newly developed methods for
monitoring use of dlsulfiram (e.g., Paulson et
d. 1977; Neiderhlser and Fuller 1982).
A possible role for lithium In the treatment
jt alcoholism has been considered because of
Its effectiveness in treating affective dis­
orders and the relatively high incidence of
tnese disorders In alcoholics. The findings thus
lar have been equivocal. In one study, de­
pressed patients taking • lithium had fewer
drinking episodes compared with placebo con­
trol patients, but without any greater alle­
viation of the depression than'occurred In the
control patients (Kline-'et al. 1974). In other
itudles, however, depressed patients did not
consume less alcohol during lithium therapy
(Pond et ah 1981). The possible value of
lithium in treating alcoholics thus remains
uncertain, with more definitive studies re­
quired, employing double-blind procedures and
comparisons with other forms of treatment
(McMillan 1981).
Ciraulo and Jaffe (1981) have reviewed the
use of tricyclic antidepressants In alcoholics
and report success In treating initial symptoms
of withdrawal, such as anxiety, depression, and
somatic discomfort, only within the first 2 to
) weeks after cessation of drinking. In a sub­
sequent study, however, they demonstrated
that alcoholics show greater clearance and
lower plasma levels of imlpramine than nonakohollcs, suggesting that previous studies
which found persistent restlessness and mal­
aise may have utilized dosages that were in­
adequate for. alcoholics (Ciraulo et al. 1982).
Future studies should seek to define subtypes
of depression in alcoholics, monitor plasma
levels of antidepressants, and evaluate drug
effects both on depression and on drinking
behavior.

Factors Affecting Treatment Outcome

Quality of Treatment
As In other areas of psychotherapy, treat- ■
ment outcome in alcoholism is affected by the
perspectives and attitudes of the therapists, '
which In -turn are functions of their training,
experience, and self-esteem (Cartwright
1980). Treatment outcome Is also affected by
the Interpersonal skills of the alcoholism
counselor. Valle
*
(1981) evaluated treatment
outcomes - in patients ^randomly assigned to
eight recovered alcoholic counselors and found
that counselors having a higher level of In­
terpersonal functioning tended to have pa­
tients who drank less, relapsed less often, and
recovered more quickly after a relapse.
Evaluations of training programs for alco­
holism counselors indicate that they are able
to achieve gains in such areas as participants
*
knowledge, attitudes; ego strength, capacity ■
for self-disclosure, and effectiveness ■ of •
counseling (Gideon et al. 1980); The success of ■
alcoholism counselor training programs has
prompted their use as a treatment method
with chronic alcohol- and drug-dependent In­
dividuals, with positive results sustained for at
•east I year (Kahn and Stephen 1981).

Response to Treatment
Treatment research has increasingly focused
on identifying personal and environmental
factors that predict positive or negative
treatment outcomes. Positive outcomes are no
longer conceived solely in terms of total ab­
stinence from alcohol, since posttreatment
functioning In such domains as physical health,
psychological adjustment, social functioning,
and occupational performance may not de­
teriorate automatically with relapse to
drinking (Finney et aL 1980); moreover, suc­
cessful abstinence Is not necessarily associ­
ated with good functioning In other areas of
adjustment.
One form of negative outcome Is attrition,
that Is, failure to complete the treatment
program. Client factors found to be related to
attrition include inadequate financial re­
sources, low social stability, and youth (Welte
et al. 1981; Kell and Esters 1982). Treatment
variables such as program duration and size of
treatment groups also can influence the

113

dropout rate (Schroeder et aL 1982). Un­
doubtedly, attrition
*
results from an inter­
action between individual and program factors
and may be reduced by Improvements in pro­
gram design and the method of assigning pa­
tients to treatments.
t
It is generally believed that treatment out­
come is affected less by the treatment process
itself than by the personal resources and .
characteristics the client brings to the
treatment situation. Numerous studies have
shown good prognosis to be associated .with ,
social stability and marital adjustment
(Baekeland 1977). Personal.. characteristics
recently rjjported to.be associated with poor
prognosis include cognitive impalement, (Ab­
bott and Gregson 1981) and depression (Hatsukami et al. 1981), While client character­
istics seem to be Important, determinants of ,
outcome regardless of the quantity of quality .
of treatment, other , research has shown that
this effect may be mediated indirectly by the
environment to which the client returns after
residential treatment (Cronkite and Moos
1980). Another study found that three ?sJtuational factors (negative, mood states, inter­
personal conflicts, aird social pressure to
drink) were most likely ,to precipitate relapse
after treatment (Cummings et al. 1980). These
studies indicate that therapeutic efforts must.
deal not only with’.the; individual character-,
istlcs of the patien
*.
but also with the envi­
ronmental contexts in which the patient Is
expected to function after treatment.
With this in mind, some have advocated
giving more attention to restructuring of the
*
client'
environment through marital or family
" therapy, while others have called for a more
general approach. focusing on frequent after­
care contact In the period after treatment
(Costello 1980)., As a neglected dimension in
the treatment system, aftercare consists of (a)
ongoing supportive activities, such as. profes­
sional .and self-help -programs designed : to
maintain treatment gains, (b) prevention of
costly rebospltalizations, and (c) improvement
in social and occupational functioning. At
present, the resources most frequently
available to fulfill these functions are halfway
houses, AA groups, and program-sponsored
support groups. In general,. . affiliation with
aftercare groups is associated with better
treatment outcome . (£ostellp.; 1980). Further
research Is needed to determine the relative
efficacy of different kinds of aftercare, the.
optimal frequency and duration of aftercare,
and how clients can be Induced ,t.o comply with
aftercare without dropping ouVqiK,,

Malching ralienta to TwFipiea

J|
•nd more severe physical symptoms ^Pinces
et aL 1980). Another approach to the classi­
The emerging concept that alcoholism
*
is.hot/^
fication of alcoholics Is based on certain In­
a unitary disorder has stimulated renewed.,ln«j;1
dicators known to predict treatment outcome.
One study (Gibbs 1981) classified alcoholics on
terest in delineating different subgroups or?,I
the dimensions of social stability and Intel­
types of alcoholic persons. As\dlscussea pre*
;;
lectual functioning and showed that mutually
viousiy, the goal of this research is iotacil
*;^
exclusive types were often assigned to the
Itate treatment planning and improve treat
*
A,
same treatment regimen despite their widely
ment outcome by matching types of alcoholic
different rehabilitation needs.
persons with the most appropriate treatment ...
In an attempt to directlytest the clinical
interventions. Although t tjils typological ap
*,'
Implications of differentiating subgroups of
proach is not new to the field of alcoholism, ; ‘
alcoholics, several investigators have studied
reqent studies have benefited from improve^-’
how certain types of patients respond to dif­
meats iq assessment technology .(Meyer et aL .'
ferent treatments. Using a classification sys­
1981) and from,,,,the application of more?.
tem that differentiates chronic alcoholics
sophisticated, statistical, techniques (Skinner.1982).
''
,
from a less severe type of behavlorally im­
paired drinker, Brown and Lyons (1981) found
Attempts to differentiate alcoholics.on.the,.
that alcoholics do slightly better in programs
basis of personality characteristics accqunf ’
having a high medical orientation/while the
for most typological research efforts,.(Morey■
behavlorally Impaired drinkers respond better
and Blashfield 1981). SeveraJ , Independent
: to treatment'having a high psychological re­
studies have denoted two comqon subgroups!
habilitation ‘orientation. Using a 1 different
(I) passive-dependent alcoholic persons.char­
classification scheme, Finney and Moos (1979)
acterized by antisocial., personality disorder ;
Studied the treatment response of alcoholics
and (2) neurotic alcoholic, persons who may use .
classified in terror of high or low social com­
alcohol as a coping mechanism, in a study de- ' ;
petence. > Contrary to the findings
*
of Brown
signed to explore the of|pn-nqted association / i
•nd Lyons (1981), no evidence was found to
between alcoholism and antisocial (psycho-.;.
indicate that various treatment programs were
pathic) personality, Hesselbrock et ^al. (In
differentially effective for different types of
press) compared alcoholics having an early
patients.
history of sqplal deviance with those w/jo were .
Although evidence supporting treatment
“datively free from pt »blems before the onset
matching remains qulvocal, there may be
of alcoholism. Alcoholics with antisocial per­
important methodological reasons why the
sonality were, found to have an .earlier
*
onset of
matching hypothesis has not been adequately
alcoholism, as well as a more .rapid ;andr,severe
tested.
First, despite improvements in the
progression of drinking problems. ^Several.
methods and theory of classification, the opother studies (McLellan et al. 1981} . Zlykh
• tlmal classification system has yet to be de­
1981) suggest the importance of psychiatric ,.
veloped. Even though family history, psychi­
disturbance, particularly ip 'the, alcoholic's .
atric disorder, alcoholic symptomatology, and
response to treatment. Alcoholic subgroups
organic brain dysfunction seem to be prom­
characterized by poor psychological^adjust­
ising differentiating characteristics, there has
ment were found to show llttlp or,mo Im­
been little attempt to integrate information
provement following treatment,..whereas those 4
from these disparate levels of analysis into
having high adjustment.,,levels shqjyed Signif­
more comprehensive typologies. Second, many
icant improvement. McLellan e|. al. (1981)
matching studies have not been designed to
conclude that because patients .having less
detect predicted interactions. In a recent re­
severe psychological disturbance respond to.
view of the matching literature (Skinner 1981),
most kinds of treatment, cost copsiderations ? .
it was found ’that evidence supporting the
would recommend this subgroup to outpatient
matching hypothesis came primarily from
settings.
J,
those experimental studies that randomly as­
The probability of a genetic,,predisposition
signed patients to treatment conditions, while
to alcoholism has prorpptcji the search lee an
the results of nonexperimental correlational
alcoholic' subtype related to family pedigree,.
studies tended to be less supportive. Finally? in
One study of more than 7,000’ alcoholic men
• number of studies’it Is possible that the as­
found that thosp with a family .history of air
signed treatments were not sufficiently dis­
coholism had more severe symptomatology,..
tinct to produce a differential effect. Thus,
more antisocial behavior and ,other psycho­
white the matching hypothesis still holds
pathology, less stable employment histories

promise as an avenye to Improved treatment
efficacy, the systematic study of patient­
treatment Interactions will have to await the
development of better typologies and
Improved scientific research methodology.

Emerging Trends and Future Directions
A consensus appears to be developing among
clinicians, researchers, and policymakers that
treatment research is passing through a tran' aitlonal period during which basic assumptions
are being reevaluated and a hew approach' to
treatment efficacy la emerging. The elements
of this trend include refinements in the defi­
nition of terms, improvements in the tech­
nology of diagnosis, a more sophisticated ap­
proach to the planning of treatments, and a
new awareness of-the cornplexity of evaluation
methodology. '
The advances noted in this chapter in the
areas of conceptualization, assessment, and
treatment Intervention epn only serve to en­
hance the quality of services available to al­
coholic persons. The notion that different de­
grees of alcohol dependence can be measured,
that different types of alcoholic persons can
be classified, and that different types of dis­
ability can be diagnosed has important im­
plications for treatment and research? Recent
reviews of treatment-related priorities conIacted by the Institute of Medicine (1980), the
Journal of Studies on Alcohol (Keller 1979),
and the World Health Organization (Edwards
et al. 1981) suggest that these themes will
constitute a promising but ambitious agenda
for the 1980s. As articulated in the writings of
many specialists in the field, a new approach
is emerging regarding the ways In which
treatment is conceptualized, conducted, and
evaluated. v
”
The traditional model,- which still dominates
much thinking about alcoholism treatment,
describes how heterogeneous groups of pa­
tients are assigned to multimodal treatment
programs. After a period of time, the relative
success or failure of treatment is evaluated
primarily on the basis of the proportion of
patients remaining abstinent, and secondarily
by global1 assessments of functioning in other
areas of living. Because both treatment vari­
ables and client variables are aggregated in
this approach, treatment effects may be ob­
scured when the Improvements of some pa­
tients are averaged with the lack of improve­
ment or even deterioration of other patients.
Even when treatment effects are observed, It
115

is not
*
clear which parts of the treatment
process are responsible. In addition to the
Conceptual limitations of this model, much of
the evaluation research conducted within this
tradition is difficult to interpret because pa­
tient characteristics differ from one study to
another, outcome criteria have not been suf­
ficiently specified, comparison groups have
not been included in the research design, and
the treatment process has not been adequately
described. Furthermore, the posttreatment
’ environment has not been taken into account,
and there have been unrealistic, expectations
about what the treatment will accomplish.
In contrast,, to the traditional model of
treatment, the .emerging .model stresses, the
heterogeneous nature of the client population,
the need for more specific and efficient in­
terventions, the importance’ of maintaining
treatment gains in the posttreatment envi­
ronment, and the diversities of different out­
comes (Skinner 1981; Cronkite and Moos 1980).
. This model differentiates among types of al­
coholic persons (e.g., less dependent or more
dependent, depressed or not depressed, cog­
nitively impaired or. not impaired) and con­
jointly attempts to match each type with the
most .appropriate combination of treatment
interventions (e.g., pharmacotherapy, behavior
therapy, family treatment, etc.). The efficacy
of various treatment combinations is evalu­
ated by comparing, patients who are matched
to appropriate treatments with those who are
. mismatched or assigned randomly to a stand­
ard package of interventions. Within the new
model, greater attention is given to evaluating
changes in behavior, attitudes, physical health,
and psychosocial functioning taking place
during the process of treatment. Another area
of focus is the posttreatment environment,
where the patient's recovery may be impeded
or supported by what takes place in the family
setting or in the job situation. Ideally, the
treatment process would continue during the
posttreatment period in the form of various
kinds of specialized aftercare. Finally, the
new model recognizes that outcome may vary
along a variety of dimensions, and that ab­
stinence is just one goal of a more ambitious
treatment strategy that includes rehabilitation
in other important areas of functioning.

Summary
The traditional concept of alcoholism as a
unitary disease has been challenged. Over the
past decade, researchers and clinicians have
116

come to realize that nwltipie patterns of al­
cohol use may result .in nwltipie forms
disability. Accordingly, a new emerging model'.of treatment stresses the heterogeneous
ture of the client population, the need for :
more specific and efficient treatments, and
the Importance of maintaining gains after <
treatment. This model differentiates among
alcoholics (e.g., depressed vs. nondepressefl;;
and attempts to match e.ach typft with ;ths:
most appropriate combination and configi
*
■’
ration of treatments.
Recognizing the Importance of accurate J
patient descriptions, the American Psychiatric.;:
Association has developed systematic, criteria fl
for classifying alcoholic patients along a num­
ber of dimensions.. The technique, a part of {
DSM 111 (Diagnostic and Statistical Manual of |
Mental Disorders) promises to provide more
standardized and comprehensive patient
diagnoses.
,
.
■
Several methods are currently used to ;
identify alcoholics before they come for ■
treatment. Laboratory tests for biological
markers or Indicators can be a powerful aid to
detecting alcoholism. Current research on the ;
use of biochemical Indicators In .the early de-'
tection of alcoholism suggests that a single '■
specific biochemical marker for alcoholism
may be elusive. The combination of GCTP, -|
pears to offer, at relatively low cost, a strong ;
indication of recent excessive alcohol coo- .
sumption. In addition, a widely used and validated self-administered test, the Michigan 1
Alcoholism Screening Test (MAST), elicits |
responses to medical, social, and behavioral
statements. The MAST is rapid, inexpensive
*
”
and relatively accurate.
Studies show that untreated alcoholics and:/
their families are disproportionately high users
of medical services. Insurance programs, ‘
especially HMOs, In recognition of the cost I
implications have begun to target alcoholism J
for increased attention. Preliminary studies
suggest that partial hospitalization or> out
*
i
patient programs may be as effective as in­
patient programs for some patients; moreover, J
the lower costs of the former may lead to h- fl
creased use.
Treatments continue to rely largely on «
psychotherapy and behavior therapy (including ..
social skills and assertiveness training, selfcontrol training, cognitive restructuring, and
aversion therapy, which pairs alcohol with
unpleasant stimuli). In addition, group ap- .
proaches like Alcoholics Anonymous are 1
widespread. Behavior therapy in conjunctia
*

with disulfiram (Antabuse) seems to be highly
effective in producing abstinence; however,
abstinence alone does not imply successful
psychosocial adjustment.

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Hl)
712

V

JONATHAN 0. COLE/RALPH S. RYBACK

MH 2-A-3
DRUGS WHICH INTERFERE WITH ALCOHOL CONSUMPTION
DISULFIRAM.

Disulfiram, at an adequate level in the body,

will interact with ingested alcohol to induce the following
symptoms in this general order: flushing, sweating, palpi­
tations, dyspnea, hyperventilation, tachycardia, hypotension,
nausea, and vomiting. These events are usually followed by
drowsiness with complete recovery generally prevailing after
sleep.These reactions are presumably dose dependent, but
the minimal amounts of either agent needed to produce the
adverse reaction are unclear in the literature. Presumably
250 mg of disulfiram a day, perhaps less, is enough; as
little as 7 ml of ethyl alcohol can produce the reaction.
Since disulfiram is fat soluble and long acting, patients ev»j
still react for as long as seven days after they stop taking
disulfiram.
Our experience at McLean Hospital is that 125 mg of

disulfiram a day in the a.m. is a satisfactory, relatively
trouble-free initial and maintenance level for patients
weighing under 170 lbs. Patients on this dose who start to
drink report typical disulfiram-alcohol reactions of moderate
intensity which are aversive without being catastrophic.
Disulfiram probably acts by blocking the metabolism of
alcohol, inhibiting the further oxidation of acetaldehyde.
The drug also inhibits the conversion of dopamine to norepine­
phrine by blocking the enzyme dopamine-B-hydroxylase. Thia

•^Tt was discovered by mistake. Two Danish scientists took
the drug themselves to assess its safety as a vermifuge.
While on disulfiram, they went to a cocktail party with
disastrous results. They inferred, correctly, that the
drug might be useful in preventing alcohol consumption.

III.19. PHARMACOLOGICAL THERAPY

' 713

second action may explain the paradox that acetaldehyde alone
causes a rise in blood pressure. The alcohol-disulfiram
interaction may have the opposite (hypotensive) effect because
of disulfiram's interference with the synthesis of norepine­
phrine, a biogenic amine active in elevating blood pressure
(Ritchie, 1965). Side effects of the drug, other than the
alcohol reaction, include fatigue, lethargy, a metallic taste,
impotence, and, rarely, toxic psychosis, perhaps secondary
to increased brain dopamine.
Although two good psychologically and psychiatrically

oriented reviews exist (Lundwell & Baeckeland, 1971; Mottin,
1973), and although disulfiram has been used in alcoholism
for almost 30 years, there is no good compilation of the
frequency or severity of the various possible side effects
at various maintenance dosage levels. These range from 1 gram
to 125 mg per day. Rumor suggests that some alcoholics
manage to drink and take disulfiram. In fact, this old drug
has almost never been exposed to double blind controlled
clinical trial. One Russian study, showing no difference
between disulfiram and placebo, is described in Mottin's
review. Wallerstein's 1957 study compared•disulfiram with
conditioned reflex therapy, hypnotherapy, and a control group.
After two-years 53% of the disulfiram patients were doing
well as against about 30% of the patients in the other three
treatment groups. Hoff (1953), in a large comparative study,
found alcoholic clinic patients who were willing and medically
able to take disulfiram did better than patients who refused
the drug. The fact that a third group, patients willing to
take disulfiram but denied it for medical reasons, did as
well as the group who actually received it, makes one sv
that the drug is only a test of motivation. An inter
*-

714

JONATHAN 0. COLE/RALPH S. RYBACK

study by Gallant and his associates (Gallant, Bishop, Faulkner,
Simpson, Cooper, Lathrop, Brisolara & Bossetta, 1968) compared
court enforced disulfiram therapy with court enforced group
psychotherapy and a voluntary program (court referral without
enforcement). They found no treatment differences. However,
they suggest that the study patients were too ill to under­
stand clearly the court's actions and believe an inpatient
detoxification phase prior to court assignment to the various
treatments might have led to a more valuable study. Over the
years a shift has occurred in the practice of disulfiram
therapy. Originally, all patients were given a test dose of
alcohol early in their disulfiram therapy to acquaint them
with the full unpleasantness of the alcohol reaction. This
practice has now almost completely stopped. It is unfortunate
that the contribution, if any, of this aversive experience to
the patient's future abstinence has never been adequately
studied.
Recently, Rosenberg's group (Gerrein, Rosenberg, 4

l.lanohar, 1973) has taken a lead from methadone maintenance
and compared disulfiram therapy given on two schedules—once
a week administration by a nurse and twice a week administra­
tion by a nurse—with the patients being expected to dose
themselves the rest of the time. This was compared to nondisulfiram programs involving once or twice weekly clinic
visits. Interestingly, the biweekly disulfiram group did
very well in terms of clinic attendance (55% at 6 weeks no
opposed to about 25% for the other groups). In addition,
40% of the biweekly disulfiram patients remained abstinent
for 8 weeks as opposed to about 10% in the other treatment
groups (including once a week disulfiram). A more recent
study (Rosenberg, 1974) compared this successful regimen

III.19. PHARMACOLOGICAL THERAPY

715

with chlordiazepoxide, vitamins, and no drug. The results
were slightly less favorable, but disulfiram was still
superior to either vitamin or no drug treatment and equal
to chlordiazepoxide. In this study, disulfiram (which is
said to cause depression as a side effect) actually acted to
decrease depression and anxiety. Patients who continued to
return to the clinic for up to 26 weeks tended to be sober
as a group; disulfiram's sobriety rate of 85% was a bit
higher than the 75% for the other treatment groups.
Lundwell and Baeckeland (1971), in their review,
observe that successful disulfiram patients tend to be older,
more socially stable, more highly motivated, better able to
form dependent relationships, less depressed, and less likely
to have blackouts or sociopathic traits. The problem, of
course, is that these same traits may be associated with a
better prognosis in chronic alcoholism in the absence of
disulfiram.
Despite the limited evidence favoring disulfiram
therapy, it seems to have an assured place in the outpatient
therapy of chronic alcoholics. The position in favor of its
use can be stated as follows: disulfiram is not a cure but
affords the patient with a sincere desire to stop drinking
support in avoiding an impulsive drink. The rationale for
its use is that the patient knows that he has to avoid
alcohol at least three days after taking disulfiram or he
will experience some or all of the previously mentioned
symptoms. In this way, the patient's self-control is increased.
He also allows himself an interval of sobriety, with regular
use of disulfiram, in which to learn to deal with his life
without alcohol. Moreover, taking disulfiram is something
positive the patient is doing to help himself. This

716

JONATHAN 0. COLE/RALPH S. RYBACK

self-imposed treatment can increase the patient’s self-esteem
and encourages his family and friends to regain confidence in
him. Many patients also see disulfiram as a "good friend"
which they take each morning with their orange Juice. This
"friend" sees that they stay out of trouble as any good
friend would.
Patients on disulfiram should avoid disguised forms
of alcohol, such as cold alcohol-laden sauces, fermented
vinegar, and certain cough syrups. Absorption of alcohol
through skin is minimal and, consequently, after-shave
lotions are not contraindicated at the disulfiram dosages
previously suggested. Gourmets need not become disheartened
as Julia Child, "The French Chef" (1974), has suggested the
substitution of "chicken broth, fish stock, and beef stock
in fish or meat dishes and orange juice or cider in desserts,
<ilong with appropriate spices and herbs in meat dishes and
cloves, cinnamon, cardomon, etc., in sweet dishes" for wine.
Finally, well-cooked dishes will evaporate off all the
alcohol during preparation.
Disulfiram should not be given to organically confused,
psychotic, severely depressed, or suicidal patients. The
confused or psychotic patient may inadvertently drink alcohol
for a variety of reasons (e.g., memory deficits, voices
telling him to), while the severely depressed or suicidal
individual may use disulfiram in an attempt to kill himself
(Jacobsen, 1952). Accordingly, because of the latter, as
well as the necessary responsibility for daily or bi-weekly
self-administration, the patients chosen for this therapy
have to have a reasonably sound personality structure. Of
course, "an alcoholic who becomes determined to desert his
sobriety will simply stop taking the pills for a few days

III.19. PHARMACOLOGICAL THERAPY

717

until he Is safe, or he may even start drinking right through
the disulfiram, accepting the frightful resulting symptoms
as a kind of punishment in advance for his break, with authorization to go on drinking thereafter with impunity" (Solomon,
1966). Finally many patients are resistant to taking
disulfiram, particularly men. They see the drug as taking
away the opportunity to "do it on their own" and in that
sense undermining their masculinity. In term "crutch" is
often used, suggesting that their having to take disulfiram
infers that they are crippled or at best unreliable. More
suspicious patients are concerned that the drug will control
them or place them under the physician's control. Education
is directed at helping the patients recognize that disulfiram
will support their own self-control as the result of their
own decision to take it. Low doses (125 to 250 mg a day)
are usually clinically useful and avoid almost all side
effects other than occasional transient skin rashes, dizzi­
ness, headache, or gastric irritability. Most doctors feel
disulfiram is contraindicated during pregnancy because of
possible danger to the fetus, and in patients with psychosis,
and even heart disease (due to its B-hydroxylase inhibiting
properties); (Kissin & Gross, 1968). Moreover, if a patient
is taking diphenylhydantoin, the dose must be decreased or
^xicity may result since disulfiram slows its metabolism.

I

It is, however, always possible that, in the social
context described, a placebo which was believed by both
parties to be disulfiram would do as well. It is unclear to
what extent actual disulfiram-alcohol reactions play a signi­
ficant role in the long-term success of disulfiram in some
patients.
•

718

JONATHAN 0. COLE/RALPH S. RYBACK

DISULFIRAM IMPLANTS. A long acting disulfiram implant which
may possibly last as long as six months has been developed
and is in clinical trial. The most positive and only compara­
tive published study (Whyte & O'Brien, 1974) compares outcome
in 22 "implanted" male alcoholics with 23 "matched controls,"
apparently not randomly assigned to nonimplant therapy. The
treatment group averaged 5.4 months until their first drink
as opposed to 1.9 months in the comparison group. In terms
of the implant itself, the eight tablets formed a sore,
inflamed nodule which was uncomfortable for the first week;
the operation was done under local anesthetic; no implants
were rejected in the series. Local infection or rejection
of the tablets occurred in 13 out of 70 implants in the
series described by Malcolm and Madden (1973). These patients
were, as a group, significantly longer abstinent than had been
the case at any time in the two years prior to implantation.
Nine patients drank and had a reaction in the first six months
after implantation, but only four of these reactions, were
judged typical of disulfiram-alcohol reaction and twelve of
the 46 patients increased their use of sedatives.
In a South African study of 19 patients (Obholzer,
1974) over half the implants were complicated by infection.
Four out of six patients began drinking within seven months
of the implant, and only two experienced the expected adverse
reaction. There is more extensive data in the Polish litera­
ture, which is summarized in the above article.
In summation, it is still too early to assess the
ability of disulfiram implants to actually induce reliable
alcohol reactions for any fixed duration of time. If they
do, it is unclear whether they will be of use in other than
specially selected and motivated patients. The potential

III.19. PHARMACOLOGICAL THERAPY

719

medico-legal problems attached to the use of this agent are
bothersome.

CITRATED CALCIUM CYANAMIDE. The literature on this shorter
acting disulfiram-like drug is well reviewed by Mottin (1973).
Its alcohol reactions are usually considered to be generally
milder than those occurring with disulfiram, and the alcohol
effect is no greater two hours after a single dose than two
hours after the seventh of seven daily 100 mg doses (Lader,

1966). In the only comparative study (Levy, Livingston, &
Collins, 1967, calcium carbimide (the generic name) was com­
pared to disulfiram. During alcohol challenges in patients,
abnormal electrocardiograms were less common when on carbimide
(4 of 19) than on disulfiram (3 of 7). Seven of the 19 calcium
carbimide patients did well as against an unknown number
(less than 5) of the 11 disulfiram patients. It appears that
the carbimide patients were local alcoholics; whereas, disul­
firam was given to patients likely to leave the area. Hence
conclusions about the real relative efficacy of the two drugs
cannot be drawn. The drug is marketed in England and Canada
but not in the United States.
METRONIDAZOLE. This drug, marketed for use in Trichomonas
infections, achieved a certain notoriety after Taylor (1964)
reported that males taking the drug reported a distaste for
alcohol and a reduction in drinking. This led to a surprising
number of studies (9 controlled) which have been well reviewed
by Mottin (1973). Although three studies were positive, most
were depressingly negative or showed only a small subsample
of patients with the metronidazole effect — i.e., alcohol
tastes different, alcohol is disliked, intoxication occurs
on lesser amounts. All in all, the effects were generally

720
small or nonexistent.

JONATHAN 0. COLE/RALPH S. RYBACK
Thus, the ability of the drug to

actually produce disulfiram-like effects when combined with
alcohol is dubious, with Gelder and Edwards study (1968)
testing this most directly. Unfortunately,the positive
placebo-controlled studies were in obscure languages and
not available to the present reviewers. In an interesting

side study, Wilson, O'Brien, and MacAirt (1973) showed that
metronidazole at 800 mg a day (but not at 600 mg) was able
to raise taste thresholds for alcohol for both aversive and
pleasurable (e.g., sweet) thresholds. (800 mg is higher than
the daily dose 500-750 mg used in most controlled studies).
The intriguing aspect of the metronidazole story is
that this weak drug has inspired such a range of invest!gat In
activity while disulfiram has remained almost unstudied by
identical controlled trial methodology.

DRUGS AS AVERSIVE STIMULI
There is modest literature on the aversion conditioning
treatment of chronic alcoholism, which is well reviewed by
Costello (1969) and less clearly reviewed by Mottin (1973).
The general principle, of course, is to associate a highly
unpleasant stimulus (the unconditioned stimulus—UCS) with
an alcoholic beverage (the conditioned stimulus—CS). This
is usually done in a Pavlovian rather than an operant con­

ditioning paradigm in the hope that the unpleasant effects
will be associated with the alcohol and lead the patient to
avoid, or be upset by, alcohol in the future. In past
decades, drugs causing vomiting were generally used—emetine
or apomorphine. Here there was a problem in timing since,

III.19. PHARMACOLOGICAL THERAPY

721

ideally, the UCS and CS should be placed only seconds apart
for maximal effect. A complex emetine regimen has been used
clinically for years at the Schick-Shadel Hospital in Seattle
and is well detailed by Costello (1969). No controlled
studies of its efficacy are available although Lemere of
Schick-Shadel Hospital reports excellent results (60? abstinent
for at least one year). One wonders whether going to a
hospital for enforced vomiting may not imply strong motivation
to stop drinking and whether being able to afford a private
sanatorium may not be associated with above average social
stability. Both are predictors of good outcome in alcoholism
independent of the specific treatment used.
In an effort to develop even more drastic and closely
timed aversive stimuli, succinylcholine and other drugs which
cause total, brief paralysis of all muscles (as well as
severe anxiety) have been tried. Here, a pair of controlled
studies have been done. In both studies, patients not
receiving both the UCS and the CS have done about as well as
patients receiving the full pairing of stimuli.
Overall, the results of these therapies are not im­
pressive. Neither approach is free from danger. One hopes
that other nonpharmacological behavioral methods using more
active operant procedures with provision for positive re­
inforcing alternative behavioral outlets would be more useful.

PSYCHOTOMIMETIC DRUGS
Early reports from hospitals in Saskatchewan, Palo
Alto, and Spring Grove, Maryland, led to a presumption that
the administration of lysergic acid diethylamide (LSD) in a

722

JONATHAN 0. COLE/RALPH S. RYBACK

context of psychotherapy resulted in remarkable changes in
drinking behavior of a favorable sort (Cole & Katz, 1964).
The Josiah Macy, Jr., Foundation Conference on "The Use of
LSD in Psychotherapy" (Abramson, I960) documents the flavor
of that exciting and controversial time.
The early claims have now been tested in at least
five well-designed controlled trials. In the most elaborate
of these, Ludwig and Levine, who earlier had found short­
term favorable effects of LSD therapy in institutionalized
drug addicts, compared hypnodelic therapy (an LSD experience
guided by hypnosis), psychedelic therapy (LSD and psycho­
therapy during the experience), LSD without psychiatric
intervention and, as a no-treatment control, an equivalent
period of quiet solitary contemplation of personal problems
by the patient. Throughout a year of detailed and successful
follow-up studies of the 44 patients in each treatment group,
no differences were found on any of a range of drinking,
social adjustment, or subjective state measures between any
of the four groups of chronic alcoholics (Ludwig, Levine,
Stark, & Lazar, 1969). Half the patients were randomly placed
on disulfiram. This also had no effect on any of the measure#

Hollister, Shelton, and Krieger (1969) compared 600
micrograms LSD with 60 milligrams dextroamphetamine in 72
alcoholics. The experience was intended as a several hour
period of self-examination. At two months the LSD group wan
somewhat better off, but at six months the drinking and social
status of the two groups were identical.
Johnson (1970) compared about 550 micrograms LSD
intravenously with psychiatric psychodynamic interviewing; n
similar period after LSD with attention from a nurse; a

III.19. PHARMACOLOGICAL THERAPY

723

psychiatric interview after intravenous administration of
sodium amobarbital and methamphentamine; and routine care. There
were approximately 25 patients per treatment group. After
one year, there were no differences in outcome between the
four groups.
Smart, Storm, Baker, and Solursh (1966) compared
800 micrograms with 60 milligrams of ephedrine and a no-drug
session control group (10 subjects per group). Interviews
with the drug patients emphasized dynamic insight. The two
drug groups showed improvements in abstinence over the 6 month
period (34% and 32%) while the no-drug group showed 20%
improvement. Overall, no significant differences were found
between groups on any of several outcome measures.

Only the Spring Grove group recorded favorable results,
but failed to use a placebo or no treatment control. In
comparing high dose LSD with low dose LSD or comparing patients
who had or failed to have intense transcendental LSD exper­
iences independent of dose (Pahnke, Kurland, Unger, Savage,
& Grof, 1970), they observed somewhat better social and drink­
ing behaviors after one year in the high dose and the intense
peak experience groups. However, this treatment program
involved 12-15 hours of counseling prior to the LSD experience,
an eight-hour elaborately programmed LSD experience with
constant presence of a therapist plus extensive counseling
after the session to consolidate and digest insights and
experience.

In sum, LSD therapy for alcoholism is generally in­
effective and, at best, is only partially effective even when
elaborate, intensive, and expensive psychotherapy is inter­
woven into the experience. Other hallucinogens have been
studied in preliminary trials in alcoholism with little in

724

JONATHAN 0. COLE/RALPH S. RYBACK

the way of substantial findings worthy of detailed review
(Denson & Sydiaha, 1970; Grof, Soskin, Richards, & Kurland,
1973; Simonopoulos, Pinto, Babikow, Kurland, & Savage, 1970).

CONDLUSIONS
The available clinical literature assessing drug
therapies in various phases of alcoholism has its limitations
and is often either inconclusive or controversial. Neverthe­
less, some general assertions are possible:
1.
In the treatment of withdrawal symptoms chlor­
diazepoxide (and probably other benzodiazepines ) is safe and
effective and can abort or avert delirium tremens.
2.
Promazine, in patients with severe withdrawal
symptoms or delirium tremens, is contraindicated. It appears
to increase the occurrence of full delirium tremens and has
been associated with a higher death rate than any other
treatment studied

3.
No antianxiety or antidepressant drug (or lithium
carbonate) has been shown to offer any clear advantage over
placebo in the treatment of detoxified alcoholics in the
community. The one available study on lithium carbonate in
alcoholics with associated depression is promising and
deserves replication.
4.
Although disulfiram is widely used and popular with
both doctors and patients and probably is useful in selected
patients, studies comparing it with placebo or no drug treat­
ment generally show it to have little or no overall clinical
value. Nevertheless, it appears to have a firm place in the
therapy of chronic alcoholism. The newer variants, calcium
carbimide and metronidazole, are equally ineffective and lack

3

III.19. PHARMACOLOGICAL THERAPY

725

the virtue of wide clinical exposure. Disulfiram implants
also seem to offer no advantage over oral medication and may
not, in fact, really provide their promised chronic anti­
alcohol effect.

5.
Aversion techniques — using either emetics or
paralyzing agents — appear crude and unvalidated and may
merely be tests of motivation.
6.
LSD and related psychotomimetics used as adjuncts
to psychotherapy of alcoholics have been well studied and
are generally without any prolonged effect on drinking
behavior.
COMMON PROPRIETARY NAMES OF DRUGS MENTIONED
amitriptyline hydrochloride

ahlordiazcpoxide hydrochIoria
chlorpromazine hydrochloride
chlorprothixene

Elavil (U.S. ),Tryptizol (U.K.)
Laroxyl (U.K.)
Librium
Thorazine (U.S.),Largactil (U.K.)
Taractan
Abstem (U.K.)

(cyanamide)
diethylpropion hydrochloride
diphenylhydantoin, sodium
disulfiram
dixyrazine

Valium
Tenuate (U.S. & U.K.),
Aplsate (U.K.)
Dilantin (U.S.), Epanutin (U.K.)
Antabuse
Esucos (Belgium), not marketed
in U.S.
Nunci tai (Sweden) not at present
marketed in U.S. or U.K.
Haldol (U.S. & U.K.)
Serenace (U.K.),
Atarax
Vistaril

III. 19. PHARMACOLOGICAL THERAPY

727

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Smart, R.G., Storm, T., Baker, E.F.W., & Solursh, L. A
controlled study of lysergide in the treatment of alco­
holism. Quarterly Journal of Studies on Alcohol, 1966,
27, 469-482.
Solomon, P. Psychiatric treatment of the alcoholic patient.
International Psychiatry Clinics, 1966, 3, 159-188.

III.19. PHARMACOLOGICAL THERAPY

733

Sydney, M.A. Ventricular arrhythmias associated with the use
of thioridazine hydrochloride in alcohol withdrawal.
British Medical Journal, 1973, 4, 467.
Taylor, J.A.T. Metronidazole, a new agent for combined
somatic and psychic therapy of alcoholism. Bulletin of
the Los Angeles Neurological Society, 1964, 29, 158-162.
Thomas, D.W., & Freedman, D.X. Treatment of the alcohol
withdrawal syndrome: A comparison of promazine and
paraldehyde. Journal of the American Medical Association,
1964, 188, 316-318.
Thompson, W.L., Johnson, A.D., & Maddrey, W.L. Diazepam and
paraldehyde for treatment of severe delirium tremens: A
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175-180.
Turek, I.S., Ota, K., Brown, C., Massari, F., & Kurland, A.A.
Tiotixene and thioridazine in alcoholism treatment.
Quarterly Journal of Studies on Alcohol, 1973, 34, 853-859.
Vlamontes, J.A. Review of drug effectiveness in the treat­
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Victor, M. The role of hypomagnesemia and respiratory
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C-.W.

o'

C / Kx

J-

REVIEW ARTICLE

Early identification of alcohol abuse:
(£ Critical issues and psychosocial indicators for a composite index
*
Harvey A Skinner, ph d. c psych; Stephen Holt. mb. ch b.Chons), mrcp. frcp[c];
Yedy Israel, ph d

Evidence
significantly reduce the prevalence of alcohol-related disabilities. However,
physicians must take systematic steps to detect alcohol abuse. Part 1 of this
two-part series discusses the need for early identification of individuals who
drink to excess and the factors that may either facilitate or hinder the
development of effective programs for detecting alcohol abuse.
A profile Is given of important psychosocial indicators of alcohol abuse.
including the classic signs of alcohol abuse, the early manifestations of heavy
drinking, the predisposing or high-risk factors for alcohol abuse, and the

raditionnelle au traitement medical des problemes relies a

I'abus de I'alcool Les donnees actuelles indiqucnt que I'identification precoce
de ceux qui boivent avec exces et qu'une Intervention a ('aide de programmes

I'alcoolisme. Cependant les mgdecins
La premiere partie de cette serie a deux volets discute de la necesslte
d'une Identification precoce des individus qui boivent excessivement et
des facteurs qui peuvcnt soft faclllter ou nuire au developpement de
Aorammes efficaces pour deceler I'abus de I'alcool.
^PBn presente un profit des indicateurs psychosociaux importants de I'abus
venements precipitants alnsi que les habitudes menant

A new patient walks into your of­
fice. After a few introductory com­
ments the 40-ycar-old man de­
scribes his nausea, diarrhea, hcart-

From the Addiction Research
the clinical and laboratory indicators
for a composite index of alcohol

JOR J issue of the Journal.

Skinner. Addiction Research Foundation
of Ontario. 3? Russell St.. Toronto.
Ont. M5S 2SI

burn and indigestion. During the
course of doing a routine physical
examination and taking a medical
history you detect several interestReproduced on the cover of this

an eloquent engraving by William
Hogarth (1697-1764) 'depicting
working class of 18th-century Lon­
don. The slide was kindly supplied
by the Addiction Research Found­
ation of Ontario through Dr. Mary­

REPRINTED FROM THE CANADIAN MEDICAL ASSOCIATION JOURNAL

ing items. The examination reveals
evidence of hypertension and peri­
orbital edema. You note several
scars on the chest and limbs, and
tobacco stains on the left hand.
Other than treatment for a peptic
ulcer 3 years ago. the patient states
that he has had no other medical
problems in the past 5 years. How­
ever. further questioning about the
body scars reveals that he has been
to lhe emergency department of a
local hospital on three occasions for
the treatment of accidental injuries
that necessitated leaves of absence
from work. In response to further
questions the patient slates that he
has had difficulty sleeping and is
troubled by growing stresses at work
You sit back in your chair for a few
moments and attempt to synthesize
this array of clinical information.
Could excessive drinking be a key
determinant of his physical com-

As there is growing evidence that
alcohol-related disabilities are a
major cause for medical consulta­
tion. there is reason to presume
that your patient may indeed have
a drinking problem. Along with
cancer, cardiovascular disorders
and mental illness, alcohol abuse is
a major public health concern.’
However, at the clinical level, evi­
dence has accumulated that physi­
cians arc experiencing a “tip of the
iceberg” phenomenon. Studies on
the 'prevalence of alcohol abuse in
hospital and private practice popu­
lations indicate that many patients
have drinking problems that are
unrecognized. ’” A study at the
Massachusetts General Hospital.

MAY I. IWI/VOL. 124 1141

t I

/

Boston, found that the chief med­
ical officers failed to detect alcohol
abuse in approximately half of the
alcoholics in the emergency ward."
Rubington’ has described the situa­
tion as analogous to a game of
“hide and seek" in which both the

ers (the physicians) participate
either actively or passively. Re­
search suggests that treatment is
in patients who
of alcohol abuse and arc not yet
suffering its many medical and so­
cial sequelae.” This underscores the
need for clinicians to employ identi­
fication procedures that can lead
to early intervention and an im­
proved prognosis.

cians to take more steps to detect
alcohol abuse. This need is but­
tressed by the staggering cost of
cohol-related disabilities, and by
the tendency for some patients to
minimize or even deny a drinking
problem
velopmcnt of screening programs
for alcohol abuse arc discussed.
Can physicians rely solely on bio­
medical abnormalities to detect ex­
cessive drinking, or must social and
psychologic variables also be con­
sidered for accurate early diag­
nosis0 More fundamentally, should
busy njwicians concern themselves
with ^^Bting alcohol abuse when
their aoniiy to treat and significant­

disorder is in question?

ant psychosocial indicators of ex­
cessive drinking, including the pre­
disposing factors, likely precipit­
ating events and early behavioural
manifestations.

discusscs the clinical signs and
symptoms and the laboratory find­
ings that arc related to excessive
alcohol consumption, and describes
the morbidity profile al various
stages in the development of alco­
hol abuse The objectives of these
papers are to provide the physician
with an up-to-date review of alco­
hol-related disabilities, to illuminate
key indicators of alcohol abuse that

should

routinely

considered

Hindering factors

The importance of identifying al­
coholism early has been recognized
for over a century. In 1867 Day.”
the first superintendent of the
Washington Home for Fallen Men.
indicated that there was a general
Early identification
lack of appreciation of the magni­
H7jy it's so important
tude of the problem presented by
alcoholism,
and referred to what
The economic costs of alcohol
we
would call the "hidden alco­
abuse are substantial. In the United
States the National Institute of holic". Earlier Marcct.” a physician
at
the
Westminster
Hospital. Lon­
Alcohol Abuse and Alcoholism
(N1AAA) estimated that alcohol- don. England made one of the first
related problems cost nearly $43 systematic studies of alcohol as a
predisposing
cause
of
a variety of
billion in 1975 as a result of lost
production, motor vehicle acci­ diseases. Emphasizing that patients
dents. crime, social problems and may attempt to conceal their drink­
ing
habits.
Marcel
slated:
"On first
demands for health care services.”
Indeed, over 129? of the total ex­ applying to his medical adviser, the
penditure on health care for adults patient will probably not state the
cause
of
his
illness,
and
thus
seri­
($13 billion) was for alcohol-related
ously mislead the physician in his
the Addiction Research Foundation estimation of the nature of tharcomplaint."
More
recent
studies
have
of Ontario estimated that in the
province during 1976 additional confirmed that the attitude of those
medical treatment due to alcohol- who abuse alcohol has not changed.4
related problems cost $320 million. Moreover, many physicians are not
approximately 11 % of the total cost trained to recognize symptoms of
of medical services in Ontario for excessive alcohol use or do not
consider it their duty to detect al­
coholics or both.’-4”
The mortality associated with al­
Clinicians frequently use data
cohol abuse is well documented ”
In 1975 the NJAAA estimated that from reports on alcohol consump­
119? of all deaths were alcohol- tion made by the patient as a basis
related.” Ashley" reported that the for diagnosing alcohol abuse. How­
*
lack of standard­
risk of death for those abusing al­ ever. physicians
cohol or drinking heavily was two ized methods for eliciting and re­
to four times that for the general cording such information and some­
population, and that hazardous times their lack of awareness of
drinking accounted for a 109? loss the many factors that influence the
of potential years of life. The mor- reliability and validity of these re­
ports lead to problems in data col­
accepted as one of the best indica­ lection. These factors, combined
tors of the prevalence of alco­ with the patient’s motivation and
hol-related health problems This ability to minimize drinking prob­
disorder ranked as the sixth most lems. may lead to inaccuracies in
common cause of death in the diagnosis.
United States in 1975. and up Io
Studies on the reliability and va­
959? of those deaths were thought lidity of patients’ reports of alcohol
to be alcohol related.H In Ontario consumption have produced con­
from 1950 to 1973 cirrhosis of the flicting results.”’*' Generalizations
liver was the most rapidly increas­ arc difficult to make since the ac­
ing cause of death in the adult pop­ curacy of these reports depends
ulation. followed by lung cancer upon the context in which they are
and suicide.” Furthermore, the in­ obtained, the patients
*
characteris­
crease was greatest among persons tics and the types of behaviour
in the productive age range of 35 being assessed. Armor and col­
to 49 years These data firmly es­ leagues” concluded that patients’
tablish alcohol abuse as a major estimates of frequency of drinking
health concern.
arc quite satisfactory, but that es­

practice patients, and to point out
some of the more promising direc­
tions of current research into the
identification of alcohol abuse.

1142 CM A JOURNAL/MAV 1. I9RI/V0L 124

I

timates of the actual quantity of
alcohol consumed, while moderate­
ly reliable for nonalcoholics, arc
low for alcoholics Hence, patients
scribing how often they drink, but
less accurate about how much they
drink. Furthermore, Sobell and co­
workers” underscored the need for
ensuring that patients arc sober, as
verified by the blood alcohol level.
n a history of drinking habits is
lined. They found that alcocs’ repons of recent alcohol
consumption were often invalid.
consumption being underreported.
when the patients had been drink­
ing
An important extension of this
observation concerns how much
credence the physician should give
to a patient's complaints when the

«

sue is especially relevant in an
emergency department, where some
patients may have been drinking or
may even be intoxicated. For in­
stance. a recent study found that
329? of the patients admitted to the
emergency department of a teach­
ing hospital in Edinburgh. Scotland
had a blood alcohol level exceeding
17.4 mmol/J (80 mg/dl).’’

Diagnostic instruments presently ■
available
Instruments for the diagnosis of
alcoholism that incorporate medical
data include the National Council
m^lcoholism (NCA) criteria.” the
MAigan Alcoholism Screening
R^(MAST)~‘ and the Munich Al­
coholism Test (MALT).” The NCA
criteria provide a reasonably com­
prehensive list of the main physical.
social and psychologic sequelae of
alcoholism. However, many of these
criteria may be redundant for
identifying the alcoholic patient
since the predictive ability of a
number of them has not been fully
established; in one study there was
no significant difference between
alcoholic and control patients ac­
cording to 38 of 86 of the NCA
criteria."
The MAST is a widely used in­
strument containing 25 items that
refer to the medical, social, intra­
personal and legal consequences of
problem drinking;” the total score
classifies patients along a continu-

cohol misuse. The test can be rapid­
ly completed by interview or by
the patients themselves, and en­
couraging data have been reported
on its reliability and validity.” In
one clinical population of alcohol
abusers the MAST yielded scores
that were relatively unaffected by
any tendency the patients might
have to deny problem areas.”
By including objective data such
as clinical signs and laboratory find­
ings that indicate the presence of
alcohol-related diseases, it may be
possible to corroborate interview
and self-reported data, and thus to
obtain a more accurate assessment
of alcohol abuse. This approach
was used by Feuerlein and asso­
ciates’'* to develop the MALT, a
test that contains two sections: pan
cian. and pan B, which contains 24
items pertaining to alcohol abuse
and its adverse social and somatic
effects, is to be completed by the
patient. Although the MALT has
produced encouraging results, it
seems that the medical items con­
tained in part A are sensitive only
to disorders that develop in the
later stages of alcohol abuse."1
Nevertheless, this test is a good pro­
totype of a short test that combines
medical and psychosocial indicators
of alcohol abuse.

The economic, social and health
costs associated with alcohol abuse
provide powerful incentives for ear­
ly identification and treatment. To
date, most efforts have concentrated
on tertiary care for persons with
relatively advanced medical and so­
cial disorders, here rehabilitation is
the goal. Considerably less attention
has been directed toward secondary
care, which involves detecting al­
cohol-related disabilities early and
intervening at a stage when the
individual's drinking behaviour
should be more amenable to treat­
ment. Available research indicates
a more favourable prognosis for in­
dividuals who arc socially stable
and have not yet ‘accrued adverse
medical or social consequences of
their drinking.” In an editorial pub­
lished in 1978 Lieber’’ called for a
major public health strategy against

alcoholism. A basic issue is whether
early identification will lead to an
improvement in the outcome of
treatment and a concomitant reduc­
tion in the overall costs related to
alcohol abuse. To answer this fund­
amental question four issues must
be addressed.
Lack of precise definitions- Con­
sensus is lacking on definitions for
the disorders that need to be ident­
ified. Most existing criteria for al­
cohol abuse, such as those of the
NCA,” are relevant primarily to the
later stages of the disorder, which
require tertiary care. More recent
recommendations for diagnostic
classes suggest including the alcohol
dependence syndrome and alcoholrelated disabilities, as proposed by
the World Health Organization
(WHO).’* as well as distinguishing
between alcohol abuse and alcohol
dependence, as advocated by the
American Psychiatric Association ’’
Although both systems represent
needed steps in the standardization
quately taken into account the in­
dicators and problems related to
the early stages of excessive drink­
ing. There is a conspicuous neglect
of the middle ground between social
drinking and chronic alcoholism.
Undoubtedly one explanation for
the lack of precise definitions is the
complexity of disorders that are in­
fluenced either directly or indirect­
ly by alcohol abuse. The traditional
concept of alcoholism as a single
specific disorder has failed to ade­
quately represent the diverse and
multifaceted problems related to
drinking, and a multiple-syndrome
concept is gaining ascendancy.”"4’
However, considerable work is
needed to refine the definitions of
these alcohol-related syndromes.
Our approach, consistent with the
WHO definitions.” is to view al­
cohol abuse as lying along a con­
tinuum of severity; that is. it exists
in degrees and may be manifest in
multiple syndromes or alcoholrelated disabilities.
Questionable effectiveness of cur­
rent interventions: An axiom of pre­
ventive medicine is that it is in­
appropriate to detect a disease for
which effective treatment is lacking.
This raises a serious question. Do
we at this time have interventions

CMA JOURNAL-MAY I. IWI/VOL. 124 1143

that can significantly alter the
course of alcohol abuse? The avail­
able evidence is far from convinc­
ing A consistent finding from re­
search on the treatment of alcohol
abuse is that patient characteris­
tics have a greater effect on the
outcome than the kind of treatment
given. In their exhaustive review
Baekeland and collaborators4' concludccHhat "over and over we were
impress with the dominant role
the pSWt a*, opposed to the kind
of treatment used on him. played
in his persistence in treatment and
in his eventual outcome." The dif­
ferent forms of treatment seem to

success with individuals who have
advanced to the later stages of
alcohol abuse.

identification of cases may yield
meagre results. Fincbcrg and Hiatt41
the use of radionuclide scanning for
brain tumours over the past decade
the onset of symptoms and surgical
treatment from 4 years to 1. Clearly
this was a significant improvement
in the early detection of tumours.
yet survival after the operation re­
mained unchanged: during a decade
less than 509? of the patients who
underwent an operation each year
. the mere identification
of patients can produce
deleterious effects. This problem
was illustrated quite dramatically
by a study of hypertension in an
industrial setting. Haynes and col­
leagues4' found that the labelling of
patients as hypertensive resulted in
increased rates of absence from
work- an 80% increase in absent­
eeism was found in the identified
group, compared with a 99? in­
crease in the general employee pop­
ulation during the study period.
Similarly, numerous critics have
voiced concern over labelling and
self-fulfilling prophecies, particular­
ly for psychiatric disorders.4*4*
Need lor innovative approaches
to treatment: If valid procedures
for the early detection of alcohol
abuse were devised, there is a dan­
ger that those identified could

swamp existing treatment resources.
Indeed. Plaut
*
’ estimated that the
treatment of every "alcoholic” in
California would require the fulland social worker in the United
States. However, the intensity of
present treatment methods, which
are aimed primarily at rehabilita­
tion. may be unnecessary for help­

cohol abuse. There arc indications
that a lower-cost intervention, con­
sisting of assessment, brief coun­
selling and follow-up. can yield re­
sults that are comparable to those
of traditional inpatient and outpa­
tient programs for alcohol abuse.4"4*
This basic intervention, summarized
in Table I. could be readily adapted
to private practices and general hos­
pitals Although further clinical in­
vestigation is needed, it appears
that a brief intervention by physi­
cians in the earlier stages of ex­
cessive drinking could have the
widespread impact of curtailing the
prevalence of alcohol-related dis­
abilities.
The impact of a brief intervenof the effects of advice against
smoking from general practitioners.
Russell and coworkers4’ assigned
2138 cigarette smokers consulting
28 general practitioners to one of
four groups, nonintervention con­
trol subjects: questionnaire-only
control subjects, subjects advised to
stop smoking; and subjects advised
to stop smoking and given a leaflet
to help them. Follow-up data col­
lected 1 month and 1 year later

1144 CMA JOURNAL'MAY I. I OKU VOL. 124

revealed a significant difference
across the groups. The percentages
of patients who had stopped smok­
ing within 1 month and remained
abstinent for 1 year were 0.3%.

ly. The Russell team estimated that
if all the general practitioners in
the United Kingdom participated.
the brief advice plus leaflet inter­
vention would yield over half a
million ex-smokers a year. Indeed.
this success rate could not be
matched by increasing the number
of specialized smoking-withdrawal
clinics in England from the present
50 to over 10 000. Thus, this study
dramatically underscores the poten­
tial impact of collective efforts by
physicians in general practice.
In addition to low-cost clinical
interventions, another approach is
a large-scale prevention program.
like the heart disease prevention
program of Stanford University in
Palo Alto. California.1® In this
study, involving three communities.
intensive instruction given to in­
dividuals identified as being at high
risk for heart disease significantlyreduced such physiologic indices of
risk as blood pressure, relative
weight and serum cholesterol con­
centration. This finding suggest^
that mass media educational cam­
paigns directed at entire communi­
ties can be effective in reducing the
risk of cardiovascular disease. Al­
though a similar program may
prove successful in reducing the
prevalence of alcohol abuse, espe­
cially for individuals identified as
being al risk, research to date in-

dicatcs that influencing patients
*
at­
titudes toward alcohol use will not
necessarily change their behaviour
to healthier patterns?’
Purposes of identification: The
early detection of disease has gen­
erated much controversy. A real
danger is that unproven or margin­
ally effective treatments will be em­
ployed merely because patients have
been identified The absolute necesfor long-term evaluation of in^^Jentions has been repeatedly
stressed. For example. Favus and
associates” found that thyroid can­
cer occurred as a late consequence
of radiotherapy for benign child­
hood conditions of the head and
neck. There is ample justification
in the history of medicine for Bcrg-

cial section in my personal demon­
ology of the health field is reserved
for the perpetrators of mass screen­
ing With some gadget or labora­
tory test to peddle, they fall upon
sclling promises of prevention or
cures like indulgences to heaven.”
Sackett and Holland1’ have con­
tended that much of the controversy
in the detection of disease arises
from inconsistent definitions and a
lack of understanding of the dif­
ferent purposes of detection. Episessment of a carefully selected
sample of a population to obtain
new knowledge; no health benefit
participants is implied. The
of screening, on the other
hWk is to detect groups at high
risk for a disorder that is more cf-

Here the implicit promise is that
volunteers will receive treatments
of proven efficacy. Sackett and Hol­
land argued that “far greater cerrecommending treatment at the
community level, especially when
patients are solicited through
screening”. In comparison, case­
finding is initiated by a patient
seeking help from a physician; a
comprehensive health assessment
may reveal a disorder that was un­
related to the patient's initial com­
plaints. Whereas case-finding may
seem optional to the busy clinician.
diagnosis is mandatory and entails
establishing the exact cause of the

patient's symptoms. With' both
case-finding and diagnosis, empha­
sis is placed on the accuracy and
predictive value of the identifica­
tion procedure. Since a given test
can often be used with any of these
methods of detecting disease, one
must be clear about the exact pur­
pose of the test when assessing its
value as a detection instrument.
In summary: We have surveyed
the challenging problems and po­
tential benefits of the early detec­
tion of alcohol abuse. It is prema­
ture to judge the value of early de­
tection. but the premise that it will
give rise to a better outcome of
treatment is attractive, especially
with the concern over the increasing
costs of health care However, a
comprehensive program of research
is needed to provide a rigorous test

Aside from the later onset of
many clinical disorders related to
alcohol abuse, a number of clinical
abnormalities are time-specific. For
instance, the levels of serum trans­
aminases may fall to normal with
abstinence or a substantia] reduc­
tion in alcohol consumption.1*" 11 On
the other hand, psychosocial prob­
lems, such as being arrested for
driving while intoxicated or being
reprimanded for drinking on the
job. span a longer time-frame and
arc not reversible since the event
either did or did not occur. In gen­
eral. research suggests that certain
psychosocial items and laboratory
findings will be more relevant in
younger individuals who began ex­
cessive drinking early.1* More clin­
ical abnormalities in addition to so­
cial and psychologic problems
could be expected in older individ-

in this research is the development

•fication.

social factors: There is growing evi­
dence that different indicators are
more sensitive to certain stages of
alcohol abuse For example, in a
study of predominantly young men
referred to a medical officer because
of problems related to suspected
alcohol abuse, most of the men
acknowledged their psychosocial
problems, but few had clinical or
laboratory manifestations of dis­
eases associated with chronic al­
cohol abuse11 Many clinical dis-

alcoholism, and an individual may
have been drinking excessively for
5 to 10 years before they develop?1
Furthermore, although over 50%
of deaths from cirrhosis of the liver
are linked to alcohol misuse, only a
small proportion (around 8%) of
those who abuse alcohol have this
disease at a given time.1” Thus, de­
spite the fact that data on mortality
due to cirrhosis provide a good es­
timate of the prevalence of alcoholrelated health problems in a popu­
lation. the signs and symptoms of
cirrhosis are not helpful for early
clinical identification.

Fig. I depicts a general sequence
of disorders in relation to the dura­
tion of excessive drinking. The
usual focus of medical interest is
on the later stages, in which treat­
ment is oriented toward rehabilita­
tion. For these patients diagnosis
is often fairly straightforward besigns of alcohol abuse. As physi­
cians attempt to detect cases at
earlier stages of excessive drinking.
various disorders are potentially
relevant. However, any single item
may lack sensitivity to alcohol
abuse, since a good proportion of
individuals who drink excessively
will not have the clinical abnormal­
ity or psychosocial problem. On the
other hand, a composite picture
based on carefully selected items
should lead to improvements in earIv diagnosis. Major challenges for
research are to determine which bio­
medical and psychosocial items are
key indicators of alcohol abuse, and
to decide how to combine these
variables in making diagnostic deciUse composite indices: Whereas
no single biomedical or psychoso­
cial item has proven to be highly
accurate for early detection, there
arc indications that carefully chosen
composite indices can improve diag­
nosis. Ryback and collaborators’"
constructed a biochemical profile.
including biochemical and hema­

CMA JOURNAL'MAY I. 1W1/V0U 124 1145

tologic indices from routine labo­
ratory tests, that might alert a phy­
sician to the possibility of alcohol
abuse in a patient. The blood chem­
istry tests included sequential mul­
tiple analyses (SMA 12 and SMA 6)
and the hematologic scries (such
measures as the mean corpuscular
volume). When used together in a
multiple discriminant function the
25 laboratory tests correctly classi­
fied lj^^ of patients in hospital
medicSWards because of alcohol
abuse, 94% of patients in a treat­
ment program whose condition had
deteriorated less and 100% of pa­
tients in medical wards for reasons
other than alcohol abuse. Although
the diagnostic accuracy of this bio­
chemical composite needs to be
cross-validated with new samples.

tial gains from devising composite
indices. Another example of this
approach in the diagnosis of alco­
holism is given by Drum and Jancomposite indices is to capitalize
on the different sensitivity of each
item to various levels of alcohol
abuse. Consider the biochemical
test for y-glutamy) transpeptidase
(GGT) and high-density-lipoprotein
cholesterol (HDL-C). The serum
concentration of GGT is a measure
of liver function that appears to re­
flect heavy drinking (consumption
of over 60 g-'d of absolute alcohol.
or eth
in the previous ’
Similarly, the

more reliable than any single item;
hence the widespread use of comor the extent of physical depend­
ence on opiates ** The MAST re­
liability estimates were quite low
for a single item, moderate for short
composites of items and quite high
for the total index based on all 24

A basic assumption in our re­
search is that alcohol abuse is likely
a steadily increasing (monotonic)
function of the number of biomed­
ical and psychosocial abnormalities
the patient demonstrates. We are
devising an overall index score for
identification that may include dif-

tient’s age sex and socioeconomic
background. The index score will
provide a quantitative estimate of
the level of alcohol abuse, consistent
with the growing support for a mul­
tidimensional diagnostic system that
views alcohol abuse as existing in
degrees rather than as an all-ornone phenomenon.’’•’*
Consider addictive behaviour in
general- Information on other poten­
tially addictive behaviours, such as
smoking, drug use. caffeine con­
sumption. gambling eating and
ly to abuse alcohol. Gilbert’* has
argued that the causes of alcohol
abuse may be common to other
forms of excessive behaviour. Ex-

graded response to moderate con­
sumption of alcohol (40 to 60 g d
of ethanol).1"” Although the GGT
and HDL-C levels may be raised
because of various factors other
than alcohol consumption, each test
may prove to be differentially sensi­
tive to levels of alcohol consump­
tion. and their composite use may
significantly improve diagnostic ac­
curacy. Evidence to support a com­
posite index of GGT and HDL-C
has recently been documented.’
Similarly. Shaw and Lieber” found

levcls of GGT and a-aminobutyric
acid improved the estimation of
level of alcohol consumption.
Composite indices yield a total
index score that will, in general, be

1146 CM A JOlIRNAl./MAV I. I9KI/VOL. 124

cessive drinking may have as much
in common with overeating as it has
with social drinking. Certain obese
individuals exhibit compulsive eat­
ing habits, such as food binges, that
arc remarkably similar to the ac­
tions of episodic or binge drinkers.”
and there is evidence that alcoholics
smoke significantly more than nonalcoholics” Hence, alcohol abuse
may be viewed as a particular ma­
nifestation of addictive behaviour
that may have much in common
with other addictions. Thus, as we
attempt to advance the level at
which we can detect alcohol abuse
to more formative stages, considera­
tion should be given to a general
model of vulnerability to addictive
behaviour.
Psychosocial indicators
Parallel to the diverse profile of
physical signs and symptoms asso­
ciated with excessive drinking (as

a patient's alcohol abuse may be
manifested in a wide range of social
and psychologic problems. Table
II highlights various psychosocial
items that surveys of the literature
signs of alcohol abuse and depend­
ence or early indicators of alcohol
misuse. In Table 111 are listed fac­
tors that potentially predispose in­
dividuals to drink excessively or
increase the likelihood that they
will do so, as well as situations
that may precipitate patterns of
maladaptive drinking, such as
stressful life events. The emphasis
is on high-risk situations that either
trigger the start of excessive drink­
ing or exacerbate an existing pat­
tern of alcohol misuse.

Several of the classic signs listed
in Table 11 have been found to be
presumptive evidence of alcohol­
ism.” Although the presence of any
one sign docs not necessarily in­
dicate alcohol dependence in an
individual, the probability of alco­
holism increases substantially when
two or more signs are present. For
instance, of the NCA criteria for
alcoholism Ringer and coworkers”
found that only 4 of the 86 (morn­
ing drinking, blackout periods.
gross tremor and regressive defence

mechanisms) were needed to pre­
dict with 90% accuracy whether
patients in hospital were alcoholics
Similarly. Costello and Baillargcon”
found that only two items, morning
drinking and blackouts, were
needed to achieve good concord­
ance with independent ratings by
psychiatrists of alcohol abuse in pa­
tients. Morning drinking and at­
tempts to cut down on drinking arc
the four CAGE
*
items that
IWr been used successfully to
screen for alcohol abuse.’* Loss of
control after one or two drinks and
morning drinking, presumably to

rclicvc or avoid alcohol withdrawal
symptoms, have been found to be
central factors in alcohol depend-

found that approximately 3.5% of
the population in Ontario over the
legal drinking age drank more than

Various amounts of alcohol con­
sumed per day have been suggested

It is well documented that long­
term alcohol abuse causes structural
and functional impairment of the
nervous system?
*
Ryback" has sug­
gested that the effect of alcohol on
memory is a continuum from speci­
fic memory deficits common to
cocktail-party drinking, to alcohol
amnesia or blackout after an acute
prolonged rise in blood alcohol
concentration, to the essentially per­
manent memory deficits of the Wer­
nicke-Korsakoff syndrome. Neuropathologic studies using computerassisted tomography have revealed
cortical atrophy among alcohol­
ics.’*’* The frontal lobes appear to
be damaged more often than other
areas of the brain. Psychometric
studies have demonstrated that
chronic alcohol abuse is particularly
detrimental to the patient’s ability
to solve problems, to manipulate
abstract concepts and to perform
complex psychomotor tasks.’* Fur­
thermore. these deficits have been
found in subjects whose general in­
tellectual level is average or above
average. When the subjects ab­
stained from alcohol some improve­
ment in their performance was
demonstrated during the first few

liver damage has been associated
with a mean consumption of 12
drinks (Tabic 111 or 160 g or more
of ethanol a day. According to Lclbach.1’ histologic examinations re­
vealed the presence of liver cir­
rhosis in one out of four alcoholics
after approximately 12 years of al­
cohol intake al this level. The Ad­
diction Research Foundation of
Ontario has conducted several
large-scale surveys within the prov­
ince. Using a criterion of 120 g of
ethanol (nine drinks) a day for al­
coholism. Schmidt and de Lint”

Table II - Psychosocial indicators of alcohol abuse
Classic signs
Very heavy drinking: often nine or more drinks" a day (about 120 g/d of ethanol)
Morning drinking
Blackouts, memory lapses when drinking
Loss of control, craving for more when drinking
Compulsive drinking style, freauent thoughts about drinking
Severe alcohol withdrawal reaction (such as delirium tremens)
Repealed attempts to cut down on drinking have failed
Gross cognitive deficits (such as "alcohol amnesia")
Social degeneration: job loss, family problems, legal convictions related to drinking

Earlier Indicators
Heavy drinking; often four or more drinks" a day (about 60 g/d of ethanol)
Increased tolerance to alcohol
Drinking quickly, gulps the first drinks
Eating lightly or skipping meals when drinking
Concern or worry about drinking by self or family or both
Intellectual impairment
Accidents In which alcohol intake is involved
Jfardmess or absence from work because of drinking

Sequent use of alcohol to relieve stress, anxiety, depression
Attempts to cut down on drinking have had limited success
"One drink « 13.6 g of absolute alcohol (ethanol) or approximately 340 ml of Canadian beer,
43 ml of Canadian liquor, 142 ml of wine or 85 ml ol sherry, port or vermouth.

Table III—Factors related to alcohol abuse
Predisposing factors
Family history of alcoholism
Birth order - born later in a large family
Disrupted family background
Early age at onset of regular drinking
Childhood history of minimal brain dysfunction
Personality traits - impulsivity, rebelliousness, low self-esteem
Delinquency
Precipitating or correlated factors
Stressful life events in recent past
Change in peer group
Greater availability of alcohol
Improved financial status
Change to higher-risk occupation
Heavy smoker
Abuse of other drugs

One of the most contentious is­
sues in alcohol research is the
establishment of a level where “ha­
zardous" alcohol consumption
begins. Popham and Schmidt” suc­
cinctly state: “In short, we do not
lion from a biomedical standpoint.”
This issue has been further com­
plicated by evidence that moder­
ate alcohol consumption protects
against ischemic heart disease.
*
1“
However, a level of consumption
that may protect against '.schemic
heart disease may predispose to
other medical and psychosocial dis-

probability estimates of threshold
values for hazardous levels of con­
sumption. and these estimates will
vary for definable subgroups. There
is evidence that the hazardous level
will van with age. sex. somatotype.
CMA JOURNAL'MAY I. 1981/VOL. 124 1147

prcscnce of medical complications.
such as liver disease or cardiac
problems, pregnancy, drinking style
(continual v. intermittent), and neu­
ropsychologic status.
This
evidence will be considered further
in part 2 of this review Hence.
there is no simple answer to the
question What is a hazardous level
of alcohol consumption0
Gi^elines have been suggested.
hou^^b for the risk of harmful
effe^^from drinking. On the
basis of epidemiologic investigations
Thaler” has suggested a danger
level for damage to the liver of 60 g

men and 20 g (one and a half
drinks) a day for women. Pcquignot
and collaborators” estimated the
different daily levels of alcohol con­
sumption. The likelihood of avoid-

at 739? for a daily consumption of
less than 60 g of ethanol. 839? for

than 20 c Despite the excellent
work of Lclbach" and Pcquignot
and collaborators.” further research
is needed to estimate the relative
logic disorders in relation to daily
alcohol consumption.
Tolerance to alcohol has been
identified as an important factor in
the escalation of drinking. In
studies on alcoholism, tolerance re­
fers to a decrease in the response

through frequent drinking, and
when an increase in dose w’ill re­
instate the effect.” However, the
scientific evidence is sketchy on
whether increased tolerance neccs-

thcr excessive drinking.-' Cappell
and LeBlanc
*'
have speculated that
tolerance may be most relevant dur­
ing the formative stages of drinking
habits, since individual differences
in tolerance may underlie differen­
tial adaptation to the noxious ef­
fects of alcohol; that is. tolerance
may be an important factor in de­
termining which individuals increase
their consumption of alcohol to ex­
cessive levels.
Another important factor that
may signal either incipient or estab­

lished alcohol abuse is the rate at
which alcohol is consumed, espe­
cially for the first few drinks. Re­
search has established that the de­
gree of intoxication is greater when
ccntration of alcohol in the blood."
Impairment is also greater when
the concentration is rising than
when it is falling, although the
actual levels may be identical;" this.
Mendelson and Mello" have ar­
gued. “may explain the frequent
observation that alcoholics tend to
initiate a drinking episode with a
large volume of ethanol and also
to gulp their drinks". Furthermore.

cohol

concentration,

individuals

drinking in order to expedite the
rise in blood alcohol level and the
development of intoxication."
Perhaps one of the best early in­
dicators of alcohol abuse is a grow­
ing. concern or worry about per­
sonal drinking habits. The recogni­
tion of alcohol-related problems by
drinkers and their family and
friends is a major factor underlying
items in the MAST questionnaire'’
In a study using a different instru­
ment (the MALT) many of the
young men who had been referred
to a medical officer for suspected
alcohol abuse recognized that they
had psychosocial problems related
to drinking.
*
4 Indeed, three of the

indicate alcohol abuse are: “1 think
alcohol is destroying my life”;
“Since I have started drinking. 1
have been in worse shape"; and “I
think 1 ought to drink less." These
concerns have consistently been
identified as significant in studies
of method^ of assessing alcohol

Prolonged heavy drinking is re­
lated to a number of cognitive def­
icits; for instance, alcohol impairs
the ability to attend to several tasks
simultaneously? Also, both alcofound to have considerable cogniof alcohol.” Parker and Noble"
found that the performance of so­
cial drinkers on tests of abstracting
and adaptive abilities was negative­
ly associated with the amount of

1148 CMA .IOURNAL/MAY I. 19RI/VO1.. 124

alcohol consumed before the test.
Although the relation was strongest
for heavy drinkers, deficits were
also noted in light and moderate
drinkers. In a sample of alcoholic
men under the age of 35 years. Lee
and associates ” found that 59%
were intellectually impaired, 49%
had cerebral atrophy revealed by
computer-assisted tomography, but
only 19% had cirrhosis of the liver.
Since other neurologic complica­
tions were considered trivial. Lee's
group argued that intellectual im­
pairment may be the earliest com­
plication of chronic alcohol abuse
and may arise at an early stage in
an individual's excessive drink’ng.
This study also corroborates our
lence of clinical signs and symptoms
of alcohol abuse among young
problem drinkers.14
Alcohol abuse is a factor in
various forms of accidents. The
NIAAA estimates that half of all
traffic fatalities and one third of all
traffic injuries arc alcohol related;
the probability of being involved in
a traffic accident increases drama­
tically as a driver's blood alcohol
concentration increases.'4 Further­
more. up to 40% of fatal industrial
accidents. 69% of drownings and
83% of fire fatalities are alcohol

matic injuries resulting from acci­
dents are often associated with al­
cohol abuse. When examining a
patient with accidental injuries the
physician should routinely consider
the possibility that the patient, fam­
ily members or others involved in
the accident were drinking to excess
at the time.
Several other items have poten­
tial as early indicators of alcohol
abuse; for instance, some organiza­
tions have found tardiness, absent­
eeism and lowered productivity
among their alcohol-troubled em­
ployees.’4 Hence, employment rec­
ords may provide valuable leads to
the presence of drinking problems.
An individual's peer group and
leisure activities may also be indi­
cative; when most friends are
heavy drinkers and most leisure ac­
tivities involve drinking, the person
may be under considerable social
pressure to drink heavily. Another

signal of maladaptive drinking that
could escalate into chronic alcohol
abuse is the frequent use of alcohol
to relieve stress, anxiety or depres­
sion. As well, if individuals have
had only moderate or limited suc­
cess in trying to alter their drinking
habits, their control over their al­
cohol intake is impaired even
though they may be consuming only
^^crate amounts of alcohol at the

separation of their parents or by
frequent moves.” Also, research has
found that children born last in
large families have an increased
probability of alcohol abuse.,w
Other research has focused on
individual characteristics that are
rclatcd to the onset of drinking
problems. There is some evidence
that children with symptoms of minimal brain dysfunction (e.g.. hyperactivity. poor control of impulses
and poor concentration) begin to
Predisposing factors
consume excessive quantities of alOne of the most challenging cohol at an early age."
*
Other
areas of research on alcohol abuse studies have found that conduct disis the study of the factors that may orders and delinquency in childpredispose individuals to drinking hood are positively associated with
problems or increase the likelihood the future development of alcohol
that such problems will develop abuse.”
Finally, there has been
(Table Hl). Recent evidence has extensive research on a possible
indicated that genetic factors arc "alcoholic personality”.’" Compariimportant determinants of the risk sons of alcoholic patients with those
of alcohol abuse. Several studies of having other disorders have failed.
individuals separated from their however. to support such a concept,
biologic relatives soon after birth Indeed. research reports have emand raised by unrelated foster par­ phasized the heterogeneity of inents have found that the risk of dividuals who abuse alcohol, and
alcohol abuse was increased in several distinct subtypes have been
those with a biologic parent who identified."5 On the other hand
was alcoholic.”"” Goodwin'"' pos­ there is some evidence to support
tulated that certain people may the concept of a prcalcoholic perhave genetically determined phy­ sonality."' Longitudinal studies
sical reactions to alcohol that lower have suggested that such personalthe likelihood that they will be able ity characteristics as impulsivity.
to drink alcohol in large enough poor self-esteem and low ego
quantities to become alcoholic. strength during childhood and earOther studies have compared those ly adulthood arc related to the suba family history of alcohol sequent development of alcoholto control subjects and found ism."’ ’”
tnai such a history influences levels „ .
of acetaldehyde in the blood.'” Preap"a"np jpelo"
self-ratings of the degree of alcohol
The final class of variables inintoxication”- and the amount of clude factors that can either trigger
static ataxia or body sway'“ after a pattern of excessive drinking or
drinking a given amount.
cxacerbatc an existing habit (Table
Aside from potential genetic in­ 111) Research has shown that as
fluences. it is well established that the number of recent stressful life
alcohol abuse is much more pre­ events increases — such as a job
valent in relatives of alcoholics than loss or the death of a spouse —
in relatives of nonalcoholics.'1" ]n a there is a greater likelihood of some
large sample of alcoholic men. those physical or mental disorder."1 The
with a family history of alcohol magnitude of the event also tends
abuse had more severe symptoms ic increase an individual’s general
of this abuse, more antisocial be­ vulnerability to illness. According
haviour. less social stability and to Rabkin and Struening."4 stressmore severe physical disorders than ful life events do not cause disease
those without alcoholism in their but ‘’alter the individual's suscepii**
family.'
Furthermore, the risk of bility at a particular period of time
alcohol abuse is increased for those and thereby serve as a precipitating
whose families were disrupted dur­ factor”. To date, research has found
ing their childhood, perhaps by the limited support for a specificity hy-

pothesis — that is. that certain life
events (e.g.. job changes) are more
highly associated with a specific
class of disorders (e g., gastrointestinal disease)."' Both the number
and the magnitude of stressful life
events in the recent past may increase the frequency of drinking
bouts and the quantity of alcohol
consumed.
A related set of variables involve
situational changes that increase an
individual's access to alcohol. These
might include an improvement in
financial status, with more money
available to spend on alcoholic bev*
erages.'
a change to a peer group
or club that encourages heavy
drinking, greater access to alcoholic
beverages because of social policy
changes.”'* and employment in a
higher-risk occupation, such as catering4
Alcohol consumption is correlated with smoking" and the nonmedical use of drugs.” Indeed, the
combined use of alcohol and other
drugs represents the second most
frequent cause of drug-related medical crises." Although no causal
relationship is assumed between
drinking, smoking and drug abuse.
these behaviours are correlated: involvement in one of these habits
may predispose to. or exacerbate.
other forms of addictive behaviour.
Taken together. Tables II and III
describe the classic signs of alcoholism, indicators of the initial
stages of excessive drinking, factors
that predispose to alcohol abuse in
,h(. ,
run and fac|or5 t|)aI may
cither increase a person’s vulnerability to heavy drinking or exacerbate an existing pattern. Consideration of all these factors should provide a fairly comprehensive assessment of a given patient's status with
respect to alcohol abuse.
_
.
Vonc UMOns
Traditional approaches to the
medical management of alcohol­
related disorders have met with limited success in reducing the prevalence of alcohol abuse. Evidence
suggests that the early detection of
problem drinking and the use of
low-cost interventions could make
significant inroads in preventing the
disabilities related to excessive alcohol consumption. Indeed, the po-

CMA JOURNAL'S! AY 1. 1981/VOL 124

icnlial impact of the use of such an
intervention by general practition­
ers is substantial. To date, the pos­
sible cumulative effort by physi­
cians in private practice and in gen­
eral hospitals has not been fully
realized. However, before interven­
tion is possible, physicians must
lake steps to identify alcohol abuse.

related £o drinking when directly
asked
their alcohol consump­
tion. bMmn arc not likely to do
so spontaneously."’ On the other
hand, there is evidence that certain
physicians avoid confronting pa­
tients who misuse alcohol and may

alcohol abus
table medical and psychosocial dis­
orders. Instruments that arc sensi­
tive to the earlier stages arc urgent­
ly needed. Pending further research.
we recommend assessing a patient
with the various indicators listed in

physical factors if medicine is to
significantly reduce alcohol-related
morbidity and mortality.

Ashley. Laurence. Blcndis. Harvey

Romilla Chhabra for her assistance in
preparing this manuscript.
The research for this paper was
supported by the Addiction Research
Foundation of Ontario. Stephen Holt
Sep! land.

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136

| REVIEW ARTICLE |

Early identification of alcohol abuse:
2: Clinical and laboratory indicators1*
»ch; Yedy Israel, ph e
associated with alcohol abuse, drinking problems often remain undetected
abuse has been emphasized repeatedly in the literature but far less attention

at a stage when intervention might be more effective and less costly.
The search for indicators of early alcohol abuse is complicated since many

present. Despite considerable in­
terest in the medical sequelae of
alcohol abuse, there is relatively lijalcohol-related diseases as predic­
tors of past or present problem

have compared the disease patterns
of patients who abuse alcohol with
the patterns of control subjects.

number of year

of both biomedical and psychosocial indicators of excessive alcohol consumption
is recommended for early identification of this problem.

value of a variety of alcohol
*

problem
...
population cannot be adequately

a la detection, en milieu hospitalier comme en pratique generale. Dans la
litterature. on a insist? sur le diagnostic de I'abus de I'alcool, mais on a acc
beaucoup moins d'attention aux indicateurs qui permettraient de deceler Tab
de I'alcool au stade ou une intervention pourrait etre plus efficace et moins

consommation exagerec. Dans la deuxieme partie de cette serie de deux, o
envisage diverses caracteristiques cliniques et de laboratoirc rattachees a la

Alcohol-related problems are
known to be a common cause for
medical consultation, and knowl­
edge of the protean manifestations
of hazardous alcohol consumption
should aid in detecting alcohol
abuse. This approach is encouraged

of medical factors known
d’un profit associant des indicateurs biomedicaux

was published in the May I. 1981

enterolop. department of medicine.

Skinner. Addicrion Research Foundation
of Oniariu, 33 Russell St.. Toronto. Ont.
M5S 2SI

screening of patient populations in
An increasing awareness that ex­ order to identify the "hidden alco­
cessive drinking is a major medical holic”.’” A recent World Health
problem has prompted research Organization (WHO) study group
aimed al determining reliable in­ indicated that an important object­
dicators of hazardous alcohol con­ ive of future research on alcohol
sumption.'" Although many of the abuse should be the "development
alcohol-induced symptoms, clinical of methods for screening and early
signs and abnormal laboratory find­ detection of alcohol-related disabil­
ities. with correlation of question­
ings arc nonspecific, it is reasonable naire
and laboratory methods"?
to assume that the more alcoholrelated problems a patient has, the
Although a number of reviews on
greater the probability that excessive the detection of alcohol abuse have
alcohol consumption has been or is appeared in recent years?" lew

REPRINTED FROM THE CANADIAN MEDICAL ASSOCIATION JOURNAL

MAY !J. 19KI/VOL. 124 1279

studies have focused on biomedical
factors associated with both early
and later clinical manifestations of
excessive alcohol consumption The
aim of this paper is to discuss the
value of various symptoms, signs
and clinical investigations for iden­
tifying alcohol abuse. Particular at­
tention is given to describing the
morbidity profile at progressive

tests and biochemical markers
such abuse
This pape
identifying problem drinking Be

Clinical Institute of the Addiction
Research Foundation of Ontario in
■oronto, attempts were made to
justify including various biomedical
and sociobehavioural items that
might form the basis of an iden-

of alcohol abuse The major thrust
curate
hoi c<msumption and related prob­
and io incorporate these into
a brief medical examination and a
questionnaire for the patient that
lings, including hospitals, industrial

Disorders related to alcohol aims
Chronic hazardous drinking re­
sults in a wide spectrum of disorders
causing a multitude of clinical sympmd signs, man) of which max
he useful in detecting alcohol abuse.
It is accepted that the functional and
morphologic changes in many or­
gans of the body that accompany or
result from excessive alcohol con­
sumption can provide reliable
cadence oi excessive drinking.
|Bwe\er. relatively few clear cor­
relations between clinical data and
prolonged heavy drinking have been
adequately demonstrated. Although
alcohol abuse and problem drink­
ing have diverse clinical manifesta­
tions. the most specific disorders
usually represent advanced and
often irreversible effects of alcohol
and therefore may not be relevant
to the early identification and treat­
ment of these problems Neverthe­

less. by accepting the assumption
that the larger the number of al­
cohol-related alterations, the greater
the probability that excessive alco­
hol consumption is present, a phy­
sician may compensate for the lack
of specificity of some clinical items
by using combinations of symptoms
and signs.
in his excellent study on the
hidden alcoholic in general practice
*
Wilkins
drew attention to items
in a patient s history that are valu­
able clues to alcohol abuse. These

sumption could aid in the detection
of problem drinking.”

sociated with a higher prevalence
of alcoholism, were compiled in an
"alcoholic at risk" register for de­
tecting individuals whose drinking
habits were already advanced.
Wilkins recognized that earlier
detection of alcohol abuse would
i the chances of arresting this
disorder but concentrated his a
lion mainly on individuals
established alcoholism.
A patient's social history.

Gastrointestinal disease

conditions

since circumstances such as divorce,
low social class and poor housing
may be associated with a higher pre­
valence of hazardous alcohol con­
sumption.Wilkins emphasized
that the general practitioner may be
in an almost ideal situation for de­
tecting alcohol abuse, as clues to
of alcoholism
graphic data reported on patients'
records even before they are seen
in a clinic or an office. Alcoholics
have a higher incidence of sickness.
absenteeism, accidents, neurologic
disorders, pulmonary disease and
hypertension than matched conthese alcohol-related disabilities may
follow a recognizable sequence, and
that early complications of alcohol
abuse may manifest themselves
before the patient or clinician is
exists.For example, trauma and
gastrointestinal disease lend to occur
earlier in the course of alcohol
abuse than neurologic disease or
cirrhosis of the liver. The recog­
nition of certain disorders as earlier
indicators of hazardous alcohol con-

1280 CM A JOURNAL/iMAY 15. 19K1/VOL. 12

the principal medical sequelae of
alcohol abuse, emphasizing the
signs and symptoms related to gas­
trointestinal disorders, liver disease.
neurologic alterations, trauma, and
cardiovascular and respiratory dis­
ease. Attempts will be made to in­
dicate disorders that are useful for
detecting early rather than more ad­
vanced stages of alcohol abuse
(Table J).
Morning retching, nausea, ano­
rexia and vomiting occur frequently
in persons who abuse alcohol, and
may be associated with hangovers or
withdrawal symptoms.Alcohol
ingestion has been causally as­
sociated with a number of inflam­
matory lesions in the upper gastro­
intestinal tract. Because alcohol
reduces the pressure of the lower
esophageal sphincter and interferes

term or long-term alcohol abuse
may promote gastroesophageal re­
flux ”* Smoking, a common habit in
abusers of alcohol.’* may also re­
duce sphincter pressure, predis­
posing the drinker who smokes to
esophageal reflux.” Portal hyper­
tension induced by alcoholic cirrho­
sis may lead to esophageal varices
and severe gastrointestinal bleeding 11
Severe vomiting after overindul­
gence m food and alcohol may tear
the mucosa at the gastroesophageal
junction and cause hematemesis
... ..
“• :ss syndrome).1' Eroand acute duodenal

ers and may lead to gastrointestinal
hemorrhage.,1-,‘ Endoscopic studies
of gastric mucosal disease in alco­
holics. Moderate to severe antral
gastritis has been found in 46% of
alcohol abusers (the proportion
was about half in a control group),”
and abnormal gastric tissue was
noted in all the members of a group
of 51 patients with chronic alcohol­
ism’* However, the evidence that
alcohol consumption causes chronic
gastritis has been questioned. ”
Many authors have stressed a
symp-

toms in alcohol abusers. In one
study of absenteeism in office staff

further investigation is required to
substantiate this apparent relation-

group of heavy drinkers were absent
from work because of upper gastro­
intestinal complaints.” It would
appear that the clinical manifesta­
tions of peptic ulceration are twice
as common in alcoholic patients
as in control subjects
Although
a number of studies suggest that
the incidence of peptic ulcer is
higher with alcohol abuse.11'”'’®

Alcohol consumption is an im­
portant etiologic factor in both acute
and chronic pancreatitis. The in­
cidence of alcohol-associated acute
pancreatitis in younger age groups
seems to be increasing.” Chronic
pancreatitis, when advanced, can
enzymes. This may account for cer­
tain abnormalities in nutrient ab-

Table I—Clinical symptoms and signs ol

Symptoms and signs
General appearance
P Excitability, irritability, nervousness
Unkempf appearance
M Alcoholic facies

Peridontal disease
Alcoholic fetor by day
Gastrointestinal tract
Dyspepsia
Morning nausea and vomiting
Recurrent diarrhea
Recurrent abdominal pain
Hepatomegaly
Splenomegaly
Gastrointestinal bleeding
Amenorrhea
Impotence
Face, skin and hands

Finger clubbing

Cardiovascular and respiratory system
Palpitations
Cardiomyopathy
Hypertension
Chronic obstructive airways disease
Recurrent chest infection and pneumonia
Poor memory for recent events
Blackouts
’ Peripheral neuropathy, myopathy
Insomnia, nightmares
Hallucinations
Delirium tremens
Wernicke Korsakoff syndrome
Miscellaneous
Random blood alcohol level
55 mmol/l (300 mg/dt)
No gross incidents of intoxication with
blood alcohol level > 33 mmol/l
(150 mg 'dl)

"E = usually early; L « usually late.
j+ - probably a good indicator of alcohol abuse.

Stage of
*appearance

Diagnostic
valuer

sorption that are associated with
chronic alcohol abuse.” Motor func­
tion of the stomach and small in­
testines is affected by alcohol.
**
”
Robles and colleagues” have shown
that impeding peristaltic waves are
decreased by alcohol, but that
propulsive movement remains un­
changed. This altered small bowel
motility could increase the rate of
transit in the small bowel and may
contribute to the diarrhea that is
associated with “binge drinking”. In
addition, chronic, heavy consump­
tion of alcohol may interfere direct­
ly with absorption in the small in­
testine.1* Recent evidence indicates
that caffeine consumed in normal
amounts may increase the serosa
to mucosa flux of fluid in the intes­
tines. leading to an intraluminal
accumulation of fluid and subse­
quently to diarrhea.” Thus, the-al­
cohol abuser who also consumes
caffeine may be even more prone to
diarrhea.
Both drinking in binges and
chronic alcohol abuse may lead to
substances, including D-xylose,
*
cal­
cium." B-complex vitamins
*®
1 and
iron ” However, other factors are
involved in the nutrient deficiencies
of alcoholics. These include an in­
adequate diet and metabolic dis­
orders secondary to chronic hazar­
dous alcohol consumption.
*
1 Overt
symptoms and signs of malnutrition

plications of alcoholism and
pear to be more prevalent in
“skid-row” alcoholic.
*'

Liver disease occurs frequently
with chronic alcohol abuse, and
alcoholic liver disease in adult
populations is positively correlated
with the overall per capita consump­
tion of alcohol.
*
4 About 10% of
alcohol abusers have cirrhosis.
which is more likely to develop in
the “continuous imbiber" than in
the “spree drinker”.* 1 The corrcla-

sumption and rates of death from
cirrhosis is well recognized.
*
4*4' In
one large study the observed death
rate from cirrhosis in 0478 alco­
holics was about 13 times more
frequent than would be expected in
the general population.
*
1 Although
CMA JOURNAL,MA^ 15. I9SI/VOL. 124 12S1

cirrhosis may present a number of
characteristic clinical symptoms and
stage in the morbidity sequence of
alcoholism.” It may take 5 to 10
years of chronic alcohol abuse
before cirrhosis appears.4* Important
precursors of cirrhosis, including
fatty liver, alcoholic hepatitis and
fibrosis, may frequently be asymp­
tomatic and have few or even no
clinical signs.4*-*' For example, the
spectrum of those with alcoholic
hepatitis may range from an asymp­
tomatic individual to a patient with
fever, jaundice, encephalopathy and
ascites.1' Rankin and coworkers
*'
drew attention to the problems of
demonstrating a lack of correlation
taj&ccn clinical signs and the sevMB of underlying liver disease as
a^ssed by liver biopsy. The degree
of overlap of clinical manifestations
of the various liver disorders is such
that differentiation on clinical
grounds is not possible with any

statistical analyses of various clinical
signs and tests of hver function,
provides greater diagnostic accuracy
than consideration of any single
*
test.
1' An important attempt to over­
come some of the problems sur­
rounding the clinical diagnosis of
alcoholic liver disease is the
development of a composite index
to assess severity of alcoholic liver
*
disease.
1 This clinical and labo­
ratory index is based on 11 clinical
signs (hepatomegaly, splenomegaly.
ascites, encephalopathy, a clinically
overt tendency to bleed, spider nevi.
palmar erythema, collateral venous
circulation on the anterior ab­
dominal wall, circulation, peripheral
edema, anorexia and weight loss)
laboratory findings (levels of
g^Rmic oxaloacetic transaminase
[SGOT], y-glulamyl transpeptidase
|GGT), alkaline phosphatase, albu­
min and bilirubin in the serum, and
prothrombin time). The scoring sys­
tem of this index is based on the
concept that the severity of the un­
derlying liver disease is proportional
to the number of abnormal clinical
and laboratory findings. Certain
items, such as encephalopathy,
ascites, a raised level of serum bili­

rubin and a prolonged prothrom­
bin lime, are weighted because they
are known to be associated with
more advanced disease and a poorer
prognosis.

cascs of chronic alcohol abuse,” ’4
it may occur only after a number of
years of heavy alcohol use.” The
onset of symptoms of this disorder
is variable but usually extends over
weeks or months. The neurologic
Neurologic disease
deficit is frequently bilateral, sym­
Both periodic heavy drinking and metric and sensorimotor in type, h
chronic alcohol abuse produce a is important to be aware that subvariety of complex metabolic and clinical neuropathy is common.
pathophysiologic alterations in the Clinical findings include weakness.
central and peripheral nervous sys­ muscle wasting and tenderness, a
tems. However, the precise cause ol loss of reflexes and distal sensory
impairment or loss. Patients may
alcohol abuse is unknown. Neu­ complain of burning feet or of
rologic disorders in the alcoholic trophic skin changes in the lower
have been classified on phenomenologic, etiologic and neuropathologic bases.
*
4*4 The main neurologic Significant defects in memorj and
disturbances in alcohol abusers
are acute intoxication, withdrawal present in alcohol abusers/1” but
symptoms (e.g, trcmulousness), hal­ clinically overt intellectual impair­
lucinations, epilepsy, delirium tre­ ment may be present in a smaller
mens. Wernicke-Korsakoff syn­ proportion of patients."4' Dementia
drome, polyneuropathy, cerebellar
degeneration, central pontine mye­
linolysis, Marchiafava-Bignami dis­
»nd it is more common in
ease, neurologic sequelae of chronic
hepatic disease (e.g., hepatic ence­
Many- of these neuropsychologic
phalopathy), cerebral atrophy with deficits have been presumed to be
neuropsychologic impairment and related to cerebral atrophy.” Recent
alcoholic dementia “ In addition to studies haw indicated that both ab­
neurologic dysfunction, alcohol
abusers may have an uncommon but tesla and cerebral atrophy, as meas­
well defined syndrome of acute al­ ured by computer-assisted transaxial
coholic myopathy, with muscle pain. tomography, are present in abusers
tenderness, swelling and variable
myoglobulinuria." ” A chronic myo­ ures may not reflect the duration of
pathy may occur with an insidious heavy drinking, and the ncuropsyonset of muscle weakness and
correlate with the amount of cere­
Although symptoms and signs of bral atrophy/' Although physicians
do not generally use neuropsycholmay be useful clinical indicators of
alcohol abuse, they are extremely tests would be effective in detecting
variable. It is especially important
to be aware of mild withdrawal re­
actions such as tremor, anxiety, in­
Alcohol abuse plays a major role
somnia. hyperreflexia, and a low­
ered seizure threshold."''" All of in accidents, criminal behavior, acts
these symptoms may appear within of violence, suicide and other serious
a few hours of withdrawal from events.'" Numerous studies have imdrinking alcohol and may last for
approximately 2 days.’1 Severe with- traffic. industrial and recreational
accidents.14'”’* A direct result of an
fusion, hallucinations, seizures and increased accident rale among
full-blown delirium tremens, are abusers of alcohol is a high inci­
often most evident between 2 and 4 dence of traumatic injuries. Past or
days after withdrawal but may per- present traumatic events are among
Although peripheral neuropaths

1282 CM A JOURNAL/MAY 15, 1981/VOL. 124

heavy drinkers admitted to treat­
ment units.
*
’” One survey estab­

lished that 36% of regular drinkers
had reported at least two accidental
injuries in the preceding year, com­
pared with an accident rate of only
8% in nondrinkers." The extent to
which alcohol is involved in acci­
dents and emergency admissions to
hospitals has been substantiated by
a recent stud) that demonstrated
that approximately one third of all
patients attending a casually depart­
ment in a large general hospital in
the evening had a blood alcohol
concentration of over 17.4 mmol/l
(80 mg/dl).” Bone fractures occur
commonly in heavy drinkers,
*
’’ and
since injuries are known to be
among the most common causes for
medical consultation in inebriated
patients ” an awareness of the pre­
valence of such alcohol-related morcan aid in detecting alcohol
.... ... ..Jgation conducted by
the Addiction Research Foundation
of Ontario in Toronto, rib or thora­
cic vertebral fractures or both were
found on the routine chest roent­
genograms of 28.9% of a group of

matched control group of social
rinkcrs. An increased exposure to
**
ber of thoracic fractures Since trau­
ma occurs early among the prob­
lems related to alcohol abuse, evi­
dence of fractures ma) be an earl)
indicator of past or present hazar­
dous alcohol use.
A number of studies have drawn
attention to the association between
acute alcohol intoxication and head
*
injury.
4'* in one prospective study

women admitted to hospital with a

Cardiovascular and respiratory

A number of investigations have
documented an association between
alcohol consumption and hyperten­
**
sion.
101 In a study of the alcoholic
employees of a large company, Pell
and D'Alonzo" found a two- to
threefold greater prevalence ol
hypertension la systolic blood pres­
sure higher than 160 mm Hg or a
diastolic pressure higher than 95 mm
Hg) in alcohol abusers than in
matched controls. From a survey
of 84 000 people Klatsky and as­
sociates"” reported that the pre­
valence of hypertension was 11.2%
in individuals ingesting six or more
drinks a day compared with 4.6%
in nondrinkers. Alcohol abusers
have an increased risk of premature
death from diseases of the cardio­
that alcohol consumption, by contri­
buting to hypertension, increases the

ditional investigation is required to
define the level of alcohol consump­
tion that is associated with an in­
creased risk of cardiovascular dis­
ease and to ascertain the underlying
mechanisms.10*
The relation between alcohol
abuse and coronary artery disease
requires further clarification, since
it appears that the prevalence of
coronary artery disease decreases as
the quantity of alcohol consumed
increases, up to an intake of about

Miscellaneous symptoms and signs
Normal sleep patterns are disrup­
ted by alcohol consumption.1" Sleep
problems such as insomnia and
frightening dreams are frequently
experienced by abusers of alcohol."’
Detailed studies of the sleep of
alcohol abusers and of normal
volunteers following alcohol inges­
tion have shown that both the qualturbed by alcohol.,,WM Complaints
of sleep disturbance, especially from
young patients, should prompt a
clinician to enquire about drinking

Reduced libido and impotence
are recognized as being associated
with chronic alcohol abuse. Masters
and Johnson"’ indicated that
secondary impotence in men is fre­
quently caused by the excessive
consumption of alcohol. Lemere
and Smith"1 reported impotence in

but found little evidence of sexual
dysfunction in women who abused
alcohol Most alcoholic patients

drink more than this amount max

been normal for a number of years
disease than nondrinkers.' A clear
association between alcohol abuse
and cardiomyopathy is well recog­
nized, and is r ---- '
congestive can
in alcohol
abusers undei . . t.. .
Alcoholic cardiomyopathy may be
acute or chronic, and is often mani-

alcohol in their blood.”’ Galbraith
and associates
*
’ observed that
its and falling while under the
nee of alcohol were common
s of head injury, whereas road
traffic accidents accounted for only
25% of cases. Preliminary data
from a study of patients
chronic subdural hematoma ad-

sion." Cardiac arrhythmias may
occur in association with cardiomy­
opathy"" or with intoxication in pa­
tients without other clinical evidence

pital in Toronto indicate that be­
tween 30% and 40% of such pa­
tients may be abusers of alcohol
(M.S. Jacobs. P.L. Carlen: personal
communication, 1979).

structivc airways disease, pul­
monary fibrosis, tuberculosis and

S

bronchiectasis.10*"*' A predisposition
to pulmonary disease may be a
direct result of the toxic effect of
alcohol on the lung or an indirect
result of the fact that alcoholics tend
to be malnourished, to suffer from
aspiration pneumonia and repeated
respiratory tract infections and to
be heavy cigarette smokers.10’1"" It
seems likely that excessive smoking
is a major cause of cardiac and pul­
monary disease in alcoholics/
*'
10’

drinking sexual ability rends to be
reduced.'" The wide variability in
what is considered normal sexual
performance and the problem of
obtaining accurate accounts of
sexual function render sexual acti­
vity difficult to study. Important
components of impotence that the
alcoholic man may experience are
a reduction or absence of sexual
drive and a failure to achieve
erection or ejaculation or both."
The causes of sexual dysfunction in

completely but Lemere and Smith"
have suggested that alcohol may
damage the complex of neurologic

CMA JOURNAL/MAY 15, 1981/VOL 124 1283

psychologic factors may often be of
secondary importance
Margolis and Roberts"0 reported
that 249? of a population of
“chronic drinkers” derived from
500 consecutive admissions to ho.sskin lesions. Metabolic derange­
ments. poor hygiene, inadequate nu­
trition and trauma may cause
in alcohol
iirictv of cuta-

rythema
with or without telangiectasia

although they may also occur in
healthy people.1” Other signs of al­
coholic liver disease include jaun­
dice. purpura, abdominal varices
(caput medusae), "paper money
skin", the venous star, Campbell de
Morgan's spots (cherry angiomas),1"
sparse axillary and pubic hair, with
testicular atrophy.,u gynecomastia.

marks."1, palmar erythema.1” Du­
puytren's contracture.'” pigmentary

Icoholism.

ur commonly in alnd problem drinkers.
bruises and scars in un­
usual numbers or sites."1’ Uncom­
mon or unusual cutaneous signs.
such as pressure sores.1” widespread
insect stings,1” tattoos,'” frostbite
leg.’” eruptions
suctions.”* cuta-

and cutanc
infections1’" may ail provide a elm
to alcohol abuse. A growing depen­

The patient ihS
jral hygiene. In addition, there apt

neurodermatitis, dermaieborrhea capitis, sebor­
rheic dermatitis, eczeinatoid derma­
titis. aggravated acne and psoriasis
When chronic alcohol abus

ease, more specific skin changes
*
appear
Vascular skin lesions such
as spider angiomas and wiry telan­
giectasia”31” are among the more
specific indicators of underlying
liver disease in an alcohol abuser,"

atic parotid gland enlargement were
alcoholic, and 25 of this group had
cirrhosis of the liver." Wolfe and
collaborators'" also drew attention
to the increased incidence of parotid
enlargement in patients with al­
coholic liver cirrhosis, but other in­
vestigators have noted this condi­
tion in patients who did not have
cirrhosis and drank only moderate

for alcohol abus
Thomson'” found i

Shav.

and

of enlargement
>o be associated
eatitis in non
*
alcoholic patients
and transient

compensator)

salivation has been recorded in an
alcoholic man in association with
recurrent attacks of acute pancrea­
titis."’ The cause of parotid swelling
in abusers of alcohol is unknown.

reduction ol alcohol intake may de­
crease the amount of enlargement of
the parotid gland, as will an im­
provement in liver function in pa­
tients with cirrhosis.150 The relative
a useful clinical sign for detecting
chronic alcohol abuse and perhaps

1284 CM A JOURNAL/MAY 15. 1981/VOL.

Laboratory tests and
biochemical markers

alcohol abuse, laboratory tests used

nonspecific.
The only true indicator of alcohol
consumption is the detection of
alcohol or one of its metabolites in

the relatively short half-life of these
compounds and the fact that their

as clubbint
banded nai

bilateral

abuse into three categoric

provide an indication of reduced or
continued alcohol consumption.

usefulness as markers of alcohol
abuse. Both the circumstances under
fluids and its concentration may be
strong indicators of the presence
of hazardous alcohol consumption.
The National Council on Alcohol­
ism (NCA) criteria for diagnosing
alcohol abuse regard a blood al­
cohol level of greater than
65 mmol/1 (300 mg/dl), recorded
at any time, or a level of more than
22 mmol/1 (100 mg/dl). recorded
during a routine clinical examina­
tion. as important indicators of alcoholism.111 A blood alcohol level
of more than 33 mmol/1 (150 mg/dl >
in a patient who is not obviously
intoxicated is evidence of tolerance

dicator of alcohol abuse.
The laboratory tests that may be
used to detect alcohol abuse will be
reviewed. A summary of key find­
Alcohol and acetaldehyde

Estimates of the level of alcohol
in urine or blood have an established
role in the diagnosis of intoxica­
tion.115 and repeating these estima­
tions may provide an indication of
chronic hazardous alcohol consump­
tion.'“1W Clinical signs such as
slurred speech, muscular incoor­
dination, alcoholic fetor and ery­
thema of the conjunctiva are often
unreliable indicators of intoxication
since a medical practitioner may
consider a patient sober when blood
alcohol concentrations arc recorded
at a level consistent with marked

inebriation.'14 When difficult man­
agement decisions occur because of
suspected intoxication, a test that
will give an immediate result is re­
quired. This has led to the analysis
of alcohol in the breath as a diag­
nostic tool in clinical practice.’1*
Inaccuracies in the use of breath al­
cohol analysers have prompted stu­
dies of saliva and sweat as indic­
ators of alcohol abuse'15.■'4* and these
methods seem promising, it may be
possible to obtain an objective
estimate of the amount of alcohol
consumed over a period of time by
analysing sweat,'5’ but the value of
this technique in general clinical
practice has not been explored in

Acetaldehyde and acetate, which
are products of the oxidation of
nlcohol in the body, can be meas­
ured in blood However, technical
difficulties in their measurement in
the laboratory, their low concentra
lions in blood and their short halt­
life render it impractical to use them
as a diagnostic test, and they offer

little advantage over measuring
blood alcohol levels.’

Multirest approaches

There are many examples of the
use of a battery of laboratory tests,
especially in patients in hospital, to

of patients attending
ilcohol consumption.

ma!, was found to affect a number
of biochemical and hematologic
findings, including the serum levels
volume

and colleagues'
*
1 suggested that
these laboratory tests could be used
to compare alcohol intake within

of time. Howe

Table II- Laboratory markers of excessive alcohol, or ethanol, consumption
Marker

Diagnostic value

Serum ^-glutamyl
transpeptidase level

Mean corpuscular volume

Serumjaspartate aminotransferase

Serum htgh-densily-lipoprotein
cholesterol level
Serum glutamate
dehydrogenase level

Serum transferrin level

Ratio of u-amino-n-butyric
acid to leucine

t

Raised in 70% to 80" of alcoholic patients.
Responds to ethanol consumption in excess
of 40 to 60 g/d. Probably one of the
best early indicators except in individuals
with nonalcoholic liver disease and those
taking other drugs.
Raised in 75% to S0~ of alcoholic patients
in excess ot 60 g/d.
Raised in 30% to 75% of alcoholic patients.
probably not responsive to low levels of
alcohol consumption.
Raised in 50% to 80% of alcoholic patients.
Probably sensitive to moderate ethanol
consumption (40 to 60 g/d) but not in
patients with severe alcoholic liver disease.
Raised in alcoholic patients with severe
liver disease and in patients with fatty
liver following excessive alcohoHngestion.

Raised in 81% of alcoholic patients who
consume over 60 g/d ot ethanol. Not
present in patients with nonalcoholic
liver disease and raised levels of serum
glutamic oxaloacetic transaminase. Sensitive
to low to moderate ethanol consumption.
Quantitation and methodologic simplification
of test methods should render this
determination valuable.
Raised in some types of alcoholic patients

used for the early identification of
alcohol abuse there might be false­
negative and false-positive results.
Therefore, it is necessary to inter­
pret laboratory findings in conjunc­
tion with other medical or sociobehavioural data.'
**

Blood lipids
Alcohol exerts an effect on the
metabolism and transport of lipids.
tending to raise serum concentra­
tions of triglycerides and highdensity-lipoprotein (HDL) choles­
terol.Results of the Coopera­
tive Lipoprotein Phenotyping Study
indicated that alcohol consumption
was correlated with HDL-cholcsterol levels in all populations, and
that lipid levels appeared to show
a graded response even over lower
ranges of alcohol consumption In
addition, it was noted that serum
triglyceride levels showed a modest
positive correlation and low-den­
sity-lipoprotein (LDL) cholesterol
levels a consistently negative corre­
lation with alcohol consumption.,r
Other studies in large populations
have confirmed these observa­
*
tions'
“* It has been demonstrated
in healthy volunteers that when al­
cohol is added to a normal diet
HDL-cholesterol levels rise, where­
as with a cessation of drinking these

alcohol consumption, there havt
been relatively feu studies of HDL-

lations. Johansson and Mcdhus"
*
measured serum HDL-cholesterol
levels in 69 alcoholic men who had
been on drinking bouts for various
periods (5 to 10 days) beiore ad­
mission to hospital. Thev observed
that HDL-choksierol levels were in­
creased in 60 of the patients but
tend&d to return to normal within
2 weeks after the patients stopped
drinking. However, they found no
correlation between HDL-cholesterol concentrations and liver
damage as assessed from the scrum
levels oi bilirubin. SOOT, glutamic
pyruvic transaminase (SGPT) and
GGT. and the retention of sulfobromophthalein. In a study of similar
design an increase in serum HDLcholesterol levels was noted in 25
of 39 alcoholic men while they

CMA JOURNAL/MA> 15. I9KI.VOL. 124 1285

*were intoxicated,but again no
correlation was found between
HDL-cholesterol levels and other
measures of liver function. How­
ever, these studies did not provide
data on the patients' dietary and nu­
tritional status, the type or amount
of alcohol they consumed, the re­
sults of liver biopsy or details of
prior drug treatment, all of which
may modify serum concentrations
of HDL-cholesterol.
Since liver disease exerts a major
effect on the level of HDL-cholesterol in the serum, using this test as
a marker of alcohol consumption
may not be useful in patients with
alcoholic hepatitis or cirrhosis. To
further examine the relationship
between serum HDL-cholesterol
ievel^nad alcohol consumption in
patiJ^Wwith liver disease, liver
function and alcohol consumption
(assessed objectively by estimating
the amount of alcohol in the urine)
were measured in 57 alcoholic pa­
tients with liver disease.’*7 HDLcholesterol levels were also deter­
mined in a control group of 67 hos­
pital employees with no known his­
tory of hazardous alcohol consump­
tion. There was no significant dif­
ference between the HDL-cholcsterol levels of the patients and the
controls However, within the pa­
tient group HDL-cholesterol was
found to be significantly higher in
those who were still drinking (posi­
tive urine tests) than in those who
had not been drinking. Nevertheless.
serum HDL-cholesterol levels were
found to be inversely correlated witn
the severity of liver disease as as­
sessed by laboratory measures of
prothrombin time, total bilirubin.
albumin and alkaline phosphatase.
Although HDL-cholesterol has a
tendency to be higher in alcoholic
patient/ who are still drinking it
max
within normal limits in
paiie^Pwith, liver disease, largely
because impaired liver functions will
lend to lower HDL-cholesterol
levels. Thus, a measure of HDLcholesterol may not be a reliable
test for detecting alcohol abuse in
patients with liver disease.

sumption. These enzymes include
SGOT (ASAT), SGPT (alanine aminotransferable [ALAT]), glutamate
dehydrogenase (GDH), lactate de­
hydrogenase (LDH) and alkaline
phosphatase Skude and Wadstein"’
found that in a group of patients
admitted to a Swedish hospital for
the treatment of alcohol abuse 77%
had raised SGOT values and 50%
had raised SGPT values. Rosalki
and Rau"
*
reported that 32% of a
similar group of patients had
raised SGOT levels. Orrego and
coworkers4' studied alcoholic pa­
tients with mild liver disease and
found that 76% had raised SGOT
and SGPT are nonspecific indicators
of liver damage, an SGOT/SGPT
ratio greater than 2 is considered
highly suggestive of alcoholic hepa­
titis or cirrhosis or both.'”
The serum GGT level appears to

holic consumption and has been
shown to be raised in about three
quarters of a group of alcoholic pa­
tients who had no evidence of hepa­
tomegaly or other clinical signs of
liver disease
While the serum
GGT level is known to be raised in
patients with a variety of liver dis-

coholic patients at a time when the
SGOT, SGPT and alkaline phos­
phatase levels are normal."’ GGT
is stored mainly in the liver as a
membrane-bound constituent of the
microsomal fraction."’ Since an in­
crease m microsomal mass is one of
the earliest results of chronic alcohol
consumption, the location of GGT
probably accounts for its special
sensitivity as an indicator of liver
disturbances in heavy drinkers. Al­
though an increased level of GGT
may correlate with liver cell nec­
rosis,"’ in many cases it probably
reflects microsomal induction. It
may also be raised because of drug
therapy."4
Rollason and associates"’ com­

alkaline phosphatase in groups of
subjects with different drinking
habits. They were able to demon­
strate significant differences in these
. levels between nondrinkers and
The concentration of a number ol heavy drinkers. Whitehead and
enzymes in the blood is known to collaborators"
*
found an increased
increase with excessive alcohol eon- level of GGT in 179? of 2034 men

1286 CMA JOURNAL/MAY 15. 1981/VOL. 124

in London. England and suggested
that excessive alcohol consumption
caused the raised levels of the en­
zyme in over 60% of cases. Pomerleau and colleagues’" confirmed this
observation by finding a significant
correlation between the ethanol con­
sumption reported by a group of
subjects seeking treatment for al­
cohol abuse and the subjects' GGT
levels. Although the relation be­
tween alcohol consumption and
raised serum levels of GGT has
been demonstrated by numerous
studies,"’”3 its use as a diagnostic
marker of alcohol abuse may have
certain limitations.”4’^
Studies of LDH concentrations in,
blood obtained from chronic abusers
of alcohol while they were in­
toxicated indicated that LDH isoen­
zyme levels change in most drinkers,
with a tendency to increases in the
LDH-1. LDH-2 and LDH-5 fraciions.”‘-,vT In a study of 100 alco­
holic patients the GDH level was
found to be a reliable marker of
liver cell necrosis.’" Raised GDH
concentrations in the blood dis­
criminated between patients with
hepatic necrosis and those without.
as assessed by liver biopsy. Further­
more, GDH measurement was able
to detect cases of alcoholic hepatitis
that were considered “clinically
silent" and seemed to yield few
false-positive results. However, data
from other studies have not con­
firmed these findings. Jenkim. and
associates'0* reported that in alco­
holic patients with fatly livers, those
who had recently consumed an
excessive amount of alcohol also
showed increased serum levels of
GDH. In addition, the level of this
enzyme was not markedly raised in
nonalcoholic volunteers consuming

Ratia oj plasma a-aniino-n?
butyric acid to leucine

Recently interest has focused on
using the ratio of a-amino-n-butyric
acid (AANB) to leucine in the plas­
ma as a potential biochemical
marker of alcohol abuse. Shaw and
Lieber”0 have shown that chronic
alcohol abuse produces an increase
in the level of AANB in the plasma.
However, this increase does not

result from a single bout of heavy
drinking, which suggests that AANB
might be a useful indicator of long­
term alcohol consumption Since the
level of AANB is known to be de­
pressed by a deficiency of dietary
protein. and since the diet of alco­
holics is frequently deficient in pro­
tein,it has been proposed that a
more accurate marker of alcoholism
might be obtained by expressing the
level of AANB relative to that of
*"
leucine.
Expression of the ratio to
leucine was chosen because the con­
centration of leucine in the blood is
depressed by protein malnutrition.
Conflicting data have been re­
ported on the use of the AANB: leu­
cine ratio for diagnosing alcohol
abuse Shaw and coworkers’" re­
^^ted an increased ratio in well
^Mirished baboons fed alcohol and
in both ambulatory and hospitalized
alcoholic patients. Furthermore.
these investigators found a signif­
icant positive correlation between
the AANB.leucine ratio and the
degree of alcohol abuse as assessed
by separate criteria (c.g.. NCA cri­
teria and reports of average daily
ethanol intake) in a sample of alco­
holic and nonalcoholic patients tak­
ing methadone. These findings were
confirmed in two subsequent studies.’,’-’,:‘ Using the AANB-.leucine
ratio in combination with GGT
levels was reported to detect alcohol
abuse in 28 out of 33 heavy drink­
ers. with a false-positive rate of only
2%.’" Recently Shaw and colla­
borators”" reported that the level
of AANB decreased during with­
drawal from, alcohol and during
abstinence.
Other investigators have dis­
agreed with the findings of Shaw’s
group. Morgan and colleagues” ‘
concluded that the AANBJeucine
• provides an indication of he• dysfunction rather than longalcohol abuse. Data from
Dienstag and associates’1' showed
that this ratio increased nonspecifically in humans with liver disease un­
related to alcohol and in animals
with liver cell injury. These findings
indicate that a raised AANB:leucine
ratio is not necessarily characteristic
of chronic alcohol abuse. Ellingboe
and coworkers”* confirmed these
findings and concluded that this
ratio cannot be used as an empirical

«

biochemical marker of long-term
alcohol abuse. Finally, Hilderbrand
and collaborators’" found no sig­
nificant correlation between the
AANB:leucine ratio and either re­
ported drinking or GGT levels.
Thus, the potential use of the
AANB'leucine ratio to screen for
alcohol abuse is questionable. El­
lingboe and coworkers’" suggested
that these conflicting results might
be explained by the fact that hepato­
cellular disease in general, rather
than alcohol consumption alone, in­
creases this ratio. It is likely that a
considerable number of patients
studied had liver disease, which
could account lor the raised AANB:
Even with unanimous
evidence to support its value, this
ratio is unlikely to be used routinely
since AANB measures are expen­
sive, requiring the use of an amino­
acid analyser.

proponion of the individuals with a
high MCV were considered to be
consuming excessive amounts of al­
cohol Wu and collaborators”1' de­
termined the MCV in 63 alcoholic
inpatients of a general hospital and
found that 899? had macrocytosis.
generally associated with anemia.
In this study megaloblastic marrow­
samples were found in only one

laborators’ ” were able to demon­
strate that macrocytosis resolved
with alcohol withdrawal but per­
sisted if alcohol intake continued,
despite folate supplementation.
They concluded that macrocytosis

study of risk factors for car:ular disease the hematologic
to both their alcohol consump-

consumption
may produc
in the hematopoietic system, includ-

erythropoicsis.”* cytoplasmic and
nuclear vacuolation of early myeloid
and erythroid precursors in the bone
marrow,’1*' ”* altered folate status

transient hemolysis with hyperlipid­
emia,'” a reversible type oi side­
roblastic erythropoiesis.” leuko­
penic and leukocytopenic responses
■ • • ' ions.”'”’ thrombocytopenia;
hemostatic de-

cytic abnormalities, including ma­
crocytosis.”*’’ ' acanthocytosis”1'* 3’
and stomaiocyiosis.”*
The most frequent hematologic
findings a clinician may observe in
an alcoholic patient arc a normal
hemoglobin concentration, a nor­
moblastic marrow, normal serum
Bn and folate concentrations and a
raised MCV.’' Several studies have
indicated that an increased MCV in­
dicates heavy alcohol consumption.
and that estimation of the MCV
may be important in the detection of
alcohol abuse.u”ws“’10 Unger and
Johnson”* found that 3% of the
company had macrocytosis (MCV
more than 96 'fl for men and more
than 100/fl for women): a large

was found that the correlation of al­
cohol consumption with erythrocyte
count and MCV was more marked
in smokers. In contrast, the corre­
lation between alcohol consumption
and leukocyte count was more
marked in nonsmokers. These find­
ings underscore the need to con­
sider smoking habits with alcohol
consumption when interpreting
changes, especially in view of the
strong association between alcohol
abuse and cigarette smoking.

Miscellanec
association with heavy drinking.

lo have higher serum uric acid levels
than light drinkers, but this dif­
ference was apparent only in men."’
w'ith a decrease in chloride and ar
increase in lactate concentrations

excretion of uric acid, may be found
in heavy drinkers.1"”’ It has been
suggested that if a patient’s serum
uric acid level is raised on admis­
sion to hospital but returns to nor­
involvement can be suspected ’
Disturbances in acid-base hal­

CMA JOURNAIJMAY 15. 1V81/VOL.

1287

ande. with ketosis,
*"
alterations in acids may be a more sensitive in­
porphyrin metabolism”' and distur­ dicator of alcoholic liver disease
bances in carbohydrate metabol­ than the results of a number of more
*
ism,
41 may occur with chronic al­ standard serologic tests
cohol abuse. Alcohol intake may
A number of studies have drawn
result in an increased excretion of attention to abnormalities of min­
porphobilinogen.
aminolevulinic eral and vitamin metabolism in al­
acid and coproporphyrins. In some coholics. The excretion of magne­
circumstances there may be a rela­ sium. zinc and calcium is increased
tion between changes in porphyrin by alcohol consumption, so that
excretion and the amount of alcohol serum magnesium and zinc con­
consumed.”*”’ Alcohol exerts a centrations may be low in alcoholic
complex effect on carbohydrate me­ patients”’ Vitamin and nutrient
tabolism. Following heavy alcohol deficiencies arc common in patients
consumption individuals can have who drink heavily n"u
low blood glucose levels while fast­ determined by a icomplex intcracing.”1 or can exhibit hyperglycemia lion of such factors; as poor diet and
or glycosuria, especially if they have malabsorption. th<e specific inter­
liver disease.
*"
”"
Terence of ethanol with the men
itients have been holism of vitamins and the present
*
in the urine an inof D-glucaric acid vitamin B and C deficiency in pa­
while drinking; this amount de- tients with alcohol-related illnesses
creases after thej • stop drinking.”' Baines
*
” found the prevalence of
Urinary glucaric acid excretion increases after the administration of that of thiamin deficiency, assessed
certain drugs and has been used as by the pyruvate tolerance test, 55%
a marker of microsomal enzyme and that of ascorbic acid deficiency
induction.”"”' While investigating 91%. Baines also reported a poor
the role of D-glucaric acid as a correlation between vitamin defi­
marker of alcohol abuse. Spencer- ciency and GGT activity in the
Peet and colleagues”* found no Cor­ serum. In view of the many influ­
relation between serum GGT and ences on vitamin status in alcoholic
urinary glucaric acid levels. This
may be due to the fact that an in­ vitamin levels to diagnose alcohol
creased GGT level in alcoholics re­ abuse may not be very rewarding.
flects both enzyme induction and
structural damage within the liver.
If a persistent increase in the
amount of D-glucaric acid excreted
is directly related to continuous plasma transferrin and salsolinol.
drinking, measurement of the urin­ Studies by Stibler and coworkers””
ary excretion of this substance may have shown that electrofocusing of
be of value in the detection of prob­ plasma proteins and further charac­
lem drinking.
terization by immunofixation reveals
Serum levels of bile acids have an abnormal transferrin band with
been found to be abnormally raised a pH of 5.7 in 81% of alcoholic
in a large number ol patients with patients admitting to consumption
uk|^dic liver disease.”1”' In a of more than 60 g of ethanol a day
sttfl^ited by Overby”4 the serum in the previous week. The percent­
levels of cholylglycine were found ages were 75% and 25% for those
to be raised in 97% of 144 patients reporting a consumption of 20 to
with alcoholic liver disease. Milstein 60 g/d and 7 to 20/d respectively,
and associates”1 detected marginally 8% for those reporting abstinence
increased or normal total bile acid and I % for control subjects. When
levels in the serum of six patients ethanol was given to eight controls
with alcohol-related fatty liver, and at a daily dose of 0.6 g/kg an ab­
significantly raised levels in 93% normal transferrin appeared after 5
of a group of 58 patients with more days in one subject at 7 days in a
second and at 11 days in a third;
These findings suggest that an in­ the SGOT level was normal in al)
creased concentration ol serum bile three. Furthermore, an abnormal

1288 CMA JOURNAL/MAY 15. I98I/VOL. 124

transferrin could not be detected in
22 patients with nonalcoholic liver
disease, although 84% had abnor­
mally high SGOT levels. The trans­
ferrin abnormalities apparently dis­
appeared after the patients stopped
drinking alcohol for 10 days.”'’"’
These data indicate that trans­
ferrin could be a good indicator of
alcohol abuse since it appears not
to reflect liver disease and may
detect low to moderate alcohol
consumption. Unfortunately, the
clccir< Hocusing-plus-immunofixation
technique is too complex for rou­
tine laboratory analysis. Another

solmol. the product of condensation
between acetaldehyde and dopa­
mine (Salsolinol has been found to
be 20 times more concentrated in
the urine of alcoholic patients ad­
mitted for detoxification than in that
of controls.”') The concentration of
salsolinol was reduced to baseline
levels following 4 days of with­
drawal of alcohol. As with trans­
ferrin. the current method for de­
termining salsolinol levels — highperformance liquid chromatography
plus mass spectrum analysis — is
too elaborate for routine analysis.
Discussion
Excessive alcohol consumption
produces measurable physiologic.
pathologic, biochemical and mor-

the body However, these changes
may also be produced by a variety
of diseases not related to alcohol
abuse. Even the most specific indica­
tors of alcohol abuse may only
measure the events resulting from
alcohol or its metabolites in a re­
latively small proportion of alco­
holic individuals Detecting alcohol
or a product of its metabolism in
body fluids is the only direct way
of ascertaining alcohol abuse, but
these compounds have a relatively
short half-life and cannot provide a
measure of alcohol tolerance or of
the duration and extent of previous
alcohol abuse. The circumstances
under which alcohol is detected is
important. For example, the pre­
sence of alcohol in blood specimens
obtained in the morning1*1 or fol­
lowing an accident”* may be a
strong indicator that an individual
has an alcohol problem.

gence dans les hcmorrhagics diges­
tives des cirrhoses A propos de

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654-658
Myrhed M, Berglund L. Bornger LE: Alcohol consumption and
hematology. Acta Med Scand 1977.
DP, Losowsks

INbX-)&7l>

and ethanol metabolism
Clin Incest 1962; 41;

ted with alcoholism in nondiabetic
subjects Ann Intern Med 1973: 78:

Effect of elhan
tabolism. J Clin

1970; 49:

108Kreuning J:

studies in chronic liver

cretion of porphyrins
coholics. Q J Stud Alcohol 1963;
24 598-609
ad L: Forearm glucose up-

in chronic alcoholic

blood cell mean corpuscular vol1974; 267:
K. Spur-cell anemia

bolnm. In Kissin

Hemolytic

acanthocytes in alcoholic cirrhosis
A' Engl J Med 1964; 271; 396-398
Donnelly WJ: Hurr cells, hemo­
lytic anemia and cirrhosis. Am J
Med 1968; 45; 78-87
Douglass CC. Twomey J J: Tran­
sient stomatocytosis with hemolysis:
a previously unrecognized com-

Med 1970; 72. 159-164
235. Alcohol and the blood (E)
Med J 1978. 1. 1504-1505
crocytose dans I’hcpatite alcoolique
chroniquc histologiqucmcnt prou-

marrow-erythroid morpholin alcoholic patients, zf/n J
Nmr 1967. 20: 716-722
Herbert V, Zalusky R, Davidson
CS. Correlation of folate deficiency

64- 309-315
237. Drum DE, Jankowski C: Diag­
nostic algorithms for detection of
alcoholism in general hospitals. In
Seixas FA. Bonner J. Peck SI

macrocytosi.s, anemia, and liver dis
case. Ann Intern Med 1963; 58
977-988
Westerman MP. Balcerzak SP.
Heinli EW Jr- Red cell lipids in
Zievc’s syndrome: their relation to
hemolysis and to red cel) osmotic
fragility J Lab Clin Med 1968; 72.
663-669
Hines JD: Reversible megaloblastic

238. Carney MWP. Sheffield B:
Serum folale and B12 and haemotological status of in-patient alco­
holics. Hr J Addict 1978; 7.3: 3-7
239. ESCHWEGE E. Papoz L, Leli.OUGH

alcoholics. Studies on "single-void­
ing” samples. Q J Stud Alcohol
1972
Hyperglycemia
coholic with hepatic insufficiency.
Clinical observations in 10 patients.
Phillips GB. Safrit HF: Alcoholic
diabetes. Induction of glucose in­
tolerance with alcohol. JAMA 1971;

DG: Effects of
carbohydrate meta-

lTEL

1976; 25: 239-243

cretion of D-glucaric acid in alco­
holism. Res Common Client Pathol
Hunter J. Maxwi

induction

1294 CMA JOURNAL/MAY 15. 1981/VOL. 124

EliaSSON G: Glucaric acid as

CM A JOURNAL/MAY 15. 1981/VOL

rtrt

•&

3

The role
of drugs
in chronic alcoholism
Moire S. Jacob, m.d., and Edward M. Sellers, m.d., Ph D.
J
|

I
•

I

Dr. Jacob is Head, Intensive Care
Unit, Addiction Research Foundation
Clinical Institute, and Dr. Sellers is
Director, Division of Clinical
Pharmacology, Addiction Research
Foundation Clinical Institute-Toronto
Western Hospital, University of
Toronto, Ontario.

Summary
Drugs are certainly not the therapy of
first choice in chronic alcoholism. But
they can play a significant role in
getting patients with anxiety and
.
endogenous depression involved in
treatment and keeping them there.
W Moreover, the threat of a disulfiram
reaction, in a well-motivated patient
taking that drug regularly, amounts to
enforced sobriety, a vital prerequisite
to any treatment or rehabilitation
i
program.

1
|

stimates of the number of people in
the United States with physical,
mental, and/or behavioral problems re­
lated to excessive consumption of alco­
hol vary between 6 and 12 million.
Approximately 3% of the work force
has drinking problems severe enough tq.
impair job performance; days lost from •
work because of alcoholism waste mil-.
lions of dollars annually in wages and
productivity. Moreover, since the annu-'
al average per capita alcohol consump­
tion is rising, so too is the number of
people with such problems.
' •.
Patients with alcohol-related prob1.
lems can be helped by treatment pri­
marily directed at correcting the etiol- •
ogy of the need for alcohol and the
secondary consequences of its long-"
term abuse. Drugs offer an effective
therapeutic adjunct, however, helping \
patients to accept and participate in
therapy and maintain their gains once
achieved.
Diagnosis of chronic alcoholism is
best begun by reviewing the patient’s
disease history, occupation, employ­
ment record, and social interactions. ..
Characteristic clues are sought, such as '
changes in the individual’s health or
disruption in family and social life (Ta- ‘
ble). No single observation during the
interview or physical examination is
proof of alcoholism, but historic clues
and physical signs will often help.1-2 A „

E

DRUG THERAPY/JANUARY 1978

53 •

CHRONIC ALCOHOLISM continued

Table: Clues on history for recognition of potential alcohol problems

full assessment of the alcoholic patient
should include extensive and careful
interviews with the patient’s spouse,
children, employer, and anyone else
who might be closely involved with him
or her. Including these various people
in the plans for therapy is also an
essential part of the overall treatment
program for alcoholic patients.
54

TREATMENT PLAN

When a person who is physically depen­
dent on alcohol stops drinking, the selflimiting withdrawal reaction seldom,
lasts longer than 2 weeks.2 Then the ,
therapy is aimed at correcting the
causes that led to the patient’s excess
intake, reducing his dependency on al­
cohol, and facilitating his reintegration
DRUG THERAPY/JANUARY 1978

into a stable social framework, prefer­
ably one including regular employment.
Since the causes of chronic alcoholism
are many and complex, the therapeutic
strategies are also varied and must be
adapted to the individual patient.

in the treatment of endogenous depres­
sion if given in adequate dosage. (With
amitriptyline, for example, patients
should receive 50 to 100 mg/day for the
first week. Since there is considerable
variability in absorption of the drug,
the dosage is tailored according to indi­
Pharmacotherapy
vidual needs. The usual daily dose after
Drugs can be invaluable in two major the first 2 weeks is 75 to 100 mg.) The
aspects of alcoholic therapy: in allevia­ need for hospitalization, however, is
tion of emotional problems, which are determined by the severity of the endo­
involved in both cause and effect of genous depression, regardless of dosage
excessive alcohol consumption, and in requirements.
the alteration of “chronic alcoholic” be­
All tricyclics have similar antide­
havior.3 Among the more commonly pressant activity and would be expected
J ted emotional or personality problems to provide the same symptomatic im­
said to lead to excessive alcohol con­ provement in chronic alcoholics with
sumption are anxiety, depression, low endogenous depression—this is the only
frustration tolerance, latent homosex­ indication for use of tricyclics in alco­
uality, and immaturity in assessment holics. These drugs produce a wide vari­
of long-term consequences. For most of ety of central and autonomic nervous
these problems, the treatment, if any, system and cardiac effects, which are
involves various forms of psychother­ particularly important and prevalent in
apy. Drugs are used primarily to alle­ older patients. Among these are the
viate anxiety or depression. They anticholinergic reactions—including
cannot, of course, substitute for psycho­ dry mouth, urinary retention, constipa­
therapy, which is aimed at replacing tion, confusion, delirium, hallucina­
alcohol consumption with more effec­ tions, bradycardia—and cardihc ar­
tive problem-solving methods. But rhythmias that have been known to
short-term (6 to 8 weeks) use of minor produce sudden death. Thus, dosage
tranquilizers and antidepressants can, must be titrated to achieve relief of
for example, help inpatients with pri­ depressive symptoms with the fewest
mary affective disorders to participate pharmacologic side effects.
Jn psychotherapeutic and rehabilitative
Neuroleptics. The group of drugs of­
^programs.
ten referred to as major tranquilizers
Anxiolytic drugs. The benzodiaze­ include chlorpromazine (Thorazine),
pines—chlordiazepoxide (Libritabs, trifluoperazine (Stelazine), thiorida­
Menrium), oxazepam (Serax), or diaze­ zine (Mellaril), and haloperidol (Hal­
pam (Valium)—are reportedly superior dol). They have not proved useful in the
to placebo with respect to subjective rehabilitation of the chronic alcoholic.
improvement of anxiety or to global Occasionally, patients may require
rating of patient response over 6 to 8 these drugs for concurrent primary
weeks. Affective changes are minimal, mental illness or extreme agitation.
however, and not all studies indicate
Disulfiram. Drinking is discouraged
even short-term effects.
by use of disulfiram (Antabuse), which
Antidepressants. The three classes
causes an aversive reaction when alco­
of tricyclic antidepressant drugs—the hol is consumed, thus directly altering
iminodibenzyls, such as imipramine the alcohol-dependent patient’s behav­
and desipramine (Norpramin, Perto- ior. Disulfiram blocks the oxidation of
frane); the dibenzocycloheptenes, which alcohol at acetaldehyde by inhibiting
include amitriptyline, nortriptyline aldehyde-NAD oxidoreductase, an en­
(Aventyl), and protriptyline (Vivactil); zyme located in liver mitochondria that
and the dibenzoxepines, such as doxe- mediates the biotransformation of ac­
pin (Adapin, Sinequan)—are effective etaldehyde to acetate. Thus, the concen55

CHRONIC ALCOHOLISM continued

tration of acetaldehyde in the blood
may be five to ten times higher than it
would be in the normal metabolism of
alcohol. Within 5 to 15 minutes of
ingesting 0.5 oz or more of spirits, the
patient feels warm and a flush begins to
develop over the upper chest, neck, and
malar region. Pulse pressure and heart
rate increase. The reaction may pro­
gress to nausea and vomiting, hypoten­
sion, severe anxiety, and dyspnea. It
may last several hours and has occa­
sionally been fatal.
The alcoholic is encouraged to take
disulfiram precisely because of the
threat of this reaction. The drug must
be taken daily by a willing patient,
however, since it loses its effect within
several days after being discontinued.
Although controlled studies of the
drug’s action and disposition have not
been done, it seems to be effective in
reducing the incidence of relapse in
some patients. When taken under direct
supervision and combined with counsel­
ing, maintenance on 250 mg/day may
result in better clinic attendance.4
The efficacy of disulfiram therapy
seems to depend on patient motivation
and on the amount and kind of coercion
imposed by legal obligation, family
members, or employer on the patient to
continue taking the drug.
Subcutaneous implantation of disul­
firam would seem a reasonable way of
ensuring patient compliance. Since it is
questionable in some patients whether
daily oral dosages of 250 to 500 mg of
disulfiram produce an adverse reaction
after alcohol, it is puzzling why im­
plants of 500 to 1,000 mg should be
effective for up to a month. The phar­
macologic actions appear to be mini­
mal; the benefits, mostly psychologic.4'5
The most commonly reported side
effects of disulfiram—fatigue, morning
sleepiness, and drowsiness—are all eas­
ily managed by having the patient take
the medication immediately before go­
ing to bed. Some patients also report
apathy, dizziness, impotence, and head­
aches. Assessment of the drug’s adverse
effects is difficult, since many of these
effects (including peripheral neuropa­
56

thy, reduced sexual potency, optic neu­
ritis, hepatitis, congestive failure, and
myocardial ischemia) may be caused by
alcohol or the nutritional deficiencies
associated with alcoholism.
Disulfiram also inhibits the biotrans­
formation of warfarin, phenytoin, diaz­
epam, and chlordiazepoxide, potentially
causing toxicity from ordinary dosage
of these agents. And since it is likely
that the biotransformation of other
drugs can also be inhibited, patients
taking disulfiram should be carefully
followed. It is contraindicated in pa­
tients with hepatitis, congestive failure,
angina, or coronary artery disease.
And, if possible, it should not be used in
patients with impaired renal or hepatic
function, hypertension, primary affec­
tive disorders, and a history of drug
overdose, as well as those who are
known to comply poorly with pre­
scribed instructions.
Citrated calcium carbimide can pro­
duce a physiologic interaction with
ethanol similar to that of disulfiram,
but the reaction is milder, of more
rapid onset, and of only half,the dura­
tion. There are no controlled studies of
its efficacy compared to placebo or to
disulfiram.
IN CONCLUSION

Drugs play a vital, but secondary, role
in the treatment and rehabilitation of
chronic alcoholic patients. Informed
prescription of appropriate antianxiety
and antidepressant agents plus disul­
firam can help the well-motivated alco­
holic face, and eventually solve, his
problem.
*
REFERENCES
1.
Criteria Committee, National Council on Alcoholism,
New York, NY: Criteria for the diagnosis of alcohol­
ism. Ann Intern Med 77:249-258,1972
2.
Jacob MS, Sellers EM: Emergency management of
alcohol withdrawal. Drug Therapy (Hospital Ed)
2:28-34, April 1977
3.
Sellers EM, Kalant H: Pharmacotherapy of acute and
chronic alcoholism and the alcohol withdrawal syn­
drome, in Clark WM, del Giudice J (eds): Principles of
Psychopharmacology, ed 2. New York, Academic
Press (in press)
4.
Kline SA, Kingstone E: Disulfiram implants: the
right treatment but the wrong drug? Can Med Assoc J
116:1382-1383, 1977
5.
Bell RG: Alcohol dependence: dlsulfiram implants.
Can Med Assoc J 116:1333-1335,1977

DRUG THERAPY/JANUARY 1978

HH 2^-'

Propranolol-Associated Confused States during Alcohol
Withdrawal
MOIRE S. JACOB, MD, FRCP(C),'-4 DUANE H. ZILM, PhD,3
STUART M. MACLEOD, MD, PhD, FRCP(C),2’4 and EDWARD
M. SELLERS, MD, PhD, FRCP(C)1'4

Departments of 'Medicine and ’Clinical Pharmacology and 3Human Responses and Biomedical
Engineering Laboratory, Clinical Institute, Addiction Research Foundation, Toronto, Ontario, Canada;
and‘'Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada

ROPRANOLOL has been used for over a decade as
an antiarrhythmic and antianginal agent. Serious
central nervous system side effects, in particular, hallu­
cinations, are not common and are usually associated
with high doses and extended durations of administra­
tion.1 Greenblatt and Koch-Weser2 reported 25 adverse
reactions in 268 hospitalized medical patients treated
with propranolol for angina, hypertension, arrhythmias,
and thyrotoxicosis. Eight were life threatening and re­
lated to cardiac depression consequent to ^-adrenergic
blocking activity. In four patients (1.5%), adverse effects
involved the central nervous system and included drow­
siness, fatigue, lightheadedness, dizziness, headache, nau-

P

Address requests for reprints to: Dr. E. M. Sellers, Addiction Re­
search Foundation, 33 Russell St., Toronto, Ontario, Canada M5S 2S1.

sea, and blurring of vision. No patients experienced hal­
lucinations or other toxic psychotic manifestations. The
frequency of delirium tremens is 0.1% in nonmedicated
chronic alcoholic patients.3
During a randomized double-blind clinical trial to com­
pare the efficacy of propranolol, chlordiazepoxide, and
placebo in the treatment of cardiac arrhythmias in alco­
hol withdrawal (referred to as the arrhythmia study),4 we
noted an exceedingly high incidence (27% of those receiv­
ing propranolol alone) of psychotoxic reactions related to
relatively small doses of propranolol. One additional pa­
tient receiving chlordiazepoxide, 25 mg, four times a day
orally, in combination with propranolol also had hallu­
cinations. In the arrhythmia study4 the four treatment
failures in the placebo group and two treatment failures
in the chlordiazepoxide group were not associated with
delirium or hallucinations.

Hrt 2-A- $

emergency
management of
alcohol withdrawal

Moire S. Jacob, M.D., KR.C.1’.,
and Edward M. Sellers, M.D., 1’h.i)., f.r.c.p.

Medicine, and Director.

28

Since the mean annual per capita consump­
tion of alcohol is increasing in all indus­
trialized countries, physicians can expect to
encounter more patients in alcohol with­
drawal. The severity of the alcohol with­
drawal reaction depends on both the inten­
sity and duration of alcohol consumption.
Generally, this withdrawal is mild and usu­
ally requires little medical treatment.
However, even mild withdrawal may pro­
gress to the major withdrawal syndrome of
delirium tremens, the mortality of which
may be as high as 15%. Morbidity in with­
drawal is highest when diagnosis of the
syndrome is delayed and when it occurs in
patients with other medical or surgical
problems.
The proper management of withdrawal
reactions depends largely on full assess­
ment and early treatment. Hull assessment
is intended to delect factors that increase
the morbidity of withdrawal (Figure 1), and
early treatment is intended to prevent
symptoms and signs from progressing to a
major reaction (Figure 2). Some complica­
tions may be overlooked, while others,
such as subdural hematoma, are difficult to
diagnose conclusively during withdrawal.
The medical and paramedical personnel
caring for the alcohol-abusing patient in the
emergency department should be sym­
pathetic and noncrilical to facilitate full as­
sessment and optimal management.

Clinical profile
of alcoholic withdrawal
In the large doses taken by alcoholics, eth­
anol has a depressant action on the central
nervous system. When alcohol ingestion is
abruptly decreased or discontinued, it is
the compensatory increase in neuronal ex­
citability that produces most of the signs
and symptoms characteristic of the alcohol
withdrawal reaction.

I’i'iiikii'h llrucuileiice
(alcohol icithilcairal si/ilili'oinc)
There is considerable individual variation
in the clinical signs and symptoms of alco­
hol 'withdrawal (Figure 2). In mild reac­
tions, the chief symptoms are hyperacuity,
hyperactivity of reflexes, tremor, anxiety,
insomnia, and reduction of seizure thresh­
old, all of which appear within a few hours
after drinking is stopped and last approxi­
mately 48 hours. Seizures during with­
drawal are typically grand mal, nonfocal,
one or two in number, and are most likely
to occur between 12 and 48 hours alter ces­
sation of drinking. In severe reactions,
tremulousnt'ss, seizures, auditory and/or
visual hallucinations, and global confusion
(delirium) tire most evident between -IS and
(>() hours after withdrawal, but may rarely
persist up to 10 days. Low-grade fever
(•• 38.5 ('■) is occasionally found in severe
withdrawal reactions without apparent
lilil G THI’.liAI’Y iliost’i Alfiui. 111"?

cause; nevertheless meticulous clinical and
laboratory assessment must always be
made to exclude infection, regardless of the
absolute level of temperature.
Secondary metabolic effects
Chronic ingestion of ethanol produces a
constellation of predictable secondary
metabolic changes (Table 1, coluritn 1).
Since most of these changes are alcohol in­
duced, they do not usually require treat­
ment other than supportive care and stop­
ping the consumption of alcohol. The laeticacidemia, hyperuricemia, hypertri­
glyceridemia, and ketosis are all attributed
to oxidation of excess nicotinamide adenine
nucleotide dehydrogenase (NADH), which
is produced during the conversion of alco­
hol to acetaldehyde by alcohol de­
hydrogenase. Insulin therapy is not re­
quired for hyperglycemia unless there is a
clinically important osmotic diuresis, keto­
acidosis, or the patient has a history of di­
abetes inellitus. On the other hand, severe
electrolyte abnormalities should he rou­
tinely treated since they may affect the
prognosis. If hypoglycemia is suspected, a
blood-sugar determination should be made,
and 50% dextrose is given (50 ml over 60
seconds). Alcohol-induced ketoacidosis
with accumulation of /3-hydroxybutyrate,
acetoacetate, and lactate develops after
several days of heavy drinking, with little
or no food, and associated vomiting. When
these anions account for the metabojic aci­
dosis, the anion gap (|N’a’ ] —([C1‘ 1+COJ)
will be greater than 15. Arterial blood-gas
determinations are necessary to assess the
nature and severity of such acid-base ab­
normalities, Bicarbonate is usually not indi­
cated if the pl I is > 7.1 and the actual bicar­
bonate value is > 15 meq/liter. These pa­
tients respond well to solutions of IN saline
and glucose that restore hydration and
liver glycogen.

Figure 1: Etiology of organic diseases
in the alcoholic patient

rhosis. It is difficult to assess the patient
accurately during withdrawal if there is co­
existent liver disease (with or without por­
tal encephalopathy), dementia, or other
neurologic problems. Excess sedation may
precipitate portal encephalopathy, as may
the common complications associated with
withdrawal—dehydration, - electrolyte im­
balance, hypoxia associated with pneu­
monia, infections, and gastrointestinal
hemorrhage.
Ascites may be aggravated if saline is ag­
gressively administered to the dehydrated
alcoholic with a history or clinical evidence

Figure 2: The time course of two typical clinical
instances of untreated alcohol withdrawal

Alcohol-induced disease
After prolonged drinking, the direct toxic
effects of alcohol produce various organic
disorders (Table 1, column 2). A careful his­
tory, obtained from either the patient or a
restive, should include the amount and
type of alcoholic beverage consumed daily
and the duration of its excessive use. An
average daily intake above SO g ethanol is
associated with an increased risk of cir­
29

alcohol
WITHDRAWAL

of portal hypertension. In these patients,
lO'r dextran (molecular weight •lO.noo) in
5% dextrose in water may temporar.lv cor­
rect serious hypovolemia.
Chest pain, arrhythmias, cardiomegaly,
congestive heart failure, or combinations of
these symptoms may indicate car­
diomyopathy. Results of careful examina­
tion of the cardiovascular system, including
a chest x-ray to assess cardiomegaly and
congestive heart failure, an electrocardio­
gram, and cardiac monitoring, will help de­
termine whether this complication is
present.

rapidly with parenteral thiamine. TVauma
(fractures, visceral injury, head injury, and
subdural hematoma) may easily be missed
in the patient who is already confused,
drowsy, and/or hallucinating. Actite bron­
chitis, aspiration, or pneumonia is often a
more difficult problem to manage in alco­
holics who smoke heavily.

Concurrent unrelated disease
Chronic alcoholics may have coincidental
diseases that are etiologically unrelated to
alcohol consumption and the withdrawal
syndrome (Table 1, column 4). Problems
arising from the concurrent use of seda­
Alcohol-associated disorders
Many concurrent clinical problems are re­ tives, tranquilizers, and alcohol often coex­
ist.
The alcoholic with diabetes mellitus
lated to the "life-style” of the alcoholic (Ta­
ble 1, column 3). For example, hypother­ may have hypoglycemia, hyperglycemia, or
diabetic
ketoacidosis. Alcoholics with epi­
mia, which may occur in the alcoholic
exposed to cold, can be missed because lepsy may discontinue anticonvulsant
therapy
and develop status epilepticus.
most clinical thermometers only register
35°C and above. (Electronic thermometers Systolic and diastolic hypertension may
subside
to
normal or mildly elevated values
with expandable scales and flexible probe
can be invaluable in the hypothermic rest­ after withdrawal has been accomplished.
less patient.)
Wernicke's encephalopathy (ataxia, ocu­ Laboratory investigation
lar palsies, nystagmus) often improves Table 2 lists important tests that should

Table 1: Clinical profiles of chronic alcoholic withdrawal

Primary alcohol dependence
(withdrawal syndrome)
Secondary metabolic
effects

Alcohol-Induced
diseases

Alcohol-associated
disorders

Electrolyte Imbalances
Hypokalemia
Hypomagnesemia
±
Hypocalcemia
Metabolic ketoacidosis
Lacticacldemia
Overhydration
Hyperglycemia
Hypoglycemia
Hypertriglyceridemia
Hyperuricemia

Cirrhosis
/ Ascites
\ Encephalopathy
j Varices
f Hepatorenal syndrome
Hepatitis
Peptic ulcer
Gl hemorrhage
Pancreatitis
Cerebellar degeneration
Dementia
Peripheral myopathy
Cardiomyopathy

Dehydration'
Anemia
Malnutrition
Hypothermia
Wernicke’s
encephalopathy
Trauma
Sepsis
Carcinoma
Oropharyngeal
Laryngeal
Bronchial
Chronic obstructive
lung disease
Aspiration pneumonia
Tuberculosis
Dysrhythmias
Subdural hematoma

Concurrent problems
not alcohol related
Use of sedatives,
tranquilizers
Diabetes mellitus
Epilepsy
Hypertension
Myocardial
infarction
Other systemic
diseases

Table 2: Clinical workup for assessing patients
in alcohol withdrawal
Additional tests

Barbiturate screening1

Urine

Urine

Biochemistry

Analysis
Microscopy
Occult blood
CBC and
differential
Glucose
Urea
Electrolytes
(Nat K+, CI-)
Carbon dioxide
Anion gap2

Arterial

Blood gases

X-ray

Skull
Bones
Chest

Stool
Hematology .

Blood may bo drawn and stored for
lator measurement of:
Calcium
Magnesium
Amylase
Serum glutamic oxaloacetic
transaminase (SCOT)
Serum bilirubin
Alkaline phosphatase
Total protein
albumin globulin
Prothrombin time
Creatinine phosphokinase (CPK)
Lactic dehydrogenase (LDH)
Hydroxybutyric dehydrogenase (HBD)
Lactate
/3-hyd roxybutyrate
Acetoacetate

Electrocardiogram
1. Other qualitative or quantitative screening ol urine or blood :s ordered on tho basis ot clinical assessment (eg, blood
ethanol, benzodiazepines, salicylates), provided that facilities ere available.
2. Calculated by' physician ( [Na
*]
-([Cl
*]
4* CO2)); if CO? content or anion gap is abnormal, arterial blood gasos should
be evaluated.

usually be considered when studying a pa­
tient in alcohol withdrawal. .Additional
helpful diagnostic tests are also cited. The
extent to which these patients can be as­
sessed will depend upon the available labo­
ratory facilities, the severity of the with­
drawal, and the presence of associated and
unrelated clinical problems.

Treatment
Many patients with mild-to-moderate with­
drawal reactions can be treated initially in
the emergency room and then safely man­
aged at home. Patients with severe uncon­
trolled withdrawal reactions or complicat­
ing problems require hospitalization. Gen­
eral emergency management includes
reassurance in surroundings that are well
lighted and quiet, monitoring of vital signs
as frequently as clinically indicated (eg,
cardiac monitoring if there are arrhyth­
mias), hydration, correction of electrolyte
abnormalities, and administration of thia­
mine, 100 mg parenterally.
P/i arniacoth era pmt ic object i res
Drug therapy for alcohol-v.ithdrawal reac­

tions is intended to relieve symptoms, pre­
vent or treat more serious complications
(eg, seizures, arrhythmias), and prepare
the patient for long-term rehabilitation
without introducing new drug-dependence
problems or therapy-related toxicity.
Various drugs are more effective than
placebo for accomplishing these objectives.
However, the benzodiazepines have re­
placed most of the older drugs because of
their wide margin of safety. Chlordiazepox­
ide (Libritabs, Menrium) is the most fre­
quently studied benzodiazepine (although
there is no evidence that any one of the
benzodiazepines is therapeutically superior
to any other). Chlordiazepoxide effectively
prevents the reactions from becoming more
severe by decreasing anxiety, restlessness,
tremor, and the frequency of seizures.
Benzodiazepines are superior to pheno­
thiazines in preventing seizures during
withdrawal. (Guidelines for managing sei­
zures are given in Table 3.) There is no di­
rect evidence that the potent antihallucinatory activity of major tranquilizers in
schizophrenia has such a specific effect in
alcohol withdrawal or on alcoholic halhici31

^l.COHOI. WlTHhltAWAl.

Table 3: Guidelines for the emergency managemen1 of alcohol withdrawal
(complete history, physical, laboratory assessment)
Agitation,
anxiety,
tremor
(mild to
sovaro)

Extreme
agitation

Seizure

F

50-100 mg
oral chlordiazepoxide/day
100 mg im
thiamine

50-100 mg iv
chlordiaze­
poxide; rate
12.5 mg/min;
initial dose
given qntil
patient is
calm

Repeated;
focal;
generalized
for first
time

Ono, with a
history of
prior with­
drawal
seizures
and no prior.
treatment

Load with
10 mg/kg iv
phenytoin;
rate not
exceeding
50 mg/min

Load with 10
mg/kg iv
phenytoin,
then 300 mg
oral plus
300 mg iv ;
rate 50
mg/min

I4

B

History of
seizure
disorder or
previous
withdrawal
seizure

If patient on
anticonvul­
sant medi­
cation, glvo
Rx for
same

If patient
stopped
anticonvul­
sant medi­
cation, give
supple-.
mentary
dose of
200-300 mg
phenytoin
daily

50-100 mg
iv chlordiaze­
poxide;
rate 12.5
mg/min
*2 mg im
halo­
peridol

Observe for
6 hours;
200 mg oral
phenytoin

Observe
vital signs
q 20-30
min for 2 h

Discharge
home;
25 mg oral
chlordiaze­
poxide qld
for 4 days

r

Hallucinations

Admit to
hospital

¥

Admit to
hospital

I

Discharge

home; 100 mg
oral
phenytoin
tid for
5 days

Admit to
hospital

V

Follow-up appointment for longer-term
rehabilitation; designate a friend or
relative to check on patient at home and
ensure that patient seek further help

hi
nations. Phenothiazines lower the seizure
threshold and cause neuroendocrine, der­
matologic, and hematologic side effects.
Bulyrophenones (eg, haloperidol (Haldol |)
cause less sedation or hypotension than
chlorpromazine and canbe reasonably tried
for the control of hallucinations, par­
ticularly after the risk of seizures has
passed. The clinical efficacy of haloperidol
can be quite dramatic. Concurrent use of a
benzodiazepine will decrease the risk of
haloperidol-induced seizures. Acute dys­

tonic reactions, such as oculogyric crisis,
may be treated with benztropine mesylate
(Cogentin), 2 mg intravenously, followed
by 1-2 mg bid orally or parenterally. All
patients with hallucinations should be ad­
mitted to the hospital.
In general, indications for hospitalization
of patients in withdrawal include:
h The presence of a medical or surgical
condition requiring treatment (hepatic de­
compensation, infection, dehydration, mal­

um <; tiii.kai v ,nosr> ai-iui. iw;

nutrition, cardiovascular collapse, cardiac pea id. continuous, <>r life threatening.
arrhythmias, trauma)
Ilo .ever. there is uncertainty about the
b Hallucinations, tachycardia
■ lot) thvrt.pi Ulic and prophylactic value of phe­
beaLs/minutc. severe tremor, extreme agi­ nytoin in alcohol-withdrawal seizures. Phe­
tation, or a history of severe withdrawal nytoin should be given orally or intrave­
symptoms
nously, since it is poorly absorbed from in­
n Fever > 38.5 C
tramuscular injection sites.
H Wernicke's encephalopathy (confusion,
Intravenous phenytoin is infused di­
ataxia, nystagmus, and ophthalmoplegia)
rectly. The loading dose is 10 mg/kg, and
n Confusion or delirium
the oral maintenance dosages are 100 mg
» Seizures: Generalized seizure occurring lid (Table 3). Phenytoin need not be con­
for the first time in the withdrawal state, tinued past the withdrawal period except in
focal seizures, status epilepticus, seizures patients with a preexisting seizure disor­
in patients withdrawing from a combina­ der. Patients withdrawing from a combina­
tion of alcohol and other drugs
tion of alcohol and other drugs, particularly
a Recent history of head injury with loss of barbiturates and nonbarbiturate hypnotics,
consciousness
should also he hospitalized, since with­
B Social isolation
drawal seizures from more than one drug
can be more serious and difficult to manage
Patients in status epilepticus should be
treated initially with 5-10 mg diazepam
(Valium) IV as needed, at a rate of 2.5 Di'iifl ticeiiiitiiltiliini
mg/ininute, until seizures are controlled. Since chlordiazepoxide and diazepam are
Equipment for maintenance of an airway both long-acting drugs with phar­
and for mechanical support of ventilation macologically active metabolites, repeated
must be immediately available. Subsequent daily dosages allow either the drug and/or
doses of 5—10 mg every 20-30 minutes IV as its metabolite to accumulate, and desired
needed, may be given if seizures recur. Ap­ therapeutic (or unwanted toxic) effects
propriate maintenance therapy with other may not appear until several days of contin­
agents should be instituted promptly. Sei­ uous therapy (Figure 3). Some drowsiness
zures require treatment if they are re­ may be of therapeutic benefit. but if dos-

Figure 3: Effect of chlordiazepoxide on clinical course of withdrawal reaction

Total daily chlordiazepoxide dose

Left panel indicates the slow cumulative
pharmacologic effect of chlordiazcpoxido
and its active metabolite, desrnethylchlordiazepoxide. during repeated daily
administration of the same dose. Max­

Severity of

imum sedative effects may only be seen
after the withdrawal period.
Right panel shows chlordiazepoxide
dose
avoid excessive sedation.
33

state of the individual patient, exeexivc
drowsiness, lethargy, ataxia, diplopia, con­
fusion, respiratory depression, and in­
creased risk of aspiration may follow. To
circumvent the consequences of drug
cumulation, doses should usually be re­
duced progressively (Figure 3, right
panel). On the first clay of treatment, large
doses of chlordiazepoxide in the range of
100—100 mg should be given. (Occasionally,
doses as high as l(>00 mg may be required;
this situation is usually associated with de­
layed treatment.) Thereafter, smaller
doses, approximately 25% less than the ini­
tial dose, are given daily if required. There

Optimal management of the
alcohol-abusing patient
includes adequate
op|X)rtunity for long-tenn
rehabilitation.
cannot be a “standard” or "rout ine" dosage
schedule because of the variability in the
severity of withdrawal symptoms, the
metabolic fate of the drugs, and the pres­
ence of other diseases.
Chlordiazepoxide and diazepam are ab­
sorbed slowly and incompletely from intra­
muscular injection sites. When a rapid and
predictable clinical effect is required, the
oral or intravenous route is preferred.
Smaller doses should be given to patients
with severe liver disease and/or low serum
albumin, since the concentrations of free
active chlordiazepoxide and diazepam will
be higher, and diazepam is metabolized
more slowly in cirrhosis.

In conclusion
Considerable clinical skill and attention are
required for the management of alcohol
withdrawal. Optimal management of the al­
cohol-abusing patient includes an adequate
opportunity for long-term rehabilitation. »
References

Coming in

HOSPITAL

Multiple sclerosis

Computer approaches to
respiratory problems

An alternative to surgery in
preterm infants with patent
ductus arteriosus

Hemophilia

Surgical use of prophylactic
antibiotics phis
self-assessment

Heparin—theory and practice

Diabetic ketoacidosis and
hypoglycemic coma
in children phis
self-assessment

August 19S2

BRIEF REPORTS

Cressman WA, Bianchine JR, Slotnick VB, et al. Plasma level
profile of haloperidol in man following intramuscular administra­
tion. Eur J Clin Pharmacol 1974;7:99-103.
5.
Johnson PC. Charalampous KP, Braun GA. Absorption and excre­
tion of titrated haloperidol in man (a preliminary report). Int J
Neuropsychiatry 1967;3(suppl. 1)24-5.
6.
Shader RI, Greenblatt DJ. Clinical implications of benzodiazepine
pharmacokinetics. Am J Psychiatry 1977;134:652-5.
7.
Foreman A, Ohman R. Interindividual variation of clinical response
to haloperidol. In: Obiols J, Ballus C, Gonzales Monclus E, et al,

4.

277

ed. Biological psychiatry today. New York: Biomedical Press,
1979:949.
8.
Endicott J, Spitzer RL. A diagnostic interview: the schedule for
affective disorders and schizophrenia. Arch Gen Psychiatry
1978;35:837-44.
9.
Spitzer RL, Endicott J, Robins E. A research diagnostic criteria
rationale and reliability. Arch Gen Psychiatry 1978;35:773-82.
10.
Foreman A, Ohman R. A gas chromatographic method for deter­
mining haloperidol. Arch Pharmacol 1974;286:113-24.

0271-0749/82/0204-0274S02.00/0
Journal of Clinical Psychopharmacology
Copyright © 1982 by Williams & Wilkins Co.

Vol. 2, No. 4
Printed in U.SA.

Monpharmacolagical Supportive Care Compared to
Chlormethiazole Infusion in the Mana *
ement of Severe
Acute Alcohol Withdrawal
RICHARD C. FRECKER, MD, PhD, JOANNE M. SHAW, BN,
DUANE H. ZILM, BSc, MPhil, PhD, MOIRE S. JACOB, MD,
EDWARD M. SELLERS, MD, PhD, and NAEMA DEGANI, MD, PhD

Clinical Pharmacology Program, and Clinical Research Unit, Clinical Institute, Addiction Research
Foundation, Toronto, Canada

EVERAL clinical investigators compare the efficacy
of various treatment strategies in the acute with­
drawal syndrome.1"5 A review of such investigations, cou­
pled with our experience in conducting such experiments,
raises a number of important considerations to be taken
into account when conducting treatment trials. First,
^hce it is obvious that those with the more severe alcohol
withdrawal symptoms should be the beneficiaries of
treatment, some reliable quantitative measure of with­
drawal is required to ensure that consistent criteria are
used in the selection of patients for treatment trials.
Second, because the withdrawal severity can be exacer­
bated by anxiety caused by the unfamiliarity of the
testing situation, a sufficiently long baseline period
should be allotted so that withdrawal signs and symp­
toms may stabilize prior to the induction of therapy.
Third, a method for repetitive and accurate monitoring
of signs and symptoms is necessary for the assessment of
baseline stability and the influence of therapy. Fourth,
for ethical reasons, certain compromises may initially
have to be made in the experimental design until it can
be determined with some certainty that the replacement
of drug therapy with placebo-supportive care (such as in

S

Address requests for reprints to: R. C. Frecker, MD. PhD, Division
of Clinical Pharmacology, Clinical Institute, Addiction Research Foun­
dation, 33 Russell St., Toronto, Ontario M5S 2S1, Canada.

double-blind, placebo-con i? oiled trials) is an appropriate
and safe alternative to ;' ^.rmacotherapy in the experi­
mental situation. Finally in order that the effect of
uncomplicated drug therapy be assessed, patients must
be carefully screened, in ini ial drug trials, to ensure that
only those in withdrawal v. iihout medical complications
are admitted for investigational purposes.
A clinical trial was conducted with a select sample of
chronic alcoholics in withdrawal using a single intrave­
nous infusion of chlormethiazole, a rapidly metabolized,
sedativ-, hypnotic, anticonvulsant drug that has been
used s ■ cessfully in Europe ." “d Australia.6 At the time
of the investigation, the drug was unapproved for general
use in North America. In conducting the trial, careful
attention was paid to the five considerations listed above.
Methods

The instrument for obtaining a reliable initial estimate
and for repetitive assessment of alcohol withdrawal se­
verity was adapted from the short assessment scale de­
veloped by Gross.and colleagues.7,8 Our scale consisted
of 13 items (summarized in Table 1) and was designed to
permit repetitive assessment at half-hourly intervals. In
addition to the assessment scale, heart rate, body tem­
perature, electrocardiogram, and an objective measure of
hand tremor9,1,1 were included.

Vol. 2. No. 4

BRIEF REPORTS

278

The assessment scale was developed prior to the study
by administering the instrument to seven patients in
acute alcohol withdrawal during a videotape session.
Repeated assessments were subsequently made from the
videotape material by nurse observers until the variation
among them (initially quite high) was small. The final
ratings of withdrawal severity were compared with rat­
ings of the same material made by experienced clinicians
on more conventional grounds, and the two methods
were found to agree. Following training and standardi­
zation of the rating procedure, all nurses were able to
score withdrawal in a consistent manner.
Five male chronic alcoholics (aged 29 to 51) were
carefully selected over a 10-month period from a large
population of patients (1613) seen in our emergency
department (Table 2). All satisfied our strict criteria of
Resenting with a withdrawal sufficiently intense (scoring
greater than 20 on the modified scale) so as to require
treatment, having no additional complicating medical
problems, not receiving other psychoactive medications,
and maintaining a high withdrawal score over the period
between initial assessment and the beginning of the

infusions. Additionally, all patients had no abnormal liver
function tests.
Patients were supine on a medical stretcher and, after
giving informed consent (blood alcohol levels were always
less than 800 mg/liter), had a Butterfly scalp needle
inserted in a left forearm vein for infusion of fluids and
drug. During the baseline stabilization phase, saline
(0.9%) was infused (0.6 ml/min) for 2 hours and, during
the drug phase, chlormethiazole was infused (0.2 to 0.4
mg/kg/min) for 3 hours or until the patient was drowsy,
whichever occurred first. Neither the patient nor the
nurse observers who entered the study area at half-hourly'
intervals to score the withdrawal were informed of the
timing of the chlormethiazole infusion in an attempt to
blind them to the start of the drug therapy phase. Sup­
portive nursing care was provided by one of us (J.M.S.)
throughout the entire period of investigation.
Blood samples were taken every 15 min for the first
hour of the drug infusion phase and at half-hourly inter­
vals thereafter for determination of plasma chlormethia­
zole levels. (Analyses were done courtesy of Astra Phar­
maceuticals.)

Table 1. Contributions of individual score components to aggregate score of 66 s iected severity assessments in five patients"
. Score component

Tremor
Anxiety
Sweats
Agitation
Auditory ."‘scurbance
Visual disturbance
Tactile disturbance
Nausea and vomiting
Level of consciousness
^Klouding of sensorium
^^uality of contact

Hallucinations
Convulsions

Rank

Total for
component

Occasions
observed

Observations in which
symptom seen (%)

Contribution
to aggregate
score (%)

196.5
95.0
92.0
88.0
55.0
49.5
47.5
41.5
27.0
25.5
12.0
8.5
0.0

58
42
48
38
29
28
27
15
18
9
5
6
0

87.9
63.3
72.7
57.6
43.9
42.4
40.9
22.7
27.3
13.6
7.7
9.1
0.0

26.6
12.9
12.5
11.9
7.5
6.7
6.4
5.6
3.7
3.5
1.6
1.2
0.0

1
2
3
5
6
7
8
9
10
11
12
13

>

"Total scores of individual subjects (aggregate = 738): 1 (240), 2 (61.5), 3 (135.5), 4 (143), 5 (158).

Table 2. Characteristics of the five chronic alcoholic patients

Patients

Mean
Age
Weight (kg)
Years of alcohol abuse
Duration of this binge (days)
Daily consumption (g/day)
Equivalent spirits (oz/day)"
Admission withdrawal score1'
Admission blood alcohol (mg/liter)'

1

2

3

4

5

29
56.5
10
10
338
30
35
150

40
67.0
20
7

45
55.0
23
21
170
15
28
230

47
80.0
20
42
230
20
.23
300

51
76.4
30
84
230
20
30
300

170
15
22
730

" 40% ethanol, volume for volume, minimum concentration in Canadian spiritous liquor.
• See text for explanation.
"Determined by Omicron Intoxilyzer, model 4011.

42.4
67.9
20.6
32.8
228.0
20.0
27.6
342

August 19S2

BRIEF REPORTS

279

Results

The individual data for withdrawal severity and the
plasma concentrations of the drug in each subject are
given in Figure 1; the mean withdrawal scores across
subjects are given in Figure 2. As shown, a slight but
statistically nonsignificant decrease in withdrawal sever­
ity occurred from the initial assessment until that ob­
tained at the start of the placebo infusion. By contrast,
however, the withdrawal score dropped significantly over
an equivalent period of time during the saline infusion
phase from 23.3 to 8.9. A further but smaller drop in the
withdrawal score was observed after the infusion was
changed to chlormethiazole; however, by the time the Fig. 2. Mean selected severity assessment (SSA) scores for five subjects.
Horizontal bars indicate duration of intravenous infusions. CMTZ =
chlormethiazole.

drug was begun, the intensity of withdrawal had abated
substantially.
As shown in Figure 1, there was a rapid rise in plasma
drug concentration to a peak between 57 and 180 min.
Four of five (CM01 to CM04) subjects experienced mod­
erate drowsiness within 2 hours (they could still be
aroused), which quickly dissipated as the plasma concen­
tration of the drug rapidly fell (half-life, 0.67 hours;
apparent terminal half-life, 1.80 hours).

Discussion
In this investigation, the development and application
of the modified scoring system provided an impoi ant
tool for selecting a homogeneous group of patients ac­
cording to withdrawal severity and for assessing, repeti­
tively, the course of withdrawal severity in a controlled
clinical trial. Such an instrument played an important
role in this study because it assured that only patients
suitable for the study were entered into the infusion
phase of the investigation. Many of the potentially suit­
able patients who were initially assessed as being in
severe withdrawal were found to have low withdrawal
scores just prior to the saline infusion and therefore were
rejected. In addition, it has been possible to adapt the
alcohol withdrawal scoring system for the accurate and
reliable monitoring of the sedative withdrawal syn­
drome."
An unexpected but exceedingly important result’of this
investigation was the demonstration of the precipitous
decrease in withdrawal severity unaided by active phar­
macotherapy. Such an observation has important impli­
cations for alcohol withdrawal treatment. In the first
place, it established that, in selected patients, supportive
care and nonpharmacological treatment may be entirely
sufficient for the management of acute alcohol with­
drawal. While admittedly the influence of supportive care
cannot be dissociated from the saline placebo treatment

Vol. 2, No. 4

BRIEF REPORTS

280

in this study, other investigators' 2 have stressed the
impact of supportive care and reality orientation in the
detoxification of alcoholics. Secondly, the observation of
the potent influence of nonpharmacological measures
underlines the considerable lability of the withdrawal
syndrome in clinical trials and should warn investigators
of the potential problems that may occur in the interpre­
tation of results if adequate considerations are not taken
of the experimental design. In our own case it was felt
that the reduction of withdrawal symptomatology was
sufficiently impressive so as to preclude continuation
with a fully blended counterbalanced design using drug
therapy first. For the future, however, this study has laid
the basis for the conduct of controlled investigations into
the efficacy of supportive care in the treatment of unse­
lected withdrawal patients. While the aim of this inves­
tigation was to provide an ideal experimental situation
Tor the elucidation of the influence of drug therapy in
withdrawal, it was found that, in doing so, a select pop­
ulation of alcoholics was perhaps isolated. The success of
nonpharmacological treatment by supportive care of
such individuals provides an exciting counterpoint to
conventional treatment and establishes a sound basis for
the ethical use of such techniques in certain settings.
Such supportive care management is, however, very in­
tensive and may not prove to be cost-effective in some
centers where drug treatment may be better applied.
What is important, however, is that individualized con­
cern and care are important for withdrawing alcoholics,
and while it may somewhat confound the ability to
quantify the exact value of a current therapy, the benefit
to the patient is apparent.

Acknowledgments
k The authors would like to thank the nursing staff of the Clinical
Research Unit and Dr. P. Iversen and staff of the Emergency Depart­

0271-0749/82/0204-0277S02.00/0
Journal of Clinical Psychopharmacology
Copyright © 1982 by Williams & Wilkins Co.

ment, Clinical Institute, Addiction Research Foundation; Dr. E. Monk­
man and staff of the Emergency Department, Toronto Western Hos­
pital; Dr. G. Hastie and staff of the Emergency Department, Wellesley
Hospital, for their professional assistance in the study; and Ms. Cathy
Van Der Giessen for her typing assistance.

References - z
Sellers EM, Kalant H. Drug therapy: alcohol intoxication and
withdrawal. New Engl J Med 1976;294:757-62.
2.
Sellers EM, Kalant H. Pharmacotherapy of acute and chronic
alcoholism and alcohol withdrawal syndrome. In: Clark WG, del
Giudice J, eds. Principles of psychopharmacology, 2nd ed. New
York: Academic Press, 1978:721-40.
3.
Benforado JM, Houden D, Thomson J. Rebos Reception Center:
The Medical (Non-Hospital) Alcohol Detoxification Unit of Dan
County, Wisconsin. In: Seixas FA, ed. Currents in alcoholism, vol.
3.
New York: Grune & Stratton, 1978.
4.
Schmitz RE. The prevention and management of the acute alcohol
withdrawal syndrome by the use of alcohol. In: Seixas FA, ed.
Currents in alcoholism, vol. 3. New York: Grune & Stratton. 1978.
5.
Sellers EM, Zilm DH, Degani NC. Comparative efficacy of pro­
pranolol and chlordiazepoxide in alcohol withdrawal. J Stud Alco­
hol 1977;38(111:2096-106.
6.
McGrath SD. A controlled trial of chlormethiazole and chlordiaz­
epoxide in the treatment of acute withdrawal phase of alcoholism.
Br J Addict 1975;70:81-90.
7.
Gross M, Lewis E, Hastey J. Acute alcohol withdrawal syndrome.
In: Kissin B, Begleiter H, eds. The biology of alcoholism, vol. 3.
New York: Plenum Press, 1974.
8.
Gross M, Lewis M, Nagarajan M. An improved quantitative system
for assessing the acute alcoholic psychoses and related states (TSA
and SSA). In: Gross MM, ed. Advances in experimental medicine
and biology, alcohol intoxication and withdrawal experimental stud­
ies, vol. 35. New York: Plenum Press, 1973.
9.
Zilm DH. The measurement, etiology and treatment of alcohol
withdrawal tremor. PhD thesis. University of Toronto, 1976.
10.
Zilm DH, Sellers EM, Frecker RC, et al. Mechanism of normal and
alcohol withdrawal tremor. IEEE Trans Biomed Eng 1979;26( 1):3—
10.
11.
Robinson GM, Sellers EM, Janecek E. Barbiturate and hvpnosedative withdrawal by a multiple oral phenobarbital loading dose
technique. Clin Pharmacol Ther 1981;30(l):71-6.
12.
Whitfield CL, Thompson G, Lamb A, et aL Detoxification of 1024
alcoholic patients without psychoactive drugs. JAMA 1978;
239(141:1409-10.

1.

Printed in U.Su4.

August 1982

BRIEF REPORTS

Cressman WA. Bianchine JR, Slotnick VB, et al. Plasma level
profile of haloperidol in man following intramuscular administra­
tion. Eur J Clin Pharmacol 1974.7:99-103.
5.
Johnson PC, Charalampous KP. Braun GA. Absorption and excre­
tion of titrated haloperidol in man (a preliminary report). Int J
Neuropsychiatry 1967;3(suppl. l):24-5.
6.
Shader Rl, Greenblatt DJ. Clinical implications of benzodiazepine
pharmacokinetics. Am J Psychiatry 1977;134:652-5.
7.
Forsman A, Ohman R. Interindividual variation of clinical response
to haloperidol. In: Obiols J, Ballus C. Gonzales Monclus E, et al,

4.

277

ed. Biological psychiatry today. New York: Biomedical Press
1979:949.
8.
Endicott J, Spitzer RL. A diagnostic interview: the schedule for
affective disorders and schizophrenia. Arch Gen Psvchiatrv
1978;35:837-44.
'
3
9.
Spitzer RL, Endicott J, Robins E. A research diagnostic criteria
rationale and reliability. Arch Gen Psychiatry 1978;35:773-82.
10.
Forsman A, Ohman R. A gas chromatographic method for determining haloperidol. Arch Pharmacol 1974;286:113-24.

0271 -0749/82/0204-0274S02.00/0
Journal of Clinical Psychopharmacology
Copyright © 1982 by Williams & Wilkins Co.

Vol. 2. No. 4
Printed in U.S.A.

^onpharmacological Supportive Care Compared to
vhlormethiazole Infusion in the Management of Severe
Acute Alcohol Withdrawal
RICHARD C. FRECKER, MD, PhD, JOANNE M. SHAW, BN,
DUANE H. ZILM, BSc, MPhil, PhD, MOIRE S. JACOB, MD,
EDWARD M. SELLERS, MD, PhD, and NAEMA DEGANI, MD, PhD

Clinical Pharmacology Program, and Clinical Research Unit, Clinical Institute, Addiction Research
Foundation, Toronto, Canada

EVERAL clinical investigators compare the efficacy
of various treatment strategies in the acute with­
drawal syndrome.1-5 A review of such investigations, cou­
pled with our experience in conducting such experiments,
raises a number of important considerations to be taken
into account when conducting treatment trials. First,
ice it is obvious that those with the more severe alcohol
thdrawal symptoms should be the beneficiaries of
treatment, some reliable quantitative measure of with­
drawal is required to ensure that consistent criteria are
used in the selection of patients for treatment trials.
Second, because the withdrawal severity can be exacer­
bated by anxiety caused by the unfamiliarity of the
testing situation, a sufficiently long baseline period
should be allotted so that withdrawal signs and symp­
toms may stabilize prior to the induction of therapy.
Third, a method for repetitive and accurate monitoring
of signs and symptoms is necessary for the assessment of
baseline stability and the influence of therapy. Fourth,
for ethical reasons, certain compromises may initially
have to be made in the experimental design until it can
be determined with some certainty that the replacement
of drug therapy with placebo-supportive care (such as in

S

«

Address requests for reprints to: R. C. Frecker, MD, PhD, Division
of Clinical Pharmacology, Clinical Institute, Addiction Research Foun­
dation, 33 Russell St, Toronto, Ontario M5S 2S1, Canada.

double-blind, placebo-controlled trials) is an appropriate
and safe alternative to pharmacotherapy in the experi­
mental situation. Finally, in order that the effect of
uncomplicated drug therapy be assessed, patients must
be carefully screened, in initial drug trials, to ensure that
only those in withdrawal without medical complications
are admitted for investigational purposes.
A clinical trial was conducted with a select sample of
chronic alcoholics in withdrawal using a single intrave­
nous infusion of chlormethiazole, a rapidly metabolized,
sedative, hypnotic, anticonvulsant drug that has been
used successfully in Europe and Australia.'1 At the time
of the investigation, the drug was unapproved for general
use in North America. In conducting the trial, careful
attention was paid to the five considerations listed above:

Methods

The instrument for obtaining a reliable initial estimate
and for repetitive assessment of alcohol withdrawal se­
verity was adapted from the short assessment scale de­
veloped by Gross and colleagues.7, R Our scale consisted
of 13 items (summarized in Table 1) and was designed to
permit repetitive assessment at half-hourly intervals. In
addition to the assessment scale, heart rate, body tem­
perature, electrocardiogram, and an objective measure of
hand tremor”' were included.

BRIEF REPORTS

278

The assessment scale was developed prior to the study
by administering the instrument to seven patients in
acute alcohol withdrawal during a videotape session.
Repeated assessments were subsequently made from the
videotape material by nurse observers until the variation
among them (initially quite high) was small. The final
ratings of withdrawal severity were compared with rat­
ings of the same material made by experienced clinicians
on more conventional grounds, and the two methods
were found to agree. Following training and standardi­
zation of the rating procedure, all nurses were able to
score withdrawal in a consistent manner.
Five male chronic alcoholics (aged 29 to 51) were
carefully selected over a 10-month period from a large
population of patients (1613) seen in our emergency
department (Table 2). All satisfied our strict criteria of
presenting with a withdrawal sufficiently intense (scoring
^greater than 20 on the modified scale) so as to require
treatment, having no additional complicating medical
problems, not receiving other psychoactive medications,
and maintaining a high withdrawal score over the period
between initial assessment and the beginning of the

Vol. 2, No. 4

infusions. Additionally, all patients had no abnormal liver
function tests.
Patients were supine on a medical stretcher and, after
giving informed consent (blood alcohol levels were always
less than 800 mg/liter), had a Butterfly scalp needle
inserted in a left forearm vein for infusion of fluids and
drug. During the baseline stabilization phase, saline
(0.9%) was infused (0.6 ml/min) for 2 hours and, during
the drug phase, chlormethiazole was infused (0.2 to 0.4
mg/kg/min) for 3 hours or until the patient was drowsy,
whichever occurred first. Neither the patient nor the
nurse observers who entered the study area at half-hourly
intervals to score the withdrawal were informed of the
timing of the chlormethiazole infusion in an attempt to
blind them to the start of the drug therapy phase. Sup­
portive nursing care was provided by one of us (J.M.S.)
throughout the entire period of investigation.
Blood samples were taken every 15 min for the first
hour of the drug infusion phase and at half-hourly inter­
vals thereafter for determination of plasma chlormethia­
zole levels. (Analyses were done courtesy of Astra Phar­
maceuticals.)

Table 1. Contributions of individual score components to aggregate score of 66 selected severity assessments in five patients"

Score component
Tremor
Anxiety
Sweats
Agitation
Auditory disturbance
Visual disturbance
Tactile disturbance
Nausea and vomiting
Level of consciousness
^Clouding of sensorium
^^Quality of contact
Hallucinations
Convulsions

Rank

Total for
component

Occasions
observed

Observations in which
symptom seen (%)

Contribution
to aggregate
score (%)

196.5
95.0
92.0
88.0
55.0
49.5
47.5
41.5
27.0
25.5
12.0
8.5
0.0

58
42
48
38
29
28
27
15
18
9
5
6
0

87.9
63.3
72.7
57.6
43.9
42.4
40.9
22.7
27.3
13.6
77
9.1
0.0

26.6
12.9
12.5
11.9
7.5
6.7
6.4
5.6
3.7
3.5
1.6
1.2
0.0

2
3
4
5
6
8
9
10
11
12
13

•

"Total scores of individual subjects (aggregate = 738): 1 (240), 2 (61.5), 3 (135.5), 4 (143), 5 (158).

Table 2. Characteristics of the five chronic alcoholic patients

Patients
Mean

1_____________ 2
Age
Weight (kg)
Years of alcohol abuse
Duration of this binge (days)
Daily consumption (g/day)
Equivalent spirits (oz/day)"
Admission withdrawal score'1
Admission blood alcohol (mg/liter)'

29
56.5
10
10
338
30
35
150

40
67.0
20
170
15
22
730

3

4

5

45
55.0
23
21
170
15
28
230

47
80.0
20
42
230
20
23
300

51
76.4
30
84
230
20
30
300

" 40% ethanol, volume for volume, minimum concentration in Canadian spiritous liquor.
h See text for explanation.
r Determined by Omicron Intoxilyzer, model 4011.

42.4
67.9
20.6
32.8
228.0
20.0
27.6
342

August 1982

BRIEF REPORTS

279

Results
The individual data for withdrawal severity and the
plasma concentrations of the drug in each subject are
given in Figure 1; the mean withdrawal scores across
subjects are given in Figure 2. As shown, a slight but
statistically nonsignificant decrease in withdrawal sever­
ity occurred from the initial assessment until that ob­
tained at the start of the placebo infusion. By contrast,
however, the withdrawal score dropped significantly over
an equivalent period of time during the saline infusion
phase from 23.3 to 8.9. A further but smaller drop in the
withdrawal score was observed after the infusion was
changed to chlormethiazole; however, by the time the
Fig. 2. Mean selected severity assessment (SSA) scores for five subjects.
Horizontal bars indicate duration of intravenous infusions. CMTZ =
chlormethiazole.

drug was begun, the intensity of withdrawal had abated
substantially.
As shown in Figure 1, there was a rapid rise in plasma
drug concentration to a peak between 57 and 180 min.
Four of five (CM01 to CM04) subjects experienced mod­
erate drowsiness within 2 hours (they could still be
aroused), which quickly dissipated as the plasma concen­
tration of the drug rapidly fell (half-life, 0.67 hours;
apparent terminal half-life, 1.80 hours).
Discussion

TIME(hours)
Fig. 1. Individual selected severity assessment scores and plasma chlor­
methiazole (CMTZ) levels for all five subjects. Horizontal bars indicate
duration of intravenous infusions.

In this investigation, the development and application
of the modified scoring system provided an important
tool for selecting a homogeneous group of patients ac­
cording to withdrawal severity and for assessing, repeti­
tively, the course of withdrawal severity in a controlled
clinical trial. Such an instrument played an important
role in this study because it assured that only patients
suitable for the study were entered into the infusion
phase of the investigation. Many of the potentially suit­
able patients who were initially assessed as being in
severe withdrawal were found to have low withdrawal
scores just prior to the saline infusion and therefore were
rejected. In addition, it has been possible to adapt the
alcohol withdrawal scoring system for the accurate and
reliable monitoring of the sedative withdrawal syn­
drome.1'
An unexpected but exceedingly important result of this
investigation was the demonstration of the precipitous
decrease in withdrawal severity unaided by active phar­
macotherapy. Such an observation has important impli­
cations for alcohol withdrawal treatment. In the first
place, it established that, in selected patients, supportive
care and nonpharmacological treatment may be entirely
sufficient for the management of acute alcohol with­
drawal. While admittedly the influence of supportive care
cannot be dissociated from the saline placebo treatment

r
BRIEF REPORTS
in this study, other investigators'2 have stressed the
impact of supportive care and reality orientation in the
detoxification of alcoholics. Secondly, the observation of
the potent influence of nonpharmacological measures
underlines the considerable lability of the withdrawal
syndrome in clinical trials and should warn investigators
of the potential problems that may occur in the interpre­
tation of results if adequate considerations are not taken
of the experimental design. In our own case it was felt
that the reduction of withdrawal symptomatology was
sufficiently impressive so as to preclude continuation
with a fully blended counterbalanced design using drug
therapy first. For the future, however, this study has laid
the basis for the conduct of controlled investigations into
the efficacy of supportive care in the treatment of unse­
lected withdrawal patients. While the aim of this inveskcigation was to provide an ideal experimental situation
iot the elucidation of the influence of drug therapy in
withdrawal, it was found that, in doing so, a select pop­
ulation of alcoholics was perhaps isolated. The success of
nonpharmacological treatment by supportive care of
such individuals provides an exciting counterpoint to
conventional treatment and establishes a sound basis for
the ethical use of such techniques in certain settings.
Such supportive care management is, however, very in­
tensive and may not prove to be cost-effective in some
centers where drug treatment may be better applied.
What is important, however, is that individualized con­
cern and care are important for withdrawing alcoholics,
and while it may somewhat confound the ability to
quantify the exact value of a current therapy, the benefit
to the patient is apparent.

Acknowledgments
. The authors would like to thank the nursing staff of the Clinical
lesearch Unit and Dr. P. Iversen and staff of the Emergency Depart­

0271 -0749/82/0204-0277$02.00/0
Journal of Clinical Psychopharmacology
Copyright© 1982 by Williams & Wilkins Co.

Vol. 2, No. 4

ment, Clinical Institute, Addiction Research Foundation; Dr. E. Monk­
man and staff of the Emergency Department, Toronto Western Hos­
pital; Dr. G. Hastie and staff of the Emergency Department, Wellesley
Hospital, for their professional assistance in the study; and Ms. Cathy
Van Der Giessen for her typing assistance.

References Sellers EM, Kalant H. Drug therapy: alcohol intoxication and
withdrawal. New Engl J Med 1976;294:757-62.
2.
Sellers EM, Kalant H. Pharmacotherapy of acute and chronic
alcoholism and alcohol withdrawal syndrome. In: Clark WG, del
Giudice J, eds. Principles of psychopharmacology, 2nd ed. New
York: Academic Press. 1978:721-40.
3.
Benforado JM, Houden D, Thomson J. Rebos Reception Center:
The Medical (Non-Hospital) Alcohol Detoxification Unit of Dan
County, Wisconsin. In: Seixas FA, ed. Currents in alcoholism, vol.
3. New York: Grune & Stratton, 1978.
4.
Schmitz RE. The prevention and management of the acute alcohol
withdrawal syndrome by the use of alcohol. In: Seixas FA, ed.
Currents in alcoholism, vol. 3. New York: Grune & Stratton, 1978.
5.
Sellers EM, Zilm DH, Degani NC. Comparative efficacy of pro­
pranolol and chlordiazepoxide in alcohol withdrawal. J Stud Alco­
hol 1977;38(111:2096-106.
6.
McGrath SD. A controlled trial of chlormethiazole and chlordiaz­
epoxide in the treatment of acute withdrawal phase of alcoholism.
Br J Addict 1975;70:81-90.
7.
Gross M, Lewis E, Hastey J. Acute alcohol withdrawal syndrome.
In: Kissin B, Begleiter H, eds. The biology of alcoholism, vol. 3.
New York: Plenum Press. 1974.
8.
Gross M, Lewis M, Nagarajan M. An improved quantitative system
for assessing the acute alcoholic psychoses and related states (TSA
and SSA). In: Gross MM, ed. Advances in experimental medicine
and biology, alcohol intoxication and withdrawal experimental stud­
ies, vol. 35. New York: Plenum Press, 1973.
9.
Zilm DH. The measurement, etiology and treatment of alcohol
withdrawal tremor. PhD thesis, University of Toronto, 1976.
10.
Zilm DH, Sellers EM, Frecker RC, et al. Mechanism of normal and
alcohol withdrawal tremor. IEEE Trans Biomed Eng 1979;26( 1 ):3—
10.
11.
Robinson GM, Sellers EM, Janecek E. Barbiturate and hypnosedative withdrawal by a multiple oral phenobarbital loading dose
technique. Clin Pharmacol Ther 1981;30(l):71-6.
12.
Whitfield CL, Thompson G, Lamb A, et al. Detoxification of 1024
alcoholic patients without psychoactive drugs. JAMA 1978;
239(141:1409-10.
1.

Printed in U.S.A.

:
I

j

226

Editorial

questions of how they were understood by their readers as if it were a serious problem. It is unfortunate that the
and what effects they might have had. As far as I am national response should have to be implemented in an
aware, no attempt has been made to look at these unplanned, last-minute rush. Let us give two cheers for
fundamental issues. In view of the ambigious and often the leaflets. But let us also hope that the Government will
discouraging results of previous drug education pur its money where its political mouth is and fund the
programmes, the Government would be ill-advised to research necessary for an effective response.
proceed on the assumption that any factually correct
information is necessarily going to help matters. How will
we know if these leaflets have helped or not? Would it not References
have been useful to pilot them on selected target groups 1 Home Office (1985) Tackling Drug Misuse: A summary of the

Medical Review Series 5

Alcohol and Fits
Ralph Johnson
Wellington Clinical School of Medicine, Wellington Hospital, Wellington, New Zealand.

It is perhaps this failure of planning that represents one

problems arc going to be with us for many years to come.
It is laudable that the Government has correctly identified
the matter as worth serious attention. It would be a
political failure of some magnitude if they now failed to act

CNO(85}4 CNO(85)1
Michael Gossop,
Bcthlem Royal Hospital

Summary
This review indicates the way in which epilepsy and excessive ethanol intake are related and the frequency ofeach in relation
to the other. There are many ways that fits may be precipitated, both during intoxication and during recoveryfrom ethanol excess.
Continuing anticonvulsant therapy is not usually indicated. The importance of abstinence is emphasised iffits occur.

Fits are only one of many neurological disorders which
may occur in relation to alcoholism [1, 2]. They are
frequent in alcoholics and proper management depends
not only on controlling the fit but also upon recognising
the contribution of excess ethanol intake and managing
that problem too. The relationship is one which has been
appreciated for centuries. William Buchan, for example,
published a treatise ‘Domestic Medicine’ in 1783 [3]. This
popular book ran to 17 editions in the next 17 years. He
‘Epilepsy is sometimes hereditary. It may likewise
proceed from blows, bruises or wounds on the head, a
collection of blood, or serious humours in the brain,
tumours or concretions within the skull. Excessive
drinking, contagion received into the body as by the
infection of the smallpox, measles etc; hysterical
affections. ..’ [3].
A medical student in 1983 might well satisfy his
examiners if he produced a modem version of this list of
differential diagnoses, but he would not be expected to
include Buchan’s other causes of epilepsy: intense study,
excessive sexual activity and suppression of customary
evacuations.. J In spite of such popular accounts, Sir

Alcoholism
Address for correspondence. Professor R. H. Johnson, Dean and
Professor of Medicine, Wellington Clinical School of Medicine,
Wellington Hospital, Wellington 2, New Zealand.

William Gowers, the eminent London neurologist,
writing at the end of the 19th century, was much less
definite about the relationship. In a two volume treatise
‘Diseases of the Nervous System’ he wrote one line on the
matter, commenting that epilepsy is occasionally an effect
of alcohol excess, usually accompanying delirium tremens
In a small group of patients, alcoholism may be a direct
result of epilepsy. The latter disorder may cause conflicts
and personality disorders which lead to drinking ethanol
in excess (in this review the terms ‘ethanol’ and ‘alcohol’
are used synonymously). This possibility is obviously
difficult to assess in practice and I shall not discuss it
further.
Fits may occur in those with primary epilepsy who
drink excessively, and in alcoholics without other
evidence of epilepsy, either during a drinking bout or in
the period of withdrawal and recovery from the excess
alcohol. A flow chart showing the causes of fits in relation
to drinking alcohol is given in Figure 1.

Primary epilepsy and ethanol excess

W/wr is the frequency of excess ethanol intake in epileptics?
Our own observations in Wellington answer this question
and our findings are very similar to those reported from
other countries. We have recently carried out a study of
pauents who have had a fit and been collected by the
ambulance service in the Wellington region in a year. One
hundred consecutive pauents were investigated by means
of a questionnaire and personal interview. Patients were
asked whether they drank ethanol and, if so, how much,

228

Ralph Johnson

Alcohol and Fits

cent of the epileptics interviewed drank regularly at least
80g of ethanol in the course of a day. Fourteen per cent of
the epileptics did so once weekly or more, an extent which
rendered effective control of the seizures by drug therapy
unlikely. Twelve per cent of seizures were probably
precipitated by ethanol in patients who could not be said
to have a major drinking problem. In a national survey of
New Zealanders aged 14-65 years 6 per cent of the total
population were estimated, on the basis of their selfreport,
to consume 80g or more of absolute alcohol per day [5].
Other surveys have also demonstrated a high percen­
tage of epileptics whose frequency of attacks is likely to be
influenced by ethanol. The range tn published reports is
very wide. One found 8 per cent of epileptics were
drinking excessively, another reported as many as 35 per
cent [6,7]. In Tasmania, a study of epileptics applying for
a driving bcence revealed 8 per cent alcoholism as the
result of self admission or through police reports [8]. In a
survey carried out in Finland, of 560 consecutive seizure
patients brought to an emergency department of a hospital
in Helsinki during the course of the year, 277 were found
to have ethanol intoxication in their immediate history [9].
In this group, ethanol provoked seizures occurred mainly
on Sunday and Monday following the weekend pattern of
alcohol consumption. It preceded delirium tremens in 21
patients. This series also highlighted the importance of
head trauma as a precipitating feature of seizures in
alcoholics — a point to which I shall return.
Why do fits occur in epileptics with ethanol excess?

with what frequency, and whether they had drunk ethanol
within the 12 hours prior-to their seizure. Those subjects
with a history suggestive of alcoholism were excluded so
that as far as possible the subjects surveyed had primary
epilepsy. They were also questioned on the nature of any

advice they had received about drinking ethanol in
relation to either their fits or their medication, if any, and
what they did about taking their medication when they
had been drinking. The answers to the latter questions
will be considered later. In the study we found that 20 per

Failure to take medication. Heavy drinkers who are also
epileptics on anticonvulsants, frequently do not take their
medication on the evening they drink heavily, or on the
morning after. Some are forgetful; memory difficulties are
common problems with alcoholics both during intoxica­
tion and between drinking periods, and others may decide
not to do so. In our Wellington series of 100 patients, six
of those who drank ethanol in excess replied that they had
deliberately stopped taking their drugs when they knew
that they would be drinking. One reason may have been
the way they had been given advice. Their doctor may
have said — ‘when you are on anticonvulsant drugs you
are not to drink
*.
The doctor will not have said the patient
could drink ethanol if he stopped taking the drugs, but the
patient may have interpreted his words in that way.

Depression of blood concentrations of anticonvulsants by
ethanol. Ethanol may increase the clearance of anuconvulsams from the blood [10,11]. Ethanol induces microsomal
enzyme activity in the liver leading to shorter half lives of

229
many drugs in the body, together with lower blood levels.
The daily intake of ethanol required to stimulate liver
enzymes is large, but it is within the range consumed by
many who regularly imbibe. About two-thirds of those
consuming alcohol in the range of 70-100g daily have the
potential of increased clearance rates of drugs and
therefore, if they are on anticonvulsants, blood levels of
these drugs will fall and seizure activity may be
unmasked. [12], There is evidence that this also occurs in
the withdrawal period [13].
Disulfiram (Antabuse), used to strengthen the resolve
of the alcoholic by producing a violently unpleasant
reaction when it is taken in association with ethanol, has
an additional advantage in epileptic alcoholics also taking
anticonvulsants. The drug is a non-specific inhibitor of
microsomal drug metabolism in the liver. It therefore
decreases anticonvulsant clearance and counteracts the
effect of ethanol [14]. If, however, the patient taking
Antabuse is epileptic and is on anticonvulsants, his blood
levels will be maintained by the drug. Should he stop
taking it abruptly, worse still should he also start drinking
again, his anticonvulsant blood levels will fall dramatically
and he is at risk of unmasking his epilepsy.
Precipitating factors during withdrawal. A number of
features may be involved in precipitating a seizure in
known epileptics. Why seizure threshold is depressed
during withdrawal is discussed in the next section.

Alcoholics without previous epilepsy who develop
seizures.
What is the frequency of seizures in alcoholics?
A study of 566 patients admitted with acute or subacute
alcohol toxicity to a detoxification unit in the U.S.A.
showed that, in those who had not been previously
admitted, a third had a seizure as one of the presenting
symptoms of the admission. Among those who had been
admitted previously, a similar proportion had a seizure
when they were admitted during the study period, even
though many of these had been put on anticonvulsants
[15]. These findings may overstate the usual proportion.
They were from a population of mixed ethnic background
which was predominantly from a low socioeconomic area:
in addition, alcoholics admitted to a detoxification unit arc
likely to be severe alcoholics. A current review of several
surveys has suggested that 5 per cent of all alcoholics will
have a fit at some stage, depending upon the severity of the
alcoholism, the duration of the disease, and the type of
beverage consumed [16].

Ralph Johnson
Effect of head injury. Some alcoholics are at risk of
developing fits because they have suffered injury to the
brain, either acutely during the relevant period of
intoxication, or due to previous injury. In over one third
of a group of patients in Helsinki who developed fits
provoked by alcohol intoxication and were taken to
hospital, a contributory cause of the fits was head injury.
In many this had been while they were intoxicated, but in
some the history of head injury had been earlier and a few
of these were found to have a subdural haematoma [8].
Subdural collections of blood should always be considered
in this group of patients.
evidence of severe ethanol brain damage, including
encephalopathy. This is particularly likely in patients who
have terminal lever cirrhosis. A further organic cause for
the development of epileptic attacks in alcoholics is brain
atrophy, which is frequently found in patients with a long
history of alcoholism. As a result of the atrophy there may
be structural changes which may induce epileptic
seizures. In a computerised tomography study of
alcoholics, 41 per cent of those with chronic epilepsy had
cerebral atrophy compared with 22 per cent of those who
only had seizures associated with ethanol withdrawal.
Another theory of seizure development without obvious
cause, in alcoholics, is that 'kindling
*
occurs: subliminal
repeated stimulation by ethanol abuse eventually result­
ing in a convulsion [17].
Due to metabolic complications. Hypoglycaemia may
develop during prolonged periods of ethanol intake in
patients who do not have adequate caloric intake. It may
unmask latent epilepsy. Hypoglycaemia may also be
precipitated when ethanol is taken in association with
some drugs, for example sulphonamides.
Low blood magnesium concentrations [17, 18] may
occur during intoxication or withdrawal. Hypomagnesaemia has an excitory effect on the central nervous system
and could influence fit development in susceptible indivi­
duals. Hyponatraemia, resulting from the excessive water
intake ofsome beer drinkers, may have similar effects.

Due to ingestion of a convulsant substance with ethanol.
Absinthe drinkers may develop convulsions due to a
convulsant substance, Thujone, normally present in the
As a result of withdrawalfrom ethanol. Such fits used to be
called 'Rum fits’ but are now normally known as

withdrawal fits. The initial seizure usually occurs after the
age of 40 when the individual has been suffering from
alcoholism for at least five years. The elderly are
particularly prone to withdrawal seizures [19], This may
be partly because the rate of ethanol metabolism decreases
with age and the aged are therefore at risk of developing
very high ethanol blood levels for a long period. Seizures
and delirium tremens may be diagnosed as complications
of psychosis, encephalitis, subarachnoid haemorrhage or
ischaemic stroke in elderly patients. Withdrawal fits
are common. In a scries which we have studied in
Wellington of patients during withdrawal from ethanol
dependence, out of 27 treated symptomatically, but
without anticonvulsants, five patients had seizures,
being just under 20 per cent [20]. Twelve per cent
of patients admitted to hospital for detoxification
developed seizures in another series [21]. Seizures are
particularly likely to occur in the preliminary stage of
delirium tremens.
During ethanol withdrawal, the majority of seizures
occur from 12-36 hours after the cessation of ethanol
intake [22]. Fits which occur arc usually grand mal
seizures without any focal symptoms, unless there is a
specific localised cerebral lesion, as already discussed.
Tetany-like spasms have been described in alcoholics
during withdrawal and may be confused with focal
epilepsy [23], About 25 per cent of patients who progress
to status epilepticus have excessive ethanol intake as a
predisposing factor [24]. There has been argument about
whether fits occurring only during ethanol withdrawal
should be considered true epilepsy. Some alcoholics only
have fits then, and never have epilepsy at any other time
in their lives. Although prophylactic anticonvulsants
frequently abolish the development of seizures, it is now
not usual to consider that such patients are true epileptics
or that they require conunuing management of fits. The
random electroencephalogram (EEG) is usually normal in
those patients who suffer from withdrawal seizures,
whereas fits that occur during the period of actual
drinking arc more likely to be related to evidence of
epileptic activity, either because the epilepsy predated the
development of the alcoholism or because it resulted from
a problem such as head trauma. Further evidence that
seizures occurring during withdrawal are not true epilepsy
is the observation that sleep deprivation rarely provokes
focal abnormalities or paroxysms in the EEGs of this
group of patients. However, in those with predisposing
features for epilepsy, EEG abnormalities are much more
frequent, particularly after sleep deprivation [25].
The underlying cause of withdrawal fits is sometimes
definable but, in many cases, there is no obviouscause and

Alcohol and Fits

i number of mechanisms have been proposed, which are
noted below:

Withdrawal of other depressants. If a patient is on a
depressant drug such as a benzodiazepine, then he may
fail to take it during and after a period of ethanol
excess, and a seizure may occur as a rebound
phenomenon. [26, 27].

anticonvulsants during withdrawal periods for, say, up to
a week after cessauon of drinking. Among the drugs
which have been used is sodium valproate [19, 31],
although this should be avoided if there is evidence ofliver

epileptic is found to require a large dose of anticonvulsant
to achieve therapeutic drug levels this may be a clue to
unreported ethanol consumption affecting the metabol­
ism of the drug, as already discussed. The value of
anticonvulsants is still debated. Some consider that
anticonvulsants are not necessary as adequate treatment
with drugs used for the treatment of withdrawal [34] such
as chlordiazepoxide (Librium) or other depressant drugs
should alleviate fit frequency [35]. Further studies are still
required.
References
Fluid retention. There is increased blood vasopressin 1 Pearce, J. M. S. (1977). Neurological aspects ofalcoholism.
during alcohol withdrawal [29]. This may result in an
British Journal ofHospital Medicine, 17, 132-142.
increase in fluid retention and eventually in cerebral
(1983). Neurological effects ofalcohol. Patient Management,
oedema: the *wet-brain syndrome in which fits are a
common symptom.
Buchan, W. (1800). Domestic Medicine 17th Edn. London:
GABA depression in the brain. Ethanol may cause a fall
in gamma-aminobutyric acid' (GABA) levels within the
brain. This has been observed in experimental
animals. It may explain the effectiveness of sodium
valproate (Epilim) treatment of withdrawal seizures as
it is a drug which elevates brain concentrations of
GABA [28].

Alteration ofelectrical activity in the brain. There may be
depression of normal rapid eye movement (REM) sleep
and, in a few patients, sleep deprivation: both may
trigger epileptic seizure activity. The possibility of
*
'kindling
of epilepsy has already been discussed.

Altered dopaminergic activity. Impaired central
dopaminergic activity has been implicated in
photosensitive epilepsy. Dopaminergic ncurotransmission is also impaired in the alcohol withdrawal
period and this may therefore contribute to the
occasional occurrence of television induced seizures as
a manifestation of alcohol withdrawal [30].

Gowers, W. R. (1893). A manual of diseases of the nervous
system. Vol,2, London: J & A Churchill, p.982.

a survey of New Zealanders aged 14-X5, pp.ll, Alcoholic
Liquor Advisory Council, Wellington.
Lennox, W. G. (1941). Alcohol and epilepsy. Quarterly
Trcbula/j. and Eibcn, e’. (1975). Abuse of alcohol by
epileptic patients. (Proceedings), Electroencephalography
and Clinical Neurophysiology, 39,438.
8
Milligcn, K. S. (1976). Epilepsy and driving. Proceedings of

6
7

9

Hillbotn, M. E. (1980). Occurrence of cerebral seizures
provoked by alcohol abuse. Epilepsia, 21,459-466.

Iber, F. L. (1969). Increased rate of clearance of drugs from
the circulation of alcoholics. AmericanJournal ofthe Medical
Sciences, 258, 35-39.
Management
Alcoholics frequently deny their pathological drinking. If 11 Sellars, E. M. and Holloway, M. R. (1978). Drug kinetics
and alcohol ingestion. Clinical Pharmacokinetics, 3,
they then develop fits during withdrawal they may run the
+40-452.
risk of being labelled as epileptics, with treatment being
addressed to the management of epilepsy rather than to
ethyl alcohol. Clinical Pharmacology and Therapeutics, 22,
735-742.
that of their alcoholism.
As long as the results ofinvestigations for organic causes
(1981). Effect of short- and long-term alcohol use on
of epilepsy are negative, therapy for fits in association with
phenytoin kinetics in chronic alcoholics. Clinical Pharmacol­
alcoholism should be directed first towards the alcohol­
ogy and Therapeutics, 30, 390-397.
ism, and complete abstinence should be achieved if at all
Impairment of drug metabolism by disulfiram in man.
possible. Non-abstinent patients have a high record of
Clinical Pharmacology and Therapeutics, 12, 785-792.
non-compliance in taking drugs, so that long-term
administration of anticonvulsant drugs is not likely to be
electroencephalogram in patients admitted for alcohol abuse
fully effective. A common therapeutic technique is to give
with seizures. Clinical Electroencephalography, 10, 40-49.

r
232

Ralph Johnson

16 Scollo-Lavizzari, G. (1983). Epilepsy in alcoholics. 27 Shaw, G. K. (1981). Alcohol dependence and withdrawal.
Hexagon, 6, 20-24.
British Medical Bulletin, 38, 99-102.
17 Ballenger, J. C. and Post, R. M. (1978). Kindling as a
model for alcohol withdrawal syndromes. British Journal of
(1979). Antagonism of the enhanced susceptibility to
Psychiatry, 133, 1-14.
audiogenic seizures during alcohol withdrawal in the rat by
18 Wolfe, S. M. and Victor, M. (1969). The relationship of
a-amniobutync acid (GABA) and GABA-mimetic agents.
hypomagnesemia and alkalosis to alcohol withdrawal
symptoms. Annals ofthe Nets York Academy ofSciences, 162,
396-403.
973-984.
29 Eisenhofer, G., Whiteside, E. A., Lambic, D. G. and
19 Dickinson, E. S. (1982). Seizure disorders in the elderly.
Johnson, R. H. (1982). Brain water during alcohol

20

Whiteside, E. A. (1980). Sodium valproate in the treatment

ZealandJournal ofPsychiatry, 14, 213-215.
21 Victor, M. and Laureno, R. (1978). Neurologic complica22

pp.603-617 Raven Press, New York.

23
24 Aminoff, M. J. and Simon, R- P. (1980). Status epilcpticus,
causes, clinical features and consequences in 98 patients.
25

after sleep deprivation. Epilepsia, 25, 526-530.
26 Finer, M. J. (1971). Diphenylhydantoin for treatment of
Medical Association, 215, 119.

30 Keyser, J. de., Michotte, A. and Ebingcr, G. (1984).
Television induced seizures in alcoholics. British Medical
Journal, 289, 119-1192.
31 Goldstein, D. B. (1979). Sodium bromide and sodium
32 Sampliner, R. and Ibcr, F. L. (1974). Diphenylhydantoin

American Medical Association, 230, 1430-1432.
33 Chu, N-S. (1979). Carbamazepine: prevenuon of alcohol
withdrawal seizures. Neurolo^, 29, 1397-1401.
34 Sellers, E. M. and Kalant, H. (1976). Alcohol intoxication
and withdrawal. New England Journal of Medicine, 294,
35 Rothstein, E. (1973). Prevention of alcohol withdrawal

1381-1382.

Morbid Cravings: The Emergence of Addiction
Dr Virginia Berridge
Znrntuu of Historical Research, Senate House, London WC1E THU
Few readers of the British Journal ofAddiction can now be
unaware that 1984 was the centenary year of the Society
for the Study of Addiction. A centennial symposium was
held at the Royal Society in October 1984; the centenary
issue of theJournal appeared and an historical conference
on alcohol and alcoholism was held in November. The
centenary was also marked in a visual way by an exhibition
SOCIETY
held at the Wellcome Institute for the History of
Medicine. Arising out of an approach by Professor
Malcolm Lader, President ofthe Society, to the Wellcome
Institute, the exhibition, entided 'Morbid Cravings: The
STUDY AND CURE OF INEBRIETY.
Emergence of Addiction’ was organised by a small group
representing both the Society and the Institute. William
Schupbach, curator of the Wellcome Iconographic
INSTITUTION OF THE SOCIETY
Collections, Julia Sheppard, archivist of the Contempor ­
ary Medical Archives Centre, came from the latter,
Malcolm Lader and myself from the Society, Robin Price,
Deputy Librarian of the Wellcome Institute both co­
ordinated and actively participated in the group.
The exhibition had a certain timeliness in another
respect in that it coincided with an upsurge of media
interest in the ‘heroin problem’ and political recognition
of public concern through the injection of funds into
regional drug teams- However, the ‘dangerous drugs’
INAUGURAL LUNCHEON.
were by no means the only addictive substances covered
in the exhibition. Addiction to tobacco, opium, cocaine,
medically prescribed drugs such as chloral hydrate, the
barbiturates and amphetamines, the ‘gentle poisons’ of
tea, coffee and chocolate, and historically and currendy,
the chief ‘problem drug’ of them all, alcohol — were all
covered. Other organisations and institutions generously
provided items. The Pharmaceutical Society, for
example, lent a selection of chlorodyne advertisements
and the University of London Library provided a copy of
the 1920 Dangerous Drugs Act. But the bulk of the Figure 1. Proceedings of the Society for the Study and Cure of
material on display came either from the library of the Inebriety. 1884, 1(1) p. 1. Institution of the Society.
Wellcome Institute itself, or from the vast collection of
medically related items initiated by Sir Henry Wellcome, Museum. The exhibition organisers were embarrassed for
originally housed in a medical museum in the Euston choice. Julia Sheppard, dealing with tobacco, had
Road building, but now on permanent loan to the Science particular problems in choosing from the vast Science

Raistrick, Dunbar and Davidson

used as one filter in deriving short-form-ADD, best separated ‘alcoholics’ and
‘regular drinkers’ with items tapping cognitive and to a lesser extent behavioural
events, rather than by items associated with more severe dependence such as
withdrawal phenomena. A Guttman analysis ofshort-form-ADD would be useful to
test fora hierarchical relationship between cognitive, behavioural and physiological
questions.
*fonn
Short

alcohol dependence data questionnaire (SADD)

The following questions cover a wide range of topics to do with drinking. Please read each question

drinking habits and answer each question by placing a tick (/) under the MOST APPROPRIATE
heading. If you have any difficulties ASK FOR HELP.

thought of drink out of your mind?
3

Do you plan your day around when and

4

Do you drink in the morning, afternoon

Do you drink for the effect of alcohol
without caring what the drink is?
6
Do you drink as much as you want
irrespective of what you are doing the

5

7 Given that many problems might be caused
by alcohol do you still drink too much?
stop drinking once you start?

10

giving it up completely for days or
weeks at a time?
The morning after a heavy drinking
session do you need your first drink to
get yourself going?

session do you wake up with a definite
12

After a heavy drinking session do you

14

After a heavy drinking session do you
see frightening things that later you
realize were imaginary?
Do you go drinking and next day find
you have fogotten what happened the
night before?

15

Questionnaire on Alcohol Dependence

Acknowledgements
Special thanks are given to Prof. Griffith Edwards and Dr Bram Oppenheim who
have given advice, criticism and support throughout this project. Thanks are also
due to John Bartie for his help in selecting the final ADD questions, and to the
Addiction Unit nursing staff for their conscientious collection and scoring of
questionnaires through several phases of development. Finally an appreciation to
Margrit Salter for her careful secretarial work on the paper.

References
1 Miller, W. R. (1976). Alcoholism Scales and Objective Assessment Methods. Psychological Bulletin,
83, 649-674.
2 Jacobson, G. R. (1976). The Alcoholisms: detection, assessment and diagnosis. Human Sciences Press,
New York.
3 Edwards, G. and Gross, M. (1976). Alcohol Dependence: provisional description of a clinical
syndrome. British Medical Journal, 1, 1058-1061.
4 Shaw, S. (1979). A critique of the Concept ofAlcohol Dependence. BritishJournal ofAddiction, 74,
339-348.
5 Jellinek, E. M. (1960). The Disease Concept of Alcoholism, Hillhousc, New Haven.
6 WHO Shortened Memorandum (1982). Nomenclature and Classification of Drug- and
Alcohol-related Problems. British Journal of Addiction, 77, 3-20.
7
Heather, N. and Robertson, I. (1981). Controlled Drinking. Methuen, London.
8 Madden, J. S. (1979). Commentary on Shaw. British Journal of Addiction, 74, 349-352
9 Stockwell, T., Hodgson, R., Edwards, G., Taylor, C. and Rankin, H. (1979). The
Development of a Questionnaire to Measure Severity of Alcohol Dependence. British Journal of
Addiction, 74, 79-87.
10 Chick, J. (1980). Alcohol Dependence: Methodological Issues in its Measurement; Reliability of
the Criteria British Journal of Addiction, 75, 175-186.
Il
Keeler, M. H., Taylor, L. and Miller, W. C. (1979). Are All Recently Detoxified Alcoholics
Depressed? American Journal of Psychiatry, 136. 586-588.
12
Clark, W. B. (1976). Loss of Control, Heavy Drinking and Drinking Problems in a Longitudinal
Study. Journal of Studies on Alcohol, 37, 1256—1290.
13
Room, R. (1977). Measurement and Distribution of Drinking Patterns and Problems in General
Populations. In Gross, M„ Edwards, G„ Keller, M., Moser. J. and Room. R. (eds) Alcohol
Related Disabilities, W.H.O., Geneva.
14
Saunders, W. M. and Kershaw, P. W. (1979). Spontaneous Remission from Alcoholism - A
Community Study. British Journal of Addiction, 74, 251-265.
15 Polich, H. M., Armor, D.J. and Braiker, H. B. (1980). The Course ofAlcoholism: Four Years After
Treatment. Rand Corporation, Santa Monica, GA.
16
Edwards, G., Orford, J., Egert, S., Gutherie, S., Hawker, A., Henaman, M., Oppenheimer,
E. and Taylor, C. (1977). Alcoholism: A Controlled Trial of‘Treatment’ and ‘Advice’. Journal of
Studies on Alcohol. 38. 1004-1031.
17 Wilson, P. (1980). Drinking in England and Wales. Office of Population Censuses and Surveys.
HMSO, London.
18 Chick, J. (1980). Is There a Unidimensional Alcohol Dependence Syndrome? Bntishjoumal of
Addiction, 75, 265-280.

' Miguel Rober^Brge and Jandira Masur
alcoholics in a setting different from that in which it was
developed. Based on the data reported here, we feel that
subjects with scores ranging from 1-9 should be classified
as non-dependent or low dependent instead of only low
dependent, as proposed by Raistrick ei al. [6].
Our alcoholic population fell into the medium or high
dependent categories, and provides further support for
Hodgson ei al.'s [13] assertion that not all people admitted
to alcohol treatment units are severely dependent,

although they share a range of complaints, problems and
disabilities caused by drink.
From the present study we were unable to analyse
whether alcoholics attending an out-patient service
differed in severity from those being treated in an in­
patient unit, or whether social class was related to severity

Appendix 1. Short-form alcohol dependence data questionnaire (SADD) as described by Raistrick, et al. [6]

The following questions cover a wide range of topics to do with drinking. Please read each questioniqueijn by placing/lick
much about its exact meaning Think about your MOST RECENT drinking habits and answer cad
(V) under the MOST APPROPRIATE heading. If you have any difficulties ASK FOR HELP.
Sometimes

1. Do you find difficulty in gening the thought of drink

2 Is getting drunk more important than your next
meal?
3. Do you plan your day around when and where you can
drink?
4. Do you drink in the morning, afternoon and
5. Do you drink for the effect of alcohol without caring
what the drink is?
you arc doing the next day?

8. Do you know that you won’t be able to stop drinking
once you sun?
9. Do you try to control your drinking by giving it up
completely for days or weeks at a time?

...

Journal of Psychiatry, 127, 1653-1658.
2 Ewing, J. A. and Rouse, B. A. (1970). Identifying the
hidden alcoholic. Read at the 29th International Congress on
Alcoholism and Drug Dependence. Sydney, Australia,

Often

Nearly Always

Rankin, H. (1979). The development of a questionnaire to
measure severity of alcohol dependence. British Journal of
Addiction, 74, 79-87.
5 Edwards, G. and Gross, M. (1976). Alcohol dependence:
SfrSjJurS lfl058-°1061.
*
6 Raistrick, D., Dunbar, G. and Davidson, R. (1983).
dependence. British Journalof Addiction, 78, 89-95.
7 Masur, J. and Monteiro, M. G. (1983). Validation of the
‘CAGE
*
alcoholism screening test in a Brazilian psychiatric
in-patient hospital setting. BrazilianJournal ofMedical and
Biological Research, 16, 215-218.

to Statistics for the Behavioural Sciences. W. B. Saunders
Laranjeira, R. R. (19
*79).

Consumo de Alcool em pacicntes

Associafdo Medica Brasileira, 25, 302-306.
Masur, J., Cunha, J. M., Zwicker, A. P., Laranjeira, R.
R., Knobel, E., Sustovich, D. R. and Lopes, A. C. (1980).
Prevalencia de pacicntes com indicadores de alcoolismo
intemados cm uma enfennaria de cllnrca gcral. Acta
Psiquidrrica y Psicoldgica de America Latina, XXVI,
125-130.
(1980). Consumo de ilcool em pacicntes ambulatoriais de
Psiquiatria, 2, 183-189.
Ministerio da Saude (Dinsam-Snpes) (1981). Subsidies

Alcoolismo. Brasilia, DF, pp. 26.
G. (1978). Alcohol dependence: the concept, its utility
and measurement. British Journal of Addiction, 73,
339-342.

....

....

....

....

....

....
....

....

need your first drink to get yourself going?

....

...

12. After a heavy drinking session do you wake up and
retch or vomit?

....

....

....

....

13‘ ^iCo7y^^I?o\\ho”^^8$^i0nd0yOU8°

14. After a heavy drinking session do you see frightening
things that later you realize were imaginary?

References
1 Setter, M. L. (1971). The Michigan Alcoholism Screening

Stinnett,’]. L. and Schechter, J. O. (1982-83). A
Quantitative Inventory of Alcohol Disorders (QIAD): a
severity scale for alcohol abuse. American Journal of Drug
and Alcohol Abuse, 9, 413-430.

questions in a further study.

Never

Use of the Short-Form Alcohol Dependence Data

5^^pti ^1-3^

MAYFIELD, MCLEOD, AND HALL

Mulford HA: Drinking and deviant drinking, U.S.A., 1963. Q J
Josscy-Bass. 1970
Stud Alcohol 25:634-650. 1964
8.
Mulford HA, Wilson RW: Identifying Problem Drinkers in a
Cahalan D. Cisin IH. Kirsch AD, et al: Behavior and Attitudes Re­
Household Health Survey. Washington, DC, US Public Health
lated to Drinking in a Medium-Sized Urban Community in New
Service, 1966
England. Social Research Project Report No 2. Washington. DC.
9.
Knupfer G: Some methodological problems in the epidemiology of
George Washington University Medical School. 1965
alcoholic beverage usage: definition of amount of intake. Am J
5.
Knupfer G: Epidemiological studies and control programs in alco­
Public Health 56:237-242. 1966
holism. V: the epidemiology of problem drinking. Am J Public
10.
Knupfer G, Room R: Age. sex and social class as factors in amount
Health 57:973-986. 1967
of drinking in a metropolitan community. Social Problems 12:224 6.
Cahalan D, Cisin IH: American drinking practices: summary of
240, 1964
findings from a national probability sample, I: extent of drinking
11.
Room R: Drinking patterns in large U.S. cities: a comparison of
by population subgroups. Q J Stud Alcohol 29:130-151. 1958
San Francisco and national samples. Q J Stud Alcohol Suppl 6,
7.
Cahalan D: Problem Drinkers: A National Survey. San Francisco,
May 1972. pp 28-57
3.

4.

The AGE Questionnaire: Validation of a New
Alcoholism Screening Instrument
BY DEMMIE MAYFIELD. M.D.. GAIL MCLEOD. M.S.W., AND PATRICIA HALL, M.S.W.

The CA GE questionnaire, a new briefalcoholism screen­
ing test, was administered to all patients (N = 366; 39
percent alcoholic) admitted to a psychiatric service over a
one-year period. The authors indicate that the CAGE
questionnaire is not a sensitive alcoholism detector ifa
four-item positive response is the criterion; however, ifa
two- or three-item criterion is used, it becomes a viable
rapid alcoholism screening technique for large groups.

A number of investigators have attempted to devise a vi­
able screening questionnaire for the detection of alcohol­
ism (1, 2). None of these questionnaires meets all the re­
quirements of brevity, ease of administration, sensitivity,
and validity desired in such an instrument. Ewing and
Rouse (3) have developed a questionnaire that promises
to correct many of the shortcomings of previous alcohol­
ism screening instruments. The CAGE questionnaire,
consisting of four questions of a nonincriminating nature,
appears in preliminary studies to be a sensitive indicator
of covert problem drinking. We conducted the following
study in order to further evaluate the usefulness of the
CAGE questionnaire.

At the time this work was done, the authors were with the Veterans Ad­
ministration Hospital. Durham, N.C., where Dr. Mayfield was Assis­
tant Chief, Psychiatry Service, and Mses McLeod and Hall are staff so­
cial workers. Dr. Mayfield is now Chief, Psychiatry Service, Veterans
Administration Hospital, Providence. R.I. 02908. and Professor of Psy­
chiatry, Brown University Program in Medicine, Providence.

METHOD

The study was conducted on the Psychiatric Service of
the Veterans Administration Hospital, Durham, N.C., a
500-bed university affiliated general hospital. The Psychi­
atric Service is an 80-bed acute inpatient facility with no
specifically designated program for alcoholics, but alco­
holic patients are regularly treated on an individual basis
intermixed with the general psychiatric population.
After admission, patients receive diagnostic evaluation
by a team of staff and resident psychiatrists, social work­
ers, psychologists, nursing personnel, and personnel from
a variety of other disciplines, plus medical and social
work students and psychology trainees. Social workers
routinely collect information from family or other infor­
mant sources and incorporate this information into the
work-up and treatment plan. Length of stay varies from
one week to six months, averaging approximately six
weeks.
Each patient admitted to the Psychiatric Service over a
one-year period was interviewed by a psychiatric research
technician one to seven days following admission. The in­
terview consisted of a standardized introduction and a se­
ries of 16 questions of a benign and indifferent nature
(education, marital status, etc.), with the CAGE ques­
tions included. The CAGE questions are: “Have you ever
felt you should cut down on your drinl<ingT~"Have
people annoyed you by criticizing your drinking?" “Have
you ever felt bad or guilty about your drinking?" ‘*Have
you ever had a drink first thing in the morning to steady
your nerves or get rid of a hang-over (eye-opener)?” Two
Am J Psychiatry 131:10, October 1974

1121

CAGE QUESTIONNAIRE

other alcohol-related questions, asked before the CAGE
questions, were: “Do you ever drink?” “Does your wife
ever drink?”
Following discharge, each patient’s name was placed
on a list maintained by the social worker (G.M., P.H.)
covering that patient’s ward area. The social worker cate­
gorized the patient as alcoholic or nonalcoholic on the
basis of diagnostic formulations by the multidisciplinary
team from the information collected from the patient and
from informant sources. The alcoholic/nonalcohohc cat­
egorization was subsequently correlated with the CAGE
responses. The alcoholism designation was correlated
with the response to each of the CAGE questions and
with the questionnaire as a one-, two-, three-, or fouritem instrument. The statistical analysis was accom­
plished by using the phi coefficient of correlation for cor­
relation of a true dichotomy with a dichotomized vari­
able (4).
RESULTS

MARK S. GOLDMAN
TABLE 1
Comparison of Positive CAGE Responses ofAlcoholic and

Twelve patients categorized as alcoholics gave positive
responses to only one CAGE question. Of these, six were
Three hundred sixty-six patients were evaluated over
psychotic (two schizophrenic and two manic patients and
the one-year period. The patients were predominantly
two patients with organic brain syndromes). The menial
male (99 percent), while (77 percent), and middle-aged
status of the remaining six alcoholics was not remark­
(63 percent between 35 and 55 years), ranging in age from
able.
19 to 75 years. Lower socioeconomic classes (5) were
Five nonalcoholic patients gave positive responses to
overrepresented (classes IV and V = 73 percent), and up­
three CAGE questions. All of these patients were clearly
per classes were underrepresented (classes I and 11=7
incompetent to give valid responses because of psychotic
percent). Sixty percent of the subjects were married, 16
status at the time of the interview. (Four were schizo­
percent separated or divorced, 2 percent widowed, and 22
phrenic, and one had an organic brain syndrome.)
percent single.
Of the 366 patients, 79 percent were alcohol users and
21 percent were abstainers, while 33 percent of their
spouses were alcohol users and 67 percent were abstain­ COMMENT
ers. Of the 366, 39 percent were categorized as alcoholics
The CAGE questionnaire is brief and easy to adminis­
and 61 percent as nonalcoholics. Table 1 shows the re­
ter, comparing quite favorably in this regard with the
sponses of the alcoholic and nonalcoholic patients to the
Michigan Alcoholism Screening Test (MAST)(1) and a
CAGE questionnaire. Used as a complete four-item
shortened version of the MAST (2). The CAGE ques­
questionnaire, there were no false positives, but only 37
tionnaire also appears to be less intimidating to the re­
percent of the alcoholics were appropriately identified,
spondent than either version of the MAST.
and the correlation was rather unimpressive (r = .65).
Our work indicates that the CAGE questionnaire is
Using two or three positive responses as criteria, how­
ever, yielded a rather impressive correlation coefficient (r not a sensitive detector of alcoholism if a complete, fouritem response is the sole criterion. Ils sensitivity is im­
= .89).
pressive, however, if a two- or three-item positive re­
The question “Have people annoyed you by criticizing
your drinking?” had substantially lower power as a pre­ sponse is accepted as the criterion. Elimination of those
dictive criterion than did the other three CAGE ques­ subjects who are clearly incompetent to give a valid re­
sponse (schizophrenic and manic patients and those with
tions, primarily because 50 percent of the alcoholics
organic brain syndromes) would further strengthen the
failed to answer it affirmatively.
We carefully examined the individual records of those sensitivity and validity of the CAGE as an indicator of al­
patients who were most clearly misidentified by their coholism. Development of a weighted scoring system
CAGE responses (alcoholics who scored zero or one pos­ would probably also improve the validity of the questionitive response and nonalcoholics who scored three posi­
Our delineation of alcoholism, based on a comprehen­
tive responses). Fourteen patients categorized as alcohol­
ics gave negative responses to all CAGE questions. Of sive multidisciplinary evaluation of the patient over a pe­
these, seven were psychotic—four with functional psy­ riod of lime and using available informant sources,
choses (three schizophrenic and one manic patient) and seems to be a practical criterion against which to validate
an instrument for the detection of alcoholism or problem
three with organic brain syndromes. The other seven
drinking. The questionnaire needs further evaluation in
patients manifested competent mental status.

1122

Am J Psychiatry 131:10, October 1974

different populations and different sellings, but it appears
to be a very promising technique for rapid screening of
alcoholism in large groups,

REFERENCES
1. Sclzer ML. The Michigan Alcoholism Screening Test; the quest for
a new diagnostic instrument, Am J Psychiatry 127.1653-1658.
1971

cncd version of the Michigan Alcoholism Screening Test
*
Am'j
Psychiatry 129:342-345. 1972
Ewing JA, Rouse BA: Identifying the hidden alcoholic. Read at the
29th International Congress on Alcoholism and Drug Dependence
Sydney. Australia, Feb 2-6, 1970
Peatman JG: Descriptive and Sampling Statistics. New York Har­
per Brothers. 1947. pp 92-93
Hollingshead AB: Two-factor index of social position. New Haven.
Conn. 1957 (processed)

To Drink or Not To Drink: An Experimental Analysis of Group
Drinking Decisions by Four Alcoholics
BY MAUK S. GOLDMAN, PHD.

The author reports on a study that examined the effects
ofsocial influence on the initiation, maintenance, and ter­
mination ofdrinking in a group offour men who were
chronic alcoholics. These men made decisions in a group
setting about alcohol and cigarette usefor which they
earned reinforcement points redeemable for drinks and
cigarettes during the study orfor money at its end. Deci­
sion making delayed the initiation ofdrinking and tended
to lower overall alcohol consumption during a period of
prolonged drinking but was not effective in inducing early
termination of the drinking episode. Mood disturbances.
physical symptoms, and psychopathology became more
pronounced when the amount ofalcohol consumed in­
creased. The extent ofdecision making changed during
.limes ofhigh motivation fordrinks or cigarettes; these
decisions were mainly a function ofindividual leadership.
In the light of thesefindings, the author discusses the pos­
sible utility ofthe group decision-making model as a tool
for the treatment ofalcoholism.

The presumption that social factors play a major role in
the etiology and maintenance of chronic alcoholism is
now well supported in the literature on alcoholism (1-3).
However, most efforts to clarify the role of social factors
in alcohol addiction to dale have depended on field obser­
vations in natural sellings. Recently, two groups of labo­
ratory-based experimenters have begun to examine the
effects of social behavior on consequent drinking behav­
ior, but these have not yet focused on the reciprocal rela­
tionships between drinking and interpersonal behav-

The extensive experimental literature on small-group
dynamics offers methods by which reciprocal relation­
ships between drinking behavior and small-group phe­
nomena can be explored. In particular, the work of Wal­
lach and associates (8.9), which explored the effects of
group decision making on willingness to come to risky
decisions, and that of Schachter (10), which studied com­
munication patterns between regular and deviant group
members during decision making, seem to offer appropri­
ate models for this purpose.
The study on which this paper reports examined the
behavior of four male chronic alcoholics who lived to­
gether in a laboratory environment for 25 days. At cer­
tain times during the study, their drinking and smoking
behavior depended on group decisions; drinking and
smoking al other limes were a function of individual deci­
sions. The study was undertaken to explore reciprocal
relationships between group behavior and the social, af­
fective. and drinking behavior of the four chronic alco­
holics who participated in the study. Because group deci­
sions to initiate, maintain, and terminate a period of
prolonged drinking were required, group behavior during
an entire episode of drinking could be subjected to de­
tailed examination.

rsily, DctrmX MfcM^0^,rtmCnl °f Pl‘)ch‘,,0*>
upported b> research gram MH-18850 from the No­
on Alcohol Abuse and Alcoholism to Peter E. Nathan.

A mJ Psychiatry 131:10. October 1974

riH

The International Journal of the Addictions, 16(2), 283-303, 1981

Acute and Chronic Drug Abuse
Emergencies in Metropolitan Toronto
*
E. M. Sellers, MD, PhD

U. Busto, PharmD

J. A. Marshman, PhD

S.

M. MacLeod, MD, PhD

H. L. Kaplan, PhD

C.

Stapleton, RN

H. G. Giles, PhD

F. Sealey, RN

B.

M. Kapur, PhD

Clinical Institute and Clinical Pharmacology Program
Addiction Research Foundation of Ontario:

Faculty of Pharmacy
Departments of Medicine and Pharmacology
Faculty of Medicine
University of Toronto
Toronto, Ontario, Canada M5S 2S1

Abstract
From 3,548 drug overdose or abuse cases presenting at 21 Metro­
politan Toronto hospitals’ Emergency departments, data con•Presented in part at the Canadian Royal College of Physicians meeting, Quebec City, Janu­
ary 1976; the Canadian Conference on Pharmaceutical Research, Saskatoon, May 1976;
and the annual meeting of the National Council on Alcoholism, Washington, D.C., May
1976.
283

Copyright© 1981 by Marcel Dekker, Inc.

284

SELLERSET AL.

cerning demographic and medical characteristics, investigative
and management procedures, drug analysis services, and dis­
position of patients were collected. Of the 3,548 cases, 2,723 (77%)
were acute overdose and 816 (23%) were drug abuse. Drug over­
dose was more common than drug abuse for both sexes, but was
more characteristic of females. The drugs most frequently alleged
ingested were benzodiazepines (34%), ethanol (32%), salicylates
(16%), and barbiturates (14%). The frequency with which particu­
lar classes of drugs are alleged in overdose corresponds closely to
the frequency of prescribing these drugs in Ontario.

INTRODUCTION
Recent studies of the epidemiology and treatment of acute drug inges­
tion in adults have highlighted the social impact of acute drug overdose.
This impact includes the incidence of such overdoses (Alderson, 1974;
Jensen, 1977; Kessel, 1965; Smith, 1972), the nature of the drugs associ­
ated with morbidity and mortality in overdose (Ghodse, 1977; Lawson
and Mitchell, 1972; Proudfoot and Park, 1978; Stewart et al., 1974), the
cost to the health care system associated with drug overdose (Smith,
1972), and the possibility of identifying a “high-risk” population (Gethin
Morgan et al., 1975; Hindmarch, 1972; Kennedy et al., 1974; Kessel,
1965).
There have been four previous studies of drug abuse emergencies in
Canada, but because of different methodologies, the results are difficult to
compare. Ruedy (1973), studying all overdose cases presenting at the
Montreal General Hospital in 1972, found benzodiazepines and nonbar­
biturate sedatives to be the most frequently ingested drug classes, with
43% of patients taking several drugs (other than ethanol, which was al­
leged in 23% of all cases). Rangno (1975), studying just the patients ad­
mitted to intensive care from the same population, found very similar
results. In both of these studies, the drug classifications were a combina­
tion of patients’ allegations and laboratory confirmations. In a study of all
Hamilton, Ontario, hospitals for 15 months in 1966 and 1967, Sims et al.
(1973) found sedatives (mostly barbiturates) more frequently implicated
than minor tranquilizers, with fewer than 10% of the cases involving mul­
tiple drugs other than ethanol. This report did not state how the respon­
sible drugs were identified. Sellers (1975) considered only the analyses of
samples sent to a central Toronto laboratory in 1972 and 1973, when an
adequate benzodiazepine assay was not available. Among the drugs de­

285

DRUG ABUSE EMERGENCIES

tectable, barbiturates were much more common than nonbarbiturate seda­
tives, and in 25% of the samples more than one drug was detected, not
including ethanol. The four studies agree in finding much less involve­
ment of “street drugs” (primarily amphetamines and hallucinogens) than
of prescription drugs in leading to acute poisoning.
The present study was designed to determine the following: the pa­
tient characteristics and alleged choice of drugs associated with drug
abuse emergencies; the accuracy of reporting by patients, their friends
and relatives, and emergency care workers of what drugs have been in­
gested; the role of drug analysis in the clinical management of such pa­
tients; the nature of the morbidity, the extent of the mortality, and the
estimated costs of caring for these patients; whether a high-risk overdose
population can be identified; and patterns of follow-up of patients who
have ingested overdoses of psychoactive drugs. Such information is
needed for evaluating and modifying medical education, government
regulation, and hospital administration.
This study includes 3,548 Emergency visits for acute adult drug inges­
tion or drug abuse during a 6-month period. All Metropolitan Toronto
general hospitals with Emergency Departments are included; therefore,
this is the first total urban catchment survey of this problem.
This first paper describes the methodology and general results of the
study. Subsequent papers will focus on particular drugs, such as ethanol;
on patient care strategies, such as the usefulness of serum analyses; on
demographic determinants of drug abuse; and on the social policy and
health care implications of our findings.

METHODS
The Patient Population

This study is based on the records of all patients with “acute drug
overdose” or “drug abuse,” presenting for Emergency services at 21 Met­
ropolitan Toronto general hospitals between January 1 and June 30, 1975.
While patients under the age of 14 were not specifically excluded from the
study, most such patients in Metropolitan Toronto are referred to a spe­
cial children’s hospital which was not included in the study. There are
eight “core” hospitals, seven of which are university-affiliated teaching
hospitals. These teaching hospitals treated 99.4% of the core patients. The
13 “suburban” hospitals treated 34.2% of all patients, and included three
teaching hospitals, which treated 44.6% of the suburban patients.

286

SELLERSET AL.

Problem Classification

Overdose, or acute drug ingestion, is defined as “A single ingestion of a
quantity of drug greater than an individual’s usual habit or greater than
the maximum recommended prescribed dose.” This category also includes
the 2% of our sample who ingested substances other than drugs, topical
agents, and household chemicals. Drug abuse is defined as “The chronic
ineestion or injection of a quantity of psychoactive or analgesic drug
which is greater than the recommended usual dose.” This category in­
cludes most “street drugs” for which there is usually no medically recom­
mended dose. From another viewpoint, the difference between overdose
and abuse is usually that between intentionally self-destructive drug tak­
ing and the accidental consequences of experimental drug use. Patients
whose sole recorded problem was excessive consumption of beverage alco­
hol (“has been drinking”) were not included in the study.

Data Collection

Nurse monitors reviewed all Emergency presentations at the 21 hospi­
tals to collect these data:
Demographic characteristics: sex, age, admission problem (overdose or
drug abuse), persons or agencies accompanying the patient.
Alleged drugs ingested: name, quantity, route of administration, legal
classification (prescription, o.t.c., or illicit), source of drug, and alleged
concomitant ethanol ingestion.
3. Clinical characteristics, if recorded: level of consciousness (alert,
drowsy, unconscious), psychic effects (confusion, delusion, hallucina­
tions), blood pressure, pulse rate, respiratory rate, rectal temperature,
reflexes.
4. Laboratory tests, if performed: blood gases, hemoglobin, hematocrit,
electrolytes, BUN, creatinine, blood sugar, x-rays.
5. Treatment in emergency: medications given, other treatments (forced
diuresis, forced emesis, intubation, lavage, etc.), duration of stay in
Emergency, type of discharge (admitted to inpatient treatment, ex­
pired, psychiatric referral, community service agency, clinic, etc.)

1.

2.

Other than the hospital records, these data were available to us:

1.

Serum and urine analyses were frequently performed to determine the
correspondence between the drugs alleged and those that could be con­
firmed, as well as to determine the overall pattern of drugs confirmable

DRUG ABUSE EMERGENCIES

287

in laboratory tests. Analytical toxicological facilities vary widely among
the hospitals in Metropolitan Toronto, but they all have access to a
common laboratory at the Addiction Research Foundation Clinical In­
stitute. All decisions concerning the selection and use of these analyti­
cal services rested with the attending physicians, and considerable care
was taken during the study not to interfere with the usual patterns of
patient management.
2.
Coroner’s office records of deaths from drug overdose during the time
of this study were made available to us, so that we could compare the
patterns of drug-related deaths outside of Emergency Departments to
the drug use of our sample.
Statistical Processing of the Data

In addition to the usual computer software, general-purpose languages
such as FORTRAN and application packages such as SPSS, we needed to
develop two special programs for the data-collection phase of this project.
The first of these programs uses a computer-driven plotter to draw com­
plex coding forms on which the nurse monitors entered data at the hospi­
tals and from which the data could be keypunched directly. The second
program facilitates data validation by reporting improbable or illegal
values in the various data fields, and subsequently combines the differing
numbers of cards from each patient (depending on the types and numbers
of tests performed) into master-file records of a common length and for­
mat. (More complete details of the data collection procedure, including
the recording forms, drug codes, and analysis procedures, are available
from the authors.)
The code numbers assigned to the drugs were chosen to facilitate subse­
quent analysis. Each drug is assigned a four-digit code, of which the first
two digits signify a pharmacologic category and the last two digits specify
a drug within that category. For example, the drugs chlordiazepoxide,
diazepam, and flurazepam are all given numbers in the 1700 series, ben­
zodiazepines. Some of the drug categories, such as benzodiazepines, bar­
biturates, salicylates, and bromides, are quite homogeneous.
Unfortunately, it was also necessary to create some less homogeneous
categories, such as “other analgesics” (not salicylates or opiates), “hallu­
cinogens,” and “household and industrial products” (which included mer­
cury, waxes, shampoo, and lye). However, almost all of the drugs alleged
were from the pharmacologically reasonable categories. All of the data re­
ported in this paper concern these categories of drugs, not specific drugs
within the categories.

288

SELLERS ET AL.

In all of our drug category statistics, unless we specifically state other­
wise, a patient may be classified into several overlapping categories, corre­
sponding to the multiple drugs ingested, whether they are dispensed as
components of a combination product or as separate products. For ex­
ample, the class of patients who have taken both ethanol and salicylates
does not exclude patients who have added barbiturates to that combina­
tion. For that reason, there are many tables in which patients appear
more than once, and in which percentages total more than 100%.

RESULTS
During the 6 months of this study, 3,548 visits were recorded at the
Emergency Departments of the 21 Metropolitan Toronto hospitals. Of
these, 816 (23.1%) were drug abuse cases and 2,723 (76.9%) were drug
overdose cases. Of the visits, 21.4% were by the 9.7% of the patients seen
at least twice during the 6-month period, including some patients who
were transferred between two hospitals’ Emergency Departments for the
same incident.
Metropolitan Toronto had, in 1975, a population estimated at
*
2,177,400.
Based on this statistic, we estimate the incidence of drug abuse
and drug overdose Emergency visits to be 75 and 250 per 100,000 popu­
lation per year. Of the 3,548 patients, only three died in Emergency as a
result of the incident. They were a 21-year-old male who had taken cya­
nide, a 33-year-old female who had taken ethanol and an unspecified
drug, and a 26-year-old female who had alleged “sleeping pills.”
Patient Characteristics

Table 1 shows the total patient population, separated into drug abuse
and overdose categories, tabulated against sex, age, and hospital location.
Compared with the general population of Metropolitan Toronto in 1975,
the patient population has a higher proportion of females and of persons
under the age of 35. The relationship between sex and problem was statis•Except for Figs. I and 2, values for the total Metropolitan population and the
core:suburban division are 1:4 interpolations between the-1971 and 1976 census data. The
age and sex proportions are from the 1971 census, excluding persons under the age of 10
years. In Figs. 1 and 2, the age distriuution graphed is based on the 1971 census distribu­
tions, with the population for each age cohort multiplied by 4 years’ growth in the total
Metropolitan Toronto population, the age bounds for each cohort advanced by 3 years, and
the resulting distribution smoothed.

Table 1
Profile of Total Patient Population (N = 3,548)*

Type of
problem
Drug
overdose
Drug
abuse
Total
Metropolitan
Toronto

Sexbc
Male
Female
N
(%)
(%)

Total patient
population
N
(%)

N

2723

930 (34.2)

N

<21
(%)

21-35
N
(%)

36-50
N
(%)

N

<50
(%)

N

Hospital location"'
*
Core
Suburban
(%)
N
(%)

1791

(65.8)

606

(22.9)

1267 (47.8)

562

(21.2)

213

(8.0)

806

1917

(70.4)

816 (23.1) 555 (68.0) 261
3539 (100.0) 1485 (42.0) 2052

(32.0)
(58.0)

347
953

(44.2)
(27.8)

335 (42.7)
1602 (46.7)

75
637

(9.6)
(18.6)

28
241

(3.6)
(7.0)

503 (61.6) 313
1309 (37.0) 2230

(38.4)
(63.0)

(22.5)

(29.4)

(25.5)

(30.7)

(69.3)

(76.9)

(48.8)

(51.2)

(22.7)

(29.6)

“Throughout the paper the percent values have been calculated after the removal of the cases with missing data (e.g., for the overdose-abuse divi­
sion, there were nine cases whose problem was not recorded).
bThe percentages in this subtable are row percents, summing to 100% across the demographic categories, not down the drug problem categories.
'Statistically significant difference (p < .01) in proportion of drug overdose between sexes, age groups and hospital location.

290

SELLERS ET AL.

tically significant (p < .01); while females were only 57.9% of the overall
patient sample, they were 65.8% of the overdose patients.
Table 2 summarizes the characteristics of the patient population in the
core and suburban hospitals. The geographic distribution of patients
(63.0% suburban, 37.0% core) is very similar to that of the general popu­
lation (64.9% suburban, 35.1% core). While the patient population for
each of the two groups of hospitals is not restricted to residents of the hos­
pital area, patients and ambulances tend to use nearby hospitals rather
than those more distant, especially in emergencies. Most drug abuse
(61.6%) was treated at the core hospitals, while most overdose (70.4%) was
treated in the suburbs (p < .01). The suburban patient population in­
cludes a significantly higher proportion of females (63.8%) than does the
core patient p;pulation (48.0%) (p < .01) or the general Metropolitan To­
ronto population (51.2%). There is also a significant relationship between
location and age (p < .01); the 21-35 group represents 50.9% of the core
patients but only 44.2% of the suburban patients. In general, this age
group is overrepresented in the patient population (46.6%) compared to its
representation in Metropolitan Toronto (28.9%). Figure 1 displays, in
greater detail, the age distribution of the Metropolitan Toronto popu­
lation at the time of the survey, the patient population, and the portion of
the patient population who alleged one of the commonly mentioned
classes of drugs, barbiturates. This class is alleged frequently in both over­
dose and drug abuse presentations. Figure 2 shows the Metropolitan and
patient distributions by age and sex, and shows all allegations of hallu­
cinogens other than cannabis, a class seen almost exclusively in drug
abuse presentations.

Use of Laboratory Services
Most Metropolitan Toronto hospitals can detect only three classes of
drugs in serum: barbiturates, salicylates, and bromides. One core hospital
can screen for a somewhat larger spectrum, but only the common labora­
tory can routinely detect alcohols, solvents, benzodiazepines, other non­
barbiturate depressants, neuroleptics, antidepressants, amphetamines, and
hallucinogens, in serum or urine as appropriate. Table 3 shows the use of
both local and common analysis facilitates by core and suburban physi­
cians. Overall, drug abuse patients are tested less often than overdose pa­
tients, even though drug abuse is largely concentrated into the core area
where the common laboratory could perform the necessary screen. Among
overdose patients, those in suburban hospitals have a lower overall rate
for screening than do core patients, even though the rate of screening in

Table 2
Characteristics of Patient Population of Core and Suburban Hospitals (N = 3,548)

Hospital
location

Total patient
population
N
(%)

Core
Suburban
Total

1313
2235
3548

(37.0)
(63.0)
(100.0)

Sex",b
Male
N

(%)

682
808
1490

(52.0)
(36.2)
(42.0)

Age"
>50

36-50

Female
N
(%)

N

(%)

N

(%)

N

(%)

N

(%)

(48.0)
(63.8)
(58.0)

337
619
956

(27.2)
(28.1)
(27.8)

631
973
1604

(50.9)
(44.2)
(46.6)

201
408
639

(16.2)
(19.9)
(18-6)

71
171
242

(5.7)
(7.8)
(7.0)

630
1426
2056

21-35

<21

“The percentages in this subtable are row percents summing to 100% across the demographic categories, not down the location category.
bStatistically significant differences (p < .01) in proportion of core and suburban patients between sexes.

SELLERS ET AL.

292

BARBITURATES

TOTAL METRO POPULATION
48,000 40,000 32.000 24,000 16,000 8,000

ALL PATIENTS BY PROBLEM

TOTAL METRO POPULATION
8,000 16,000 24,000 32,000 40,000 48,000

Fig. 1. Age distribution for Metropolitan Toronto in 1975 for patients requiring emergency
treatment for acute overdose or drug abuse in the first half of 1975, and for the 504 patients
(14%) alleging barbiturates among the drugs responsible for their admission.

the hospital of admission is twice as high. That is, almost all of the subur­
ban patients’ screens are done at the home hospital, with little use of the
central, common laboratory. In the core area, twice as many screens are
done at the common laboratory than at the hospital of admission.

Drug Classes Ingested
Table 4 summarizes the drug classes most frequently alleged by the to­
tal patient population. By “alleged,” we mean whatever drugs were listed
in the hospital Emergency record, whether the drugs were reported by the

Table 3
Use of Toxicological Laboratory Services as a Function of Hospital Location*

Type of
problem

Overdose

Abuse

Hospital
location

Core,
N = 806
Suburban,
N = 1,917
Total,
N = 2,723
Core,
N = 503
Suburban,
N = 313
Total,
N = 816

Primary care
■ laboratory
N
(%)

Common
laboratory
N
(%)

Both
laboratories
N
(%)

(29.8)

171

(21.2)

347

(43.1)

48

(44.4)

827

(43.1)

176

(9.2)

62

1092

(40.1)

998

(36.7)

523

(19.2)

257

(51.1)

19

(3.8)

220

221

(70.6)

58

(18.5)

478

(58.6)

77

(9-4)

No use
N

(%)

240
852

Any
screen

N

(%)

(6.0)

566

(70.2)

(3.2)

1065

(55.6)

110

(4.0)

1631

(59.9)

(43.7)

7

(1-4)

246

(48.9)

29

(9.3)

5

(1.6)

92

(29.4)

249

(30.5)

12

(1.5)

338

(41.4)

“In each row of this table, the first four percentages sum to 100%. The last column is the sum of the preceding three columns.

294

SELLERSET AL.

Table 4
Drugs Most Frequently Alleged Ingested

Drugs or
drug group
Benzodiazepines
Ethanol
Salicylates
Barbiturates
Nonbarbiturate' hypnotics
Narcotic analgesics
Tricyclic antidepressants
Hallucinogens
Major tranquilizers
Other analgesics
Amphetamines
Cannabis
Solvents
Bromides
Cocaine

Allegation of use in
total patient population0
N
(%)
1,201
1,125
559
504
388
295
247
219
217
214
180
135
45
32
24

33.9
31.7
15.8
14.2
10.9
8.3
7.0
6.2
6.1
6.0
5.1
3.8
1.3
0.9
0.7

■When drugs of two or more groups were allegedly ingested by a given patient, the patient was
included in each of the relevant groups.

patient or persons accompanying the patient, listed on bottle or pill labels,
or suggested by physicians’ clinical judgment. Benzodiazepines and eth­
anol were each alleged by approximately one-third of the total patients,
followed by salicylates and their combinations, barbiturates, and other
hypnotics. The “streeet drugs,” hallucinogens and cannabis (9.3%) and
amphetamines (5.1%) were alleged by only a small proportion of the pa­
tients, and by very few patients in the overdose category.
The users of each drug category are clasifled by sex and problem in
Table 5. The drugs in this table can be divided into two categories.
“Street” drugs form one category, including cannabis, other hallucinogens,
amphetamines, solvents, and cocaine. These drugs are characteristic of
males and of drug abuse. The other category consists of drugs of legiti­
mate medical uses, including analgesics, antidepressants, and depressants,
along with ethanol, which is pharmacologically similar to the prescription
depressants. These drugs are characteristic of overdose patients, and many
of them are characteristic of female patients.
Multiple Drug Use
Approximately half (51.6%) of all patients had alleged more than one
drug, including ethanol, prior to their presentation at Emergency. “Mui-

DRUG ABUSE EMERGENCIES

HALLUCINOGENS
METRO MALE POPULATION
24,000 20.000 16,000 12.000 8,000 4,000

295

ALL PATIENTS BY SEX
METRO FEMALE POPULATION
4,000 8,000 12,000 16,000 20,000 24,000

Fig. 2. Age distribution by sex for Metropolitan Toronto in 1975 for patients requiring emer­
gency treatment for acute overdose for drug abuse in the first half of 1975, and for the 209
patients (6%) alleging hallucinogens other than cannabis among the drugs responsible for
their admission.

tiple drugs” includes single formulations with several active ingredients of
different pharmacological classes (such as over-the-counter combinations
of ASA, caffeine, and codeine), but not combinations of separate products
from the same category (such as amobarbital and secobarbital). Excluding
ethanol, 33.5% of the patients alleged multiple drugs. The distribution of
the number of drug categories alleged is shown in Table 6. No difference
in multiple drug use is found between males and females, but the inci­
dence of multiple use is slightly higher in overdose than in drug abuse
(Fig. 3). The two categories most frequently encountered in multiple use
are ethanol and benzodiazepines (17.4% of patients alleging multiple
drugs, including ethanol). In 9.2% of the patients, both ethanol and ben-

Table 5
Characteristics of Alleged User Population for Specific Drug Groups

Drug or
drug group

N

%of
all
patients

% of
overdose
patients

All patients
Benzodiazepines
Ethanol
Salicylates
Barbiturates
Nonbarbiturate hypnotics
Narcotic analgesics
Tricyclic antidepressants
Hallucinogens
Major tranquilizers
Other analgesics
Amphetamines
Cannabis
Solvents
Cocaine

3,548
1,201
1,125
559
504
387
295
247
219
217
214
180
135
45
24

100.0
33.8
31.7
15.8
14.2
10.9
8.3
7.0
6.2
6.1
6.0
5.1
3.8
1.3
0.7

100.0
39.3

‘Significantly different from 1.00.
"Significantly different from the overdosetabuse ratio in patients not alleging this category.
'Significantly different from the female-.male ratio among the Toronto population.
"Significantly different from the femaletmale ratio among patients not alleging this category.

19.0
15.2
12.4
8.2
8.8
0.7
7.4
7.3
1.0
0.7
0.5
0.1

Overdose
Abuse

Female
Male

*-"
8.38
*3.06
*-"
12.56
*"
4.69
*-"
6.88
*
3.13
*39.81
“
0.06“-"
*"
14.38
*-"
12.38
*"
0.19
0.13
*-"
*-"
0.38
*-"
0.06

1.38'
l.88'-a
1.00"
2.25'-a
1.19
1.25
1.44'
2.44'-a
0.3I'-a
1.75'
2.56'-a
0.56'-a
0.44 *- d
0.19'-d
0.50"

DRUG ABUSE EMERGENCIES

Number of drug categories alleged, other than ethanol and "unknown"
Fig. 3. Number of drug categories alleged ingested, other than ethanol and “unknown,” for
patients in the overdose and drug abuse categories (overdose n = 2,723, drug abuse n = 816).

zodiazepines were alleged. Table 6 shows the exact combinations of drug
categories that were most frequently alleged. In this table, unlike Tables 4
and 5, no patient appears more than once.
Disposition of Patients

Overall, 1,263 (35.6%) of the patients presenting at Emergency were
subsequently admitted for inpatient treatment. The overdose cases were
admitted more frequently (41.1%) than the drug abuse cases (17.2%, p <
.01). The suburban hospitals, which had a disproportionate share of the
overdose cases, had an overall admission rate twice that of the core hospi-

298

SELLERSET AL.

Table 6
Frequencies of Most Commonly Alleged Multiple Drug Combinations (N = 3,548)

__________ Frequency__________
N
(%)

Drug combination
Ethanol
+ Benzodiazepines
+•■ Barbiturates
+ Opiates + salicylates + caffeine6
•f Nonbarbiturate sedatives
+ Other categories0
+ Barbiturates
+ Hallucinogens (including cannabis)
+ Nonbarbiturate sedatives
+ Antidepressants
4- Nonsalicylate analgesics
+ Amphetamines
+ Other single categories
+ Opiates + salicylates + caffeine6
+ Other categories’ without benzodiazepines
Benzodiazepines
-r Salicylates
+ Nonbarbiturate hypnotics
+ Barbiturates
+ Opiates + salicylates + caffeine6
+ Other categories" without ethanol
Opiates + salicylates + caffeine6
Other combinations"
Single drug categories

255
35
22
14
130
98
74
40
35
24
20
74
22
315

(7.2)
(1-0)
(0.6)
(0.4)
(5.1)
(2.8)
(2.1)
(1.1)
(1.0)
(0.7)
(0.6)
(2.0)
(0.6)
(8.9)

40
37
33
26
247
63
595
1349

(1.1)
(1-0)
(0.9)
(0.7)
(7.0)
(1-8)
(16.8)
(38.0)

‘Including the category “unknown” when the patient was suspected of having taken one or
more drugs in addition to any that could be identified.
bIn Canada, this combination is a common analgesic product in various strengths, available
without written prescription for the smaller quantities of codeine.

tals (44.0% compared to 21.3%, p< .01), and the higher suburban admis­
sion rate remains true for patients presenting with all levels of
consciousness. The total of 1,263 inpatient admissions during this study
represents only 0.6% of the total of 190,000 admissions to these hospitals
for all causes in the first half of 1975. Of the patients not admitted, about
half were referred to their own physicians or to medical or community
agencies for further treatment.

DISCUSSION
The results of this study of Metropolitan Toronto indicate that acute
and chronic drug abuse are common, resulting in 325 Emergency visits

DRUG ABUSE EMERGENCIES

299

and 116 inpatient admissions per 100,000 population per year. Many of
the results of the study coincide well with general experience. For ex­
ample, mortality is low, chronic drug abuse is more common in the male
and younger age groups, frequently more than one drug is alleged, and
many patients have repeated incidents. Such observations assure us that
the study methodology was adequate.
The division of patients into (acute) overdose and (chronic) drug abuse
groups is much less objective than the classification of patients by age or
sex. It is sensible to speak of a patient’s “sex role” or “age group identi­
fication,” self-concepts that may well influence the way in which drugs are
used. It is doubtful that many patients have well-defined “abuse roles,”
continuing identifications with the class of acute or chronic substance
abusers. Therefore, we see our division of patients into these two cate­
gories as only a summary judgment of the circumstances of drug inges­
tion, which might correlate with or predict more objectively classifiable
events, but cannot really be said to cause them. Only the self-perception
of “attempted suicide,” an extreme type of overdose which we could not
differentiate from other overdose, might alter the patient’s choice of sub­
stances, quantities, and circumstances in drug abuse.
Successful drug-induced suicide is not as rare as the three deaths in
this study might imply. The Metropolitan Toronto Coroner (1975) reports
103 cases of drug suicide during 1975. While those data do not differ­
entiate among deaths at home, in ambulances, in Emergency, or after­
wards, clinical experience suggests that few overdose patients pass through
Emergency only to die soon afterwards as inpatients. As death rates are
generally low, we must look for differences among lesser consequences of
these drugs’ ingestion, such as admission rates and duration of hospital
stay.
The greater suburban admission rate cannot be explained by the fact
that more patients do present in critical condition: the greater admission
rate holds for all levels of consciousness. The reasons more patients are
admitted to suburban hospitals may relate to different emergency staff
levels, availability of hospital beds, or lack of alternate community facil­
ities. From the point of view of controlling health care costs, the doubled
suburban hospitals’ admission rate for drug overdose patients deserves
careful scrutiny.
The most striking pattern of results concerns which drugs are chosen
by patients taking an intentional overdose (Table 5). Among prescription
drugs, the ranking is benzodiazepines (39.3%), barbiturates (15.2%), non­
barbiturate sedatives (12.4%), tricyclic antidepressants (8.8%), and neuro­
leptics (7.4%). The same rank ordering, with almost the same proportions
of use (39.6, 16.4, 11.1, 10.9, and 6.2%), is found for these five classes of

300

SELLERS ET AL.

drugs in the 1973 Parcost survey of Ontario prescription patterns (Cooper­
stock, 1976a). The figure of 16.4% for barbiturates excludes phenobarbital,
which is not usually prescribed to the general population for the same
sedative uses as other barbiturates, but is usually restricted to the treat­
ment of epilepsy. Drugs easily obtainable without a prescription, ethanol,
salicylates, and (in Canada, in small doses per tablet) codeine, are also
high on the list of agents chosen for overdose. These data are consistent
with the hypothesis that the patient who wishes to take an overdose will
simply ingest whatever psychoactive or analgesic drugs are available. The
sex ratio in overdose, roughly 1.9:1 female, supports this availability hy­
pothesis, as Cooperstock (1976b) found that about 1.7 times as many fe­
males as males receive prescriptions for psychoactive drugs. Our data
imply that females are only slightly more liable to drug overdose (in the
sense of mental predisposition) than are males; twice as many females
simply have the opportunity to act upon the impulse to take an overdose.
It is interesting that no drug classes’ users are strongly overrepresented
among the overdose population. That is, patients with antidepressants
available for overdose, patients who were presumably “depressed” before
drug therapy, do not develop the predisposition to overdose any more
often than patients who were in pain or in need of tranquility. This is con­
sistent with a very successful titration of therapy to the needs of the pa­
tient population. While patients taking antidepressants may have entered
therapy with more “depression” (a state that might predispose a patient to
self-destructive behavior), the patients actually taking such drugs show no
more tendency to engage in such behavior than do the patients taking
other classes of drugs. This could be viewed as evidence that the physi­
cians who dispense psychoactive drugs are having remarkable success in
reducing or raising all patients to the same psychologic state.
Another hypothesis can also account for the close correspondence be­
tween drugs available to the population and drugs used in overdose, de­
spite the available drugs’ being directed at quite different mental states.
According to this alternate hypothesis, the conditions that lead a physician
to prescribe a particular psychoactive drug are simply unrelated to the
conditions that lead to overdose, and the various drugs have no differ­
ential effect on that predisposition. In other words, if different psychoac­
tive drugs that had equal effects (or no effect) on self-destructive
predispositions were to be dispensed at random to patients with psycho­
logical problems, including self-destructive tendencies, we would see
exactly the pattern of drug overdose as is seen in this study. Such drugs
may be affecting other components of psychological adjustment, but there
may be no differences in their rates of eliciting or preventing self-destruc­
tive drug-taking behavior.

DRUG ABUSE EMERGENCIES

301

One of the remarkable results of this study is that it is rare for a drug
overdose case that reaches hospital to result in death in Emergency. This
may simply mean that if a drug is going to do serious damage, then it is
going to do such damage immediately, rather than slowly. There is not
much that we can say about the relative safety of different drugs, based
on the results of this study, as we have neither accurate control nor mea­
surement of the amount of drug consumed by the patients.
While it is clear that drug-related parasuicide is a major problem, it is
not clear what steps the medical community should be taking to reduce
the problem. The close correspondence between drug availability and
parasuicidal drug use suggests that these acts are largely impulsive, mak­
ing use of whatever substances are at hand when the impulse strikes.
However, this study provides no data from which we can determine how
many patients use other alternatives when no drugs are available. In other
words, if we could reduce the availability of drugs to these patients, we
might simply be converting parasuicide into successful suicide, as patients
opt for other available and potentially more dangerous (para)-suicidal be­
havior. It is overly simplistic to call drug-related parasuicide a “medical”
problem, just because physicians prescribe the drugs that are used. If the
drugs being prescribed were effective agents of suicide, then perhaps we
could blame physicians for releasing them to the public. However, this
study suggests that if we construct a “social interaction ratio” for forms of
attempted suicide, the probability that the act will gain needed attention
compared to the probability that it will kill the actor, drugs must rate as
safe, compared to guns, carbon monoxide, or lye.
We must also consider another view of these emergencies. Perhaps
they are not impulsive acts, unrelated to drug therapy, which simply use
drugs as the handiest alternative form of self-damage. Instead, they might
be logical extensions of the same drug-taking behavior that the physicians
prescribe. A patient consumes drugs for the course of several weeks or
months, obtaining reinforcement for every pill-taking act or, more dan­
gerously, for almost every pill-taking act. This latter situation is known as
partial reinforcement, and generates very stable and persistent behavior
patterns. If, at some point, the situation for which the drugs are consumed
becomes worse, or tolerance sets in and the drugs become less effective,
the act of taking a pill fails to produce its expected effect. By the usual
laws of operant conditioning, this situation should lead to an immediate
increase in the rate of taking the pills. Only after a long history of no ob­
servable effect from taking the drug will the response extinguish, and by
that time the patient has already consumed an overdose. If this is what
happens in overdose, in some if not all cases, then we can no longer hold
the physicians as blameless as if the parasuicides were impulses unrelated

SELLERS ET AL.

302

to therapy. Instead, we would need to hold the physicians primarily to
blame, as the agents who first taught the patients, individually or as a so­
ciety, to use drugs as partially and temporarily effective solutions to their
emotional problems. Clearly the data from this study cannot be used to
evaluate such a detailed behavioral hypothesis, and clearly the act of tak­
ing an overdose is more complex than a simple increase in the rate of
emitting an operant behavior at the beginning of extinction. However,
such a possibility must be considered to counteract the view that physi­
cians are blameless in the incidence of parasuicide, as stated above.
An epidemiological study such as this one can measure the scope and
costs of some publicly-observable form of behavior, such as taking an
overdose of drugs. As such, it can tell us whether the problem is of major
or minor significance in the population. It cannot tell us much about the
individual psychology of overdose. Without such information, we cannot
tell whether to encourage physicians to prescribe drugs, because of their
high “social interaction ratio,” or discourage them, because of the danger
of conditioning the patients to consume drugs. In making the usual call
for further research, we would strongly suggest that it be directed toward
intensive study of individuals rather than a survey of large groups. Educa­
tional programs that develop out of such studies should realistically com­
bine social policy considerations with training in the identification and
management of certain high-risk patients, those who are likely to resort to
dangerous attention-getting behaviors.
ACKNOWLEDGMENTS

We are indebted to the Medical Directors, physicians, Medical
Records staffs, Emergency Department Head Nurses, and nursing staff of
each hospital that participated in this study. Without their cooperation,
advice, and considerable work, the study would have been impossible.
This study was supported in part by the Non-Medical Use of Drug Di­
rectorate, Health Protection Branch, National Department of Health and
Welfare, RODA Grant No. 1212-5-144.
REFERENCES
ALDERSON, N.R. Self-poisoning-What is the future? Lancet 1: 1040-1043, 1974.
COOPERSTOCK, R. Current trends in prescribed psychotropic drug use. In R. J. Gibbins,
Y. Israel, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart (eds.) Research Ad­
vances in Alcohol and Drug Problems, Vol. 3. Toronto: Wiley, 1976a, pp. 297-316.
COOPERSTOCK, R. Psychotropic drug use among women. Can. Med. Assoc. J. 115:
760-763, 1976b.

DRUG ABUSE EMERGENCIES

303

GETHIN MORGAN. H., POCOCK, H., and POTTLE, S. The urban distribution of non fa­
tal deliberate self harm. Br. J. Psychiatry 126: 319-328, 1975.
GHODSE, A.H. Deliberate self-poisoning: A study in London casualty departments. Br.
Med. J. 1: 805-808, 1977.
HINDMARCH, J. Drugs and their abuse: Age groups particularly at risk. Br. J. Addict. 67:
209-214, 1972.
JENSEN, K. Epidemiology of poisoning. Acta Pharmacol. Toxicol. 41(Suppl. 11): 437-443,
1977.
KENNEDY. P., KREITMAN, N., and OVENSTONE, M.K. The prevalence of suicide and
parasuicide (attempted-suicide) in Edinburgh. Br. J. Psychiatry 124: 36-41. 1974.
KESSEL, N. Self-poisoning. Part I. Br. Med. J. 2; 1265-1270, 1965.
LAWSON. A.A.H., and MITCHELL, I. Patients with acute poisoning seen in a general
medical unit (1960-71). Br. Med. J. 4: 153-156, 1972.
METROPOLITAN TORONTO CORONER’S OFFICE. Statistical Report. Toronto. 1975.
PROUDFOOT. A.T., AND PARK. J. Changing patterns of drugs used for self-poisoning.
Br. Med. J. 1: 90-93, 1978.
RANGNO, R.E. Epidemiology and therapy of suicidal drug intoxication. In E. M. Sellers
(ed.) Clinical Pharmacology of Psychoactive Drugs. Toronto: Addiction Research Foun­
dation of Ontario, 1975, pp. 43-54.
RUEDY, J. Acute drug poisoning in the adult. Can. Med. Assoc. J. 109: 603-608, 1973.
SELLERS, E.M. Factors influencing the interpretation of drug concentration in acute drug
overdose. In E. M. Sellers (ed.) Clinical Pharmacology of Psychoactive Drugs. Toronto:
Addiction Research Foundation of Ontario, 1975, pp. 73-86.
SIMS, M., PURDY. M., and DEVENYI. P. Drug overdoses in a Canadian city. Am. J. Pub­
lic Health 63: 215-226. 1973.
SMITH, A.J. Self-poisoning with drugs: A worsening situation. Br. Med. J. 4: 157-159, 1972.
STEWART. R.B., FORTNONE, M.. MAY. F., FORBES. J., and CLUFF, L.E. Epidemio­
logy of acute drug intoxications: Patient characteristics, drugs and medical complica­
tions. Clin. Toxicol. 7: 513-530, 1974.

[

HH-XA

, AlcoholiclLiver Disease: Information in Search
of Knowledge?
Hector Orreco, Yedt Israel, and Laurence M. Blendis

ALCOHOLIC UVEH DISEASE

i |« U
UH

R. Sandyk and MA. Gillman
the effects of chronic alcohol intake on basal ganglia
diseases [3,4]. Alcohol in large doses has been reported to
have relieved the symptoms of unilateral parkinsonism
[6], as well as to be detrimental to parkinsonian patients
[5]. Mullen et al. [7], reported generalised chorea
associated with alcoholism and Carlen [5] reported
transient orafacial dyskinesia during ethanol withdrawal.
Chronic alcohol intake and withdrawal have been
variously reported to cause subsensitivity of striatal
dopamine-sensitive cyclic adenosine monophosphate [8],
behavioural superscnsiiivity of dopamine receptors in the
caudate nucleus and nucleus accumbcns [9], and
increased spiroperiodol binding sites in the nenstriamm
[10].
Hypersensitivity of. dopamine receptor sites as a
proposed to trigger Gilles de la Tourette syndrome [1,2].
Chronic alcohol intake has been shown to block dopamine
release in the striatum [11], This could give rise to
dopamine receptor supersensiuvity [12]. At withdrawal of

blocked, resulting in hyperactivity of the dopaminergic

movements.
In our patient, this would have been aggravated by
underlying basal ganglia pathology (evident by the history
of past habit spasms) that could have intensified the
occurcnce of the abnormal movements and tics. Although
the occurencc of Gilles de la Tourette syndrome is rare, it
alcohol withdrawal has been made.
This is particularly so, in view of the enormous
incidence of alcohol abuse coupled with the fact that
alcohol is known to cause such variable effects in basal
ganglia disorders [4].
This report however, suggests that alcohol withdrawal

may occasionally precipitate the symptomatology of Gilles
de la Tourette syndrome most probably by altering striatal
dopaminergic balance.
References

2 Singer, W. D. (1981). Transient Gilles de la Tourette
3 Singer, H. S. (1982). Tics and Turctte syndrome. The John

Carlen, P. L-, Lee, M. A., Jacot, M., and Livshits (1981).
Parkinsonism provoked by alcoholism. Annals ofNeurology,
9, 84-86.

involuntary movements. Research Publications -Association
7 Mullin, P. J., Kershaw, P. W., Bolt, J. M. W. (1970).
Chorcathetotic movement disorder in alcoholism. British
Medical Journal, 4, 278-281.
8 Tabakoff, B., Hoffman, P. L., Rittman, R. F. (1978).

9 Liljequist, S. (1978). Changes in the sensitivity ofdopamine
induced by chronic ethanol administration. Acta
Pharmacologica el Toxicologica (Copenhagen), 43, 19-28.
ethanol on central dopamine function. Life Sei., 27, 29911 Darden, J. H., Hunt, W. A. (1977) Reduction of striatal
dopamine release during an ethanol withdrawal syndrome.
Journal ofNeurochemistry, 29, 1143-45.
12 Gillman, M. A., Lichtifeld, F. J. (1984). In P. Mandel, and
pharmacology to behaviour, pp. 405-418. Raven Press, New
York.

©1985 Society for the Study of Addiction toWobol end other Drags

tZ

£)V~“

'

Underestimation of Recalled Alcohol Intake in Relation to
Actual Consumption
Kari Poikolainen, M.D.
Department of Public Health Science, University of Helsinki, Haanmaninkatu 3, Sr-00290
Helsinki, Finland
Summary
, , ,
Drinking of 58 males was observed for six evening hours in simulated restaurant surroundings Interviews on alcohol
consumption were carried out the next day (in two cases two days) after the drinking session. Recalled mean number ofdnnks
was ten dnnks, the actual mean intake II drinks. Degree of underestimation in recall was positively associated with the actual
amount imbibed. On the average, heavy consumers underestimated their intake by 12 per cent and light consumers byfour per

One crucial question in measuring alcohol consumption is
how recall of intake is associated with the actual
consumption of the respondent. It has been argued that
heavy drinkers tend to underestimate their alcohol
consumption more than light drinkers but the evidence
for this argument is far from convincing [I]. However,
dissimulation, as measured by the Lie Scale of the
Eysenck Personality Questionnaire, has been found to
correlate negatively with reported alcohol consumption
[2]. Such a tendency, if true for most drinking
populations, could undermine results on the health and
social risks of alcohol use and distort the observed
relationships between alcohol intake and its correlates in
general. Unfortunately, solid empirical evidence for or
against selective under-reporting is hard to come by, since
precise measurement of the actual alcohol intake is usually
not possible. Some data are, however, available from an
experiment where real drinking situations were simulated
in order to study drinking behaviour. Data from this
experiment have now been analysed focusing on the
association between actual and recalled alcohol intake.

session together. The experiment involved 15 groups, all
starting drinking at 6 p.m. and stopping at 12 p.m. in a
room disguised as a restaurant room for private parties.
The subjects were told that aim of the experiment was to
study the influence of alcohol upon behaviour, and each
group was given discussion tasks while the investigators
observed social interaction behind a one-way mirror
window.
Subjects were instructed that they were free to choose
how much they like to drink. All drinks were provided
free of charge by a waitress, who kept a log of the dnnks.
Behind the one-way mirror window, observers registered
the actual intake and behaviour. Types of beverages
included beer, vodka, gin, and brandy. The latter two
were also available as pre-mixed long drinks. Transport to
home was arranged to prevent continuation of drinking.
One day (in two cases two days) after the experiment the
subjects were interviewed at lunchtime at their working
place and asked how much they had drunk during the
group session. Numbers of drinks and types of beverages
were recorded. One of the subjects was not able to give a
clear opinion, and the file of another case was not found
for the rcanalysis. The present study is thus based on 58
responses.

Subjects and methods
The subjects and the design of the experiment providing
the present data have been described earlier in detail [3].
Briefly, the subjects were male skilled workers, aged On the average, the subjects had around 11 drinks but
25-54 years, recruited by informal contacts from the recalled having had 10 drinks during the experiment.
metal industries in Helsinki. Alcoholics and those guilty There was considerable variation in the number of drinks
of crimes of violence were excluded. The subjects were consumed (Table 1).
Recalled intake correlated moderately with actual
studied in groups of four, and members of a group were
required to have shared at least one earlier drinking consumption. Spearman rank order correlation coef-

K. Poikolauun

Table 1. Actual and recalled numbers of drinks

fident between recalled and actual number of drinks i
actual amount of alcohol was .63 (pc.001).

drinks consumed, 22 were mistaken by one drink, while
four overestimated and 19 underestimated their untake by
more than one drink. The product-moment correlation
coefficient between the underestimation in recalling
(actual minus recalled number of drinks) and the actual
number of drinks was significant (r=+.34; p=.004).
The sample was divided into light and heavy consumers
with 11 drinks or less as a cutpoint to obtain two groups
corresponding in size as closely as possible. This yielded
31 subjects who had imbibed 11 drinks or less and 27
subjects who had had 12 drinks or more. The mean degree
of underestimation was four per cent among light
consumers but 12 per cent among heavy consumers (Table
2). T-test (pooled variance estimate) indicated a sig­
nificant difference (p= .007).
In contrast to the above, the actual volume of alcohol

was brought about by the fact that, on the average, the
subjects underestimated less the number of drinks with
high alcohol content (gin, brandy, vodka) than the
number of drinks with low alcohol content (beer, long
drinks).

The experimental study providing the data of the present
investigation showed, first, that group norms favoured
heavy drinking, secondly, that drinking more than the
other members of the group was esteemed and, thirdly,
that drinking less than the others was disapproved [3].
Such a normative atmosphere could be expected to
encourage over-reporting of alcohol consumption. In
addition, forgetting was minimized, since the subjects

second day) after the experiment. Even under these
stringent conditions a slight underestimation in the mean
number of recalled drinks was observed. The error in
recall was clearly correlated with the actual alcohol intake.
The higher the actual intake, the higher also the mean
number of drinks left unreported. This finding suggests
that heavy drinkers tend to underestimate their alcohol
intake relatively more than light drinkers. Due to the
nature of the study population this finding cannot,
however, be generalized to alcoholics, who perhaps have
the highest tendency to underreporting with probably the
numbers of drinks and types of beverages did not differ largest unpact to the apparent distribution of alcohol
(Table 3). The mean actual consumption was 17.5d, and consumption in general populations. Moreover, even if
the recall estimate 17.6d. Nor was the correlation recall of number of drinks is influenced by the level of
actual consumption, it is still possible, as in the present
scries, that this bias may be compensated for by
significant (r=+.10;p=.22). This .
differentials in recall of various beverage types. Finally,
Spearman correlation coefficients were considerably
below unity suggesting that ranking of individuals based
on recall estimates may not correspond to the actual rank
Number of drinks
order of alcohol consumption. Whether this undermines
Variable
Light consumers Heavy consumers
studies on alcohol-related hazards awaits further clarifica(7-11 drinks)
(12-16 drinks)
Actual intake
9.76
13.37
Acknowledgement
recalled intake
9.40
11.72
I thank Professor Ketul Bruun for his help and advice in
Difference
0.35
1.65
Number of cases
31
27
References
1 Popham, R. E., and Schmidt, W. (1981). Words and deeds.

Table 3. Actual and recalled alcohol
consumption (cl)
Mean
Range
Actual
17.5
11.4-24.0
Recalled
17.610.1-26.2

Mulford & J. L. Fitzgerald, and H. Wechsler). Journal of
Smdiet on Alcohol. 42, 355-368.
2 Cooke, D. J., ud A1U>, C. A. ()9U). SelT reponed alcohol
consumption and dissimulation in a Scottish urban sample.
Journal ofSrudui on Alcohol, 44, 617-629.
3
K* (,959) Drinking behaviour in mall groupi. The
- Finnish Foundation for Alcohol CndlM
..^i o

Book Reviews

Measurement in the Analysis and
Treatment of Smoking Behavior
Edited by J. Grabowski and C. S. Bell
NIDA Research Monograph 48. Department
of Health and Human Services, Washington,
1983. 121 pp.
For many years research into smoking was seduced by its
apparent simplicity. Here was a behaviour which
provided psychologists with readily observable discrete
acts easily counted and analysed. The focus on overt
responses with its Skinnerian overtones naturally led to
theoretical accounts of smoking which were couched
almost entirely in behavioural terms^ Psychologists were
not the only ones to be beguiled. Epidemiologists too felt
there was no need to go beyond self-reported smoking
habits. Sometimes consumption might be multiplied by
the tar yield of the cigarette smoke to derive an index of
tar exposure, but no direct measures were made of the
exposure of the respiratory tract to tobacco smoke and the
dose of smoke constituents entering the blood stream.
This situation has now changed, and the last few years
have seen something of a paradigm shift in the field.
Biochemical markers of smoke intake have been
developed and their application has forced a radical
reappraisal of the nature of smoking. It has become
apparent that self reported cigarettes per day is at best a
crude measure of the quantity of smoke inhaled, and the
relevance of tar and nicotine yields of cigarettes as
measured by standard machine smoking has been
seriously questioned by data showing the pervasiveness
and overriding importance of individual patterns of
puffing and inhalation that can generate similar intakes
from cigarettes of widely differing nominal deliveries. In
the area of smoking cessation biochemical validation of
claims of abstinence has revealed deception rates that vary
widely from one study to another and range up to 40 per
cent. More generally there has been a shift in emphasis
from purely behavioural to pharmacological aspects of the
smoking habit. As measures of nicotine and its major
metabolite, continine, have become available, so has

interest focused more on smoking as a form of nicotine
self-adminstration.
This volume indicates an increasing awareness of the
need for account to be taken of these measurment
advances. The monograph is a summary of presentations
made at a meeting convened by the U.S. National
Institute on Drug Abuse and the National Cancer
Institute in August 1982. The topics covered range from
the core one of the use of biochemical markers of smoke
intake through to survey methods in the evaluation of
children’s smoking, and problems in the design and
evaluation of cessation studies.
Benowitz provides an excellent summary review of
biochemical markers, focusing on carbon monoxide,
thiocyanate, nicotine and cotinine. As well as commenting

marker of smoke consumption, there is a welcome
emphasis on the cost of each measure, and the point is
made that choice of a biochemical test must be influenced
by the research question at issue, if the aim is simply to
categorize people into smokers and non-smokers, then
expired air carbon monoxide is a simple and inexpensive
measure providing adequate information. On the other
hand blood cotinine concentration is probably the best
measure to use to obtain a quantitative guide to daily
nicotine consumption. Although the degree of individual
variation in the fractional conversion of nicotine to
cotinine is not yet known, it is provocatively estimated
that a blood concentrauon of cotinine of 100 ng/ml
represents an average 24 hour consumption of 12 mg of
nicotine. If this relationship is confirmed it will permit a
simple estimation of smokers
*
daily nicotine intake, a
measure which would be of great value.
Kozlowski's chapter gives an interesting account of the
historical origins of the 2 sec 35 ml puff/min. standard
machine smoking regimen used for determining tar and
nicotine yields. It turns out that the choice of these
particular puffing parameters was largely arbitrary and
never reflected smokers
*
actual puffing even on the high
yield plain cigarettes sold in the 1930s. It comes as no
surprise, then, that machine smoked yields of modem
cigarettes should bear Utile relationship to yields as

SERIAL NO:

HOSP.

NO:

PSYCH. NO:

UNIT
LCO.HJ'

R3SU\nTI-P-a£M3£g

3E:

SEX:

:

- SELF REPORTED INFORMATION

NAME:

A. CAGE QUESTIO: ■.. .'J RE

If the answers to the following questions are ’YES' encircle
them:—

1.

Have you ever felt you should cut down your drinking?

2.

Have people annoyed you by criticizing your drinking ?

3.

Have you ever felt had or guilty about your drinking ?

4.

Have you ever had a drink first thing in the morning to

steady you®’ nerves or get rid of a hang-over ?

3.

SAPP QUESTIONNAIRE:
Think about your most recent drinking habits and answer

each questions placing a tick ('■') under the mo s t apo roo ri ate

heading :1.

Do you find difficulty in getting the
thought of drinking out of your mind ?

2.

Is getting drank more important than

your next meal ?
3.

Do you plan your day around when
and where you can drink ?

4.

Do you drink in the morning, after­

noon and evening ?
5.

Do you drink for the effect of alcoh­

ol without caring what the drink is ?
6.

Do you drink as much as you want
irrespective of what you are doing the

next day ?
7.

Given that many problems

might be

caused by alcohol do you still drink

too much ?

8.

Do you know that you won11 be able
to stop drinking once you. start ?

Nearly
iever Sometimes Often always

9.

Do you try to control your drinking
by giving it up completely for days

or weeks at a time' ?

10.

The morning after a heavy drinking
session do you need your first drink
to get yourself going ?

11.

•■

The morning after a heavy drinking

session do you wake up with a definite
shakiness of your hands ?
12.

•.

After a heavy drinking session do

you wake up and retch or vomit ?
13.

.

The morning after a heavy drinking ■'

session do you go out of your way

to avoid people ? .
14.

•

Ater a heavy drinking session do
you/ see frightening things that

later you realize were imaginary ?

15.

Do you go drinking and next day find
you have forgotten what happened the
night before ?

C. RDLAP5E PRECIPITANTS INVENTORY

Encircle the appropriate facts concerning you.
DO YOU GET THE IRRESISTIBLE URGE TO CONSUME ALCOHOL ....
1.

When you pass a pub or wine shop ?

2.

When you are drinking with other people who are drinking ?

3.

When you feel no one really cares what happens to you.?

4.

When you feel tense ?

5.

When you have to meet people ?

6.

When you start thinking that just one drink would cause no harm ?

7.

When you feel depressed ?

8.

When there are problems at work ?

9.

When you feel you are being punished unjustly ?

10.

When you feel afraid ?

11.

When you are on a holiday ?

12.

When you feel happy with everything ?

13.

When you have money to sp^nd ?

- -

- -

-

14,

When you remember the good time when you were drinking ?

15.

When th? re are arguments at home ?

16.

When you are full of ..resentments ?

17.

When you f.?el irritable ?

18.

When you are at a party ?

19.

When you start thinking you are not really hooked on alcohol ?

20.

When you feel yourself getting very angry ?

21.

When there are special ocaassions like festivals and birthdays etc. ?

22.

When you start feeling frustrated and fed up with life ?

23.

When you feel tired ?

24.

When you feel disappointed that other people are letting you clown ?

25.

When you have already taken some drink ?

AVERAGE FREQUENCY OF DRIMKIUG DURING LAST 30' D/YS

D.

EneiS&l§he most appropriate heading consenting you.

1.

Under 4 drinks a day.

( Qne drink. = 13>6 g/d of ethanol )

2.

Between 4 to 8 drinks a day.

(

4 drinks = 60 g/d

-

3.

9 or more drinks a day.

{

9 drinks = 120g/d

„ '

)
}

ESTIMATE. OF DURATION OF MCOHOI COl-.-SU?fl?j.OM

E.

Answer the following questions regarding alcohol consumption
as best as you can.

1. How long have you been consuming alcohol ?
2. How long have you been drinking alone without company ?
3. How long have you been drinking in the mornings ?

*
4. How long have you been getting 'shaking

of the hands if you

don’t consume alcohol ?

F.

ix

ESTID-aTB OF TH-. PSYCHOSOCIAL DISRUPTION.

Encircle if the answer is * YES' for the following facts regarding

you.
1.

In the last 12 months have you had

major' family

disruptions : eg. separation, divorce or threats of divorce ?
2.

In the last 12 months have you had any difficulty with law due

consumption of alcohol ?
3.

In the last 12 months have you had difficulties with business/job
due to consumption of alcohol ?

4.

In the lest 12 months have you had m££ financial difficulties or
debts due to alcohol consumption ?

5.

In the last 12 months have you been changing friends or changing

place of residence due to alcohol consumption ?
6.

7.

In the last 12 months have ever attempted suicide ?
In the last 12 months have been feeling sad for weeks or months

at a stretch ?

IF YOU HAVE MOT /iNSWERED ANY OF THE PREVIOUS QUESTIONS TRUTHFULLY
please go baxk wd correct them, THfcsf information* regarding you

WILL HELP YOUR DOCTOR IN TREATING YOU CORRECTLY.

oP

iPrT(?V.

COMPufj)

Ttrotnfps

M 3

Serial Ho:
I-bspital No:
Psvchi at;ho:

It N'T
MFD

No:

Date of Adm:
ALOOHOL DEPENDENCE - CHECK LIST "

Hi stori'- taken by:-

R-’liable/unreliable

THIS IS A LIST OF SIGNIFICANT HISTORICAL FINDINGS. IF ANY OF
THEM NEEDS ELABORATION, AS SOME WILL REQUIRE, PLEASE DETAIL
THEM I

TH

CTXET FILE, USING TH

CODE NUMBER OF THE QUESTION

IN THE LEFT-HAND SIDE MARGIN. "(EG: A4, or B3 etc.)

A. EVO'UTION OF DRINKING I zgTERN

Fill in the duration (in number of years),prior to the present

consultation, t'e symptoms listed below manifested itself:1.

Social drinking.

2/.Drinking alone.

•3. Morning dinking.
4.

Preference to drinking companions and bars etc.

5.

Excuses from work for variety of reasons because of alcohol.

6.

Shifting from costlier forms of alcoholic beaverages to cheaper

forms.
7.

Repeated consious attempts at abstinence.

8.

Alcoholic ’Black-outs’.

9.

Patients subjective complaints that he cannot stop drinking once
he starts with a small quantity (Loss of control).

10.

Alcaholic tremelousness (Early morning shakes).

11.

Alcoholic halucinosis (Auditory hallucinations).

12.

Withdrawal siezures (Rum fits).

13.

Delirium tremens.

14.

Drinking despite strong medical contraindications to thu
known to the patient.

15.

Accidents while intoxicated with alcohol.

Hw %a-i 6
EPIDEMIOLOGY OF ALCOHOL USE AND ITS HAZARDS
mortality associated with abstention was confined to those who
had become abstainers and was not found in lifetime abstainers.
A major difficulty is in the inference that not drinking is the
cause of the slightly greater mortality in the abstainers. Person­
ality characteristics, believed to be relevant to death from heart
disease, have not been studied in abstainers: for example
abstainers might contain a greater proportion of those driving,
ambitious individuals prone to coronary disease than light
drinkers.
More important is that (i) the effect noted by Marmot et al. is
aery small (the relative risk of abstainers is only 1-6 that of light
drinkers); (ii) it apparently occurs with reported drinking as low
as I unit (half a pint of beer) a week to 1 unit a day, which is a
small dose if a direct pharmacological action is hypothesized;
■ nr it disappears at fairly low levels of drinking (4 units/day);
os > it is not demonstrable in the 40-49 year olds, only in the
'0 64 year olds; (v) a similar effect is not demonstrable in the
study already described of Dyer et al. (data analysed by me).
Further specifically designed studies are now required.

5

Natural History of Problem Drinking

I'pidemiologists have demonstrated that the problem drinker
is not an individual irredeemably condemned but rather that
people move into and out of problem drinking. Surveys record
'-•» rates of drinking problems after age 50. Drew (1968),
examining the ages of alcoholics known to agencies, concluded
-■>< the prevalence of alcoholism in the population diminishes
more rapidly with age than can be accounted for by mortality
and successful treatment. One-half to one-third of respondents
■n tsso large US surveys who reported a given “problem” no
- nger reported that problem when re-interviewed 4 years later.
I hough some accrue a different alcohol-related problem in the
"cantime it is by no means inevitable (Clark & Cahalan, 1976).
O.csjd (1981) re-interviewed after a 15 year interval a general
-filiation cohort and found that of the 96 alcoholics identified
■■ finally 29 were now inactive or “much improved”; (25 had
-<d). Work in this area has shown that, of the external
-cnees, changes in social circumstances such as job and
,<rumal relationships are important.
6

J Chick

between consumption and indices of harm (Bruun et al. 1975;
Skog, 1980), though there is no example where a sudden
decrease in per caput consumption has occurred that was not in
wartime. This correlation is not seen so clearly in a recent
report by de Lint (1981) of changes in the Netherlands in the
period 1950-75.
Two of the examples cited above (section 2(vi)) of successive
surveys in the same population provide data on changes in
problem rates. In the Finnish study (Simpura, 1978), where per
caput consumption increased by 67% from 1969 to 1976, an
increase in the percentage of drinkers reporting problems also
occurred: “Worrying about controlling my drinking” was
reported by 15% of men in 1969 and 29% in 1976 (women, 4%
and 14%); “social problems” were reported by 22% of men in
1969 and 32% in 1976 (women, 3% and 7%). However, the
proportion having problems rose at every consumption level,
meaning that either a certain amount of alcohol caused more
problems in 1976 than in 1969 or, more likely, the threshold at
which people admitted a problem had fallen.
The London comparison between 1965 and 1974 (Cart­
wright et al. 1978) also does not provide strong evidence.
Although the authors found that an increase in admitted
problems had accompanied the 47% rise in per caput con­
sumption, 3 of the 5 problem items were rather trivial. Because
of the small sample size in the 1974 study, only 2 individuals
were identified who had had 4 items and none who had had 5.
It is not going beyond the current evidence to state that a
change in per caput consumption is a marker of change in
problem rates and, indeed, that recent trends (in particular
increased availability) have made a contribution to rise in the
indices of harm. What is not known is whether this association
can be put into reverse, though it is widely advocated as the
most expedient solution given the magnitude of the alternative
task of educating whole populations to drink safely.

Per Caput Consumption and Prevalence of Harm

most pressing question is whether influences on mean
-^ntumption, such as availability of alcoholic beverages and
.- csii mg attitudes to drinking, afreet the prevalence of harmful
-sequences of drinking. Although this is related to the issue
Acd ■ a,3ove’
whether rises in mean consumption are
■u ■■ Wlt*1 r’ses. ’n ProPort>on of heavy consumers, it is clearer
( jj'wuss each issue separately. It is, of course, the prevalence
_ *rm ul consequences that is practically more important than
:
I rs of heavy drinkers. Falling real price, increasing
., ?ul,ets and ^renter advertising, as already mentioned, may
f*ctor»
3 r°'e in *ncreas*nS consumption since 1945. These
■he rise^ un'‘lce'y> however, to be sufficient explanations for
-Ganges i” preva'ence °f harm in this period. Other relevant
•eakeni S°clely include: increasing secularization, continuing
'J name buta f^ exten£*e<* fan,i'y anci the blurring of sex roles,
-■■dixjbtedi'1655’ comPar’sons between nations and regions

and cirrh • Show coYariation between per caput consumption
n-dence tb'S m?rta'* ty- Furthermore, there is considerable
■ at within regions there is covariation over time

APPENDIX: SCREENING METHODS

i Screening for Problems
Questionnaires such as the Michigan Alcoholism Screening
Test (MAST) (Selzer, 1971) and the Severity of Alcohol
Dependence Questionnaire (SADQ) (Stockwell et al. 1979)
have shown that a variety of populations will admit, in a pencil
and paper exercise, to a range of alcohol-related problems and
symptoms. Some of the MAST items are rather trivial. The
SADQ restricts itself to “dependence” items. Where skilled
personnel are available reliability can be improved by direct
interviewing (Chick, 1980). Decisions about cut-off points in
terms of number and severity of problems are an arbitrary
matter. The time-frame in such instruments is also arbitrary.
Many of the MAST questions are phrased in the form “Have
you ever ...?”, thus identifying “cases” who may now be “in
remission”.

EPIDEMIOLOGY OF ALCOHOL USE AND ITS HAZARDS

J Chick

their use as indicators of heavy drinking in working men. Fifty
per cent of men who admit drinking over 450g (56 units) a week
have a y-GT of >50 iu (false positives about 15%) and 23-32%
have a MCV of over 98 fl (false positives about 5%), after men
with other causes of increased values, such as taking anti­
convulsants or specific physical disorder, have been excluded.
Raised MCV is commoner in heavy smokers and in men whose
pattern of drinking is sustained rather than episodic.
The false-positive rates, when self-reported consumption is the
criterion, are in part probably due to lying and minimizing. The
crucial study, of the risk of having a raised value on either of
these two tests in a population whose consumption is known
with certainty to be slight, has yet to be conducted.
Of the more expensive tests which have been proposed,
abnormal heterogeneity of transferrin is still being investigated
(Stibler et al. 1979) and the ratio of a-aminobutyric acid to
leucine is probably only useful in detecting alcoholic patients
who have drunk heavily and very recently (Chick et al. 1981c).
Phillips (1981) has measured alcohol content of a sweat patch
which collects for up to 10 days. The fact that drinking is being
monitored may alter habitual consumption, however, and
clearly a degree of co-operation is required.

ii Screening for Heavy Consumption
As in survey work, consumption is best elicited by taking a
very recent period and asking the subject in detail about each
drinking occasion during that period. He should be asked to
recall his leisure activities and his daily routine for each day, to
jog his memory. In countries where drinking tends to be
relatively infrequent such as Norway, the past 4 weeks is a
suitable period. In Britain, the last 7 days suffice. It has been
shown that in working populations those who claim their last 7
days were atypically heavy tend to be reporting a trivial
difference (Chick et al. 1981b). However, in hospital samples,
patients whose life leading up to admission was far from normal
should be asked to detail a “typical” week. If they do not have a
typical week, a “typical heavy week” is the next best measure.
Informants, such as spouse, have not been shown to improve
the accuracy of self-reported consumption. However, several
blood tests may be abnormal in regular drinkers and return to
normal, with a roughly logarithmic decline over 2-3 weeks,
when drinking ceases. Mean red-cell volume (MCV) and y-GT
are the cheapest and most commonly available of the existing
tests, though they lack power. Chick et al. (1981a) describe

References
Adelstein A & White G (1976) Popul. Trends, 6,7-13
Blackwelder W C, Yano K. Rhoads G G. Kagan A, Gordon T & Palesch Y
(1980) Am. J. Med. 68, 164-169
Brewers' Society (1980) Statistical handbook. Brewing Publications Ltd.
London
Bruun K. Edwards G, Lumio M, Makcla, K, Pan L. Popham R E , Room R,
Schmidt W, Skog O-J, Sulkunen P & Osterberg E (1975) Alcohol control
policies in public health perspective. (Report no. 25). Finnish Foundation
for Alcohol Studies, Helsinki
Cartwright A K J, Shaw S J & Spralley T A (1978) Br. J. Addict. 73,247-258
Chick J. (1980) Br. J. Addict. 75, 175-186
Chick J, Kreitman N & Plant M (1981a) Lancet. 1, 1249-1251
Chick J, Kreitman N & Plant M (198 lb) Drug Alcohol Depend. 7,265-272
Chick J, Thatcher D & LongstafT M (1981c) In: Raltenbury J, ed. Amino acid
analysis in clinical chemistry and medical research. Ellis Horwood,
Chichester. See also J. Slud. A Icohol (In press)
Clark W (1966) Q.J. Slud. Alcohol, 27,648-668
Clark W & Cahalan D (1976) Addict. Behav. 1,251-259
Day N L (1978) Alcohol and mortality: separating the drink from the drinker
(Thesis for PhD degree). University of California, Berkeley
de Lint J (1981) Br. J. Addict. 76,77-84
Dight S (1976) Scottish drinking habits. HMSO, London
Drew L R H (1968) Q. J. Slud. Alcohol, 29,956-967
Dyer A R, Stamler J, Paul D, Lepper M, Shekclle R B, McKean H & Garside
D (1980) Prev. Med. 9, 78-90
Edwards G, Chandler J & Hcnsman C (1972) Q.J. Stud. Alcohol, suppl. 6, pp.
69-93
Edwards G, Kyle E & Nicholls P (1974) Q.J. Slud. Alcohol, 35, 841-855
Knight I & Wilson P (1980) Scottish licensing laws. HMSO, London
Knox E G (1977) Br. J. Prev. Soc. Med. 31,71-80
Kozarevic Dj, McGee D, Vojvodic N, Racic Z, Dawber T, Gordon T & Zukel
W (1980) Lancer, 1,613-616
Kreitman N (1977) In: Edwards G & Grant M, ed. Alcoholism: new knowledge
and new responses, pp. 48-59. Croom Helm, London
Lelbach W K (1974) Res. Adv. Alcohol Drug Probl. 1,93-198
McGuinness T (1980) J. Ind. Econ. 39,85-109
Makela K (1978) Res. Ado. Alcohol Drug Probl. 4,303-348

Marmot M G, Rose G, Shipley M J & Thomas B J (1981) Lancer, 1,580-583
Ojesjd L (1981) Br. J. Addict. 76,391-400
Pequignot G & Tuyns A (1976) Colloq. Inst. Natl. Sante Rech. Med. 54,23-39
Pequignot G, Tuyns A J & Berta J L (1978) Int. J. Epidemiol. 7,113-120
Pernanen K (1974) Res. Adv. Alcohol Drug Probl. 1,355-374
Peterson B, Kristenson H, Sternby N H, Trell E, Fex G & Hood B (1980) Br.
Med. J. 280, 1403-1406
Phillips M (1981) Lower, 1,328
Plant M A (1979) Drinking careers. Tavistock, London
Ritson B (1977) In: Edwards G & Grant M, ed. AIcoholism: new knowledge and
new responses, pp. 271-278. Croom Helm, London
Room R (1974) Drinking Drug Pract. Surv. 9,3-7
St Leger A S, Cochrane A L & Moore F (1979) Lancet, 1, 1017-1020
Saunders J B, Davis M & Williams R (1981) Br. Med. J. 282, 1140-1143
Schmidt W (1977a) In: Edwards G & Grant M, ed. Alcoholism: new knowledge
and new responses, pp. 15-47. Croom Helm, London
Schmidt W (1977b) In: Fisher M & Rankin J, ed. Alcohol and the liver, pp.
19-30. Plenum Press, New York
Schmidt W & Popham R E (1976) Drug Alcohol Depend. 1,27-50
Selzcr M L (1971) Am. J. Psychiatr. 127, 1653-1658
Shaw S (1980) In: Camberwell Council on Alcoholism, ed. Women and alcohol,
pp. 1-40. Tavistock, London
Simpura J (1978) Report no. 114. Social Research Institute of Alcohol Studies,
Helsinki
Skog O-J (1980) Br. J. Addict. 75,227-243
Spring J A & Buss D H (1977) Nature (London), 270,567-572
Stibler H, Borg S & Allgulander C (1979) A eta Med. Scand. 205, 313-316
Stockwell T, Hodgson R, Edwards G, Taylor C & Rankin H (1979) Br. J.
Addict. 74,79-87
Taylor D (1981) Alcohol—reducing the harm. Office of Health Economics,
London
Weissman M N. Myers J K & Harding P S (1980) J. Stud. Alcohol, 41,
672-681
Whitlock F A & Evans L E J (1978) Drugs, 15,53-71
Wilson P (1980a) Popul. Trends, 22,14-18
Wilson P (1980b) Drinking in England and Wales. HMSO, London
Wynder E L & Mabuchi K (1972) Prev. Med. 1,300-334

8

Counselling to
check
alcoholism
COIMBATORE
The Inner Wheel Club of Coimbatore main
and the Rotary Club of Coimbatore jointly or­
ganised a seminar-cum workshop recently to
consider the social problems created by
alcoHism and drug addiction and to devise
waj^pnd means to prevent them besides re­
habilitating those already affected.
The seminar was inaugurated by Rotary Gover­
nor Mr. P. N. Gopal of district 320 who em­
phasised the need for launching a campaign to
educate the poor and the backward classes
about the dangers of alcoholism and drug ad­
diction and to mobilise opinion against con­
sumption of alcohol.
The participants in the seminar included the
past District Governor. Mr. C. Govind, Dr.
George Thomas. Dr. G. Lakshmipathy, Dr.
Gurudas. Professors N. Surendra Prasad, Mrs.
Devi Balakrishnan. Balasubramaniam, V.
Ganesh, T. Jothimani and K. Muralidharan be­
sides representatives of students from various
educational institutions in the city. From the
police side. Mr. Sreedharan, Additional Super­
intendent of Police took part in the discussions
and explained the legal and enforcement as­
pects of prohibition and narcotic control. Mr. V.
K. Jawaharlal. President, Alcoholics Anonym­
ous and Mrs. Sarojlni Anantharaman cited speci­
fic cases and family experiences with
alcoholics.
Inja paper presented on the occasion, Dr. G.
Lsj^knipathy dealt with 'Alcoholism and drug
adcBon yesterday, today and tomorrow'. He
said the problem had assumed alarming pro­
portions due to relaxation of prohibition and indi­
scriminate opening of arrack shops. Dr. Laksh­
mipathy pointed out that the future would be
bleak if the problem was not tackled with a
sense of commitment and with the overall wel­
fare of society. He said the voluntary service
organisations had a very important role to play
in educating the vulnerable sections of the
public about the evils of drinking.
During the panel discussion the causes for
the spread of alcoholism were analysed by spea­
kers. The -participants expressed the view that

rkw -

lack of parental care mingled with peer group
Influence made adolescents victims of alcohol­
ism. The view was expressed that in college
campus alcoholism and drug addiction occurr­
ed due to curiosity or experimentation, inability
to cope with academic stress, imitation of
models, feeling of a false sense of insecurity
and undesirable associations. It was suggested
that alternatives to drinking must be devised
and pncouraged and supportive centres must
be set up to provide counselling and guidance
to students getting into the habit.
The doctor participants and psychiatrists clari­
fied that creativity and intelligence were not sti­
mulated in anyway by addictive behaviour but
on the other hand it led to chromosomal ab­
normalities. It was explained how consumption
of alcohol by pregnant women led to congeni­
tal defects, mental retardation etc., among child­
ren.
The speakers laid emphasis on the responsi­
bility of the Government in preventing drug ad­
diction and alcoholism. They said the Governmnent instead of relying on arrack shops to- in-'
crease its revenue should think of alternative
methods of raising revenue and put an end to
this social evil. The. consensus of opinion
among the speakers was that the Government
should not shirk its responsibility for political
gains and exploit the gullibility of the weaker
sections but must act to improve the well-being
of the socially and economically backward
people.
The Inner Wheel Club of Coimbatore main
has charted out a follow up programme on the
basis of the recommendations of the seminar.
The programme envisages distribution of hand­
bills in both English and Tamil in educational in­
stitutions, slums, villages and offices explaining
how the public at large could help in the eradica­
tion of alcoholism and drug addiction, display
of posters urging the Government not to locate
arrack and toddy shops in the vicinity of educa­
tional institutions, temples, hostels, industries.
etc., closure of arrack shops on holidays and
strict adherence to timings for the sale of liquor
and strict enforcement of law that liquor shall
not be sold to persons below 21 years.
The club has also decided to launch audio
visual programmes to create awareness among
the youth about the hazards of drug and
alcohol addiction and to bring about better inter­
action between parents ano children and also
between teachers and children.—Coimbatore
Staff Reporter

PluvunabuZtetin

No. 107

1986

ALCOHOL AND DRUG USE AND RELATED PROBLEMS IN THE
MEDICAL

Professor

PROFESSION

J.R.B.

Ball*

At meetings where much learned discussion occurs about the misuse of legal
and the use of illegal drugs within the general community, with comment
about the psychosocial and biological causes of such behaviour, the context
often suggests that the problems are all out in ’‘society" but in fact they
also are found within the helping professions.
As well as looking at the
"public's" problems the medical profession needs to look at its own frames
of reference, personality problems, professional and social pressures and the
other factors which contribute to doctors' misuse of such agents.
Of
course in recent times much critical attention has been paid to the medical
profession.
McCall's magazine commented, "physicians are poor husbands,
poor fathers, absent companions, prima donnas and about as useless in bed
as an electric blanket when the power is cut off".
It might also be added
that they have some other problems!
So far within Australia local information
is inadequate and inaccurate but the problems can be outlined by reference to
work which has taken place abroad;
one might assume that physicians in
Australia may not differ much from those in U.K. and U.S.A.
Earlier it had been though that doctors, by virtue of their role and lifestyle,
suffered a high incidence of physical disorder but this does not seem to be
so.
British doctors have a standard mortality ratio of 81, i.e. taking 100
as the norm;
that is they are 19% better off than the general population in
relation to age.
Doctors standard mortality rate for cancer is 73% (1).

Amongst United States doctors, for 1938-1942 the mortality rate was equal to
that of the general population, but less than for other professions, whilst
between 1969-1973, the mortality rate for male doctors was 74.7% and for
female doctors 84.1%, as against the general population matched for age.
Relevant factors possibly related to the situation in Britain and the United
States could be the physicians
*
good socio-economic status, easier recognition
of illness and, earlier and more appropriate treatment being sought and given
(2,3).
However United States doctors appear to have a high incidence of affective
disorders, drug abuse and alcohol addiction (4,5,6,7,8).
In relation to
completed suicide this figure ranged from 27-39 per 100,000 per year, which
was far higher than that found in the general U.S.A, population (9). Female
physicians appeared to kill themselves at four times the rate of the general
U.S.A, population.
Lately whilst supporting the higher rate of suicide in
female physicians - equal to that of their male colleagues, the general rate
for physicians in the U.S.A, has been shown to be similar to other professional;
which is a better comparison than with the general population (10).

Doctors were also said to have unhappy marriages giving rise to the question Do the unhappy marriages cause greater general vulnerability for physicians or
does the physician's greater vulnerability and maladaptatlon plus other factors,
help make their marriages unsatisfactory? (11,12,13,14)
British doctors have a standard mortality ratio for suicide of 335%, cirrhosis
of the liver 311% and accidental injuries 180%, matched against the population
(100%).
Work in Scotland shows that physicians have a mean admission rate to

.../23

PhaAinabMMn Ho. 107

1986

23.

psychiatric units of 449 per 100,000, whilst other social class I patients only
reached 205 per 100,000.
There was no significant difference in relation to
admissions for schizophrenia, pre-senile psychosis or senile psychosis, but the
differences were highly significant in regard to drug dependence, alcoholism
and depression.
The structure of health services and the pattern of their
use, in the British Isles suggests that the figure could be a fairly accurate
guide (2,3,15).
It is also claimed that 1% of doctors in the U.S.A., are or
will become narcotic dependent, whereas for the general population of the
United States 1 per 3,000 are so affected.
Information from the United States
indicates that 10% of all physicians will become dependent on psychoactive
drugs or alcohol sufficient to impair the practice of medicine at some time
during their careers, that 10% of physician alcoholics or narcotic addicts,
will commit suicide, and that 7% of all physicians are or will become alcoholics
at some time during their careers and that one-half of the alcoholic physicians
will become dependent on other drugs.
More recent United States information
(which does not quite match with that from the United Kingdom), is that the
occurrence of alcoholism amongst physicians is similar to matched professional
groups within the population but that narcotic addiction is 30-100 times more
frequent than in the general population and also much higher than that found
in matched professional groups within the population and sedative hypnotic
abuse is also thought to be common amongst physicians (16,17).
Australian figures are almost certainly quite inaccurate, but here as found
elsewhere, pharmacists, dentisits and veterinary surgeons seem to have little
drug dependence, or at least are rarely reported to have such problems.
One
can argue that pharmacists and veterinary surgeons (animals can't explain or
complain) can more easily cover up their drug misuse and dependence and avoid
detection, whilst dentisits have less direct access to narcotics, hypnotics
and sedatives than physicians.
One can of course see cases from such
professions within the patient population, but the general 'private' impression
from colleagues working with the drug dependent and from local official sources
is that dependency has been rarely officially reported amongst members of such
professions and is Infrequently seen in clinical practice.
Such evidence
clearly relates only to those who seek help, or are 'found out'.
The
Victorian state figures (18) over a 20 year period show that there have been
sixty two (62) cases of serious drug dependence 'reported' of whom fifty four
(54) were physicians, six (6) were nurses, one (1) was a dentist and one (1)
a pharmacist.
Pethidine or morphine was used in 46 cases and all of the
other cases were multiple users of Fortral, Palfium, Percodan, and amphetamines.
During this period the number of registered medical practitioners in Victoria
rose from 5,000 + (est.)(1964) to 10,616 (1984).
Many physicians know of
numbers of colleagues who have never been reported to the Medical Board and/or
to the 'drug dependency unit' when suffering from narcotic dependency and/or
misuse of other drugs including alcohol.
If we assume that Australian physicians are similar to their colleagues in
N. American and the United Kingdom, then we might expect that up to 1% are
or will become narcotic dependent, that a relatively high proportion will
become sedative or hypnotic dependent, that the use of alcohol will be a
least comparable to that of matched groups within the population and possibly
higher if we are closer to the British rather than the United States situation.
(If it is not so then the explanation should prove illuminating).
The factors which may determine such differences from the general population
and similar non-medical professional groups must include aspects of vocational
choice, student selection, training and life style within the medical
profession.
'Nice' vocational motives for entering the medical profession
such as the search for honour, prestige, good income and the gratification of
altruistic inclination certainly apply to many within the profession but a
multitude of other factors may also affect such choice (14,19,20.)

.../24

PhaAmabMtZin No. J07

1986

24.

Dynamic influences may operate such as introspective identification with
parents or some other significant figure who might have a healing or physician
role, or compliance with the parental image of oneself, l.e. meeting the
parental expectations in reference to vocational choice.
A quest for
omnipotence and expression of the need to dominate certainly seems to exist
in many physicians; this may be associated with the denial of dependency by
making others dependent upon one’s self.
A more esoteric possibility is
the suggestion that one becomes a healer as part of a means of reparation of
fantasy damage to initial love objects, in effect doing a 180 degree turn.
The flight from death, the transmutation of anxiety about one’s own death
and the death of others, into the healing role where one combats death and
associated with this the need to administer to others and not to oneself has
also been suggested as an influence in some Individuals.
In like vein the
patient is the shadow, in a Jungian sense, of the doctor;
i.e. the sick or
needful part of ourselves.
In regard to the suggestions of marital disharmony and problems within doctors’
families, some suggest that partly this is the product of the difficulties
which physicians may have with unqualified relationships, thus we ’find’
(vulnerable and sick people and marry them, or alternatively need the spouse
to become a patient to whom the physician can then guardedly safely relate;
a family member can become ’a patient’ deliberately to get attention and
consideration.
The childrens' problems which emerge in some medical families,
can illustrate a mechanism whereby the child becomes the 'delegate' or
vicariously meets the parental behavioural needs which cannot be met within
themselves or expressed without professional and/or social difficulties.
Certainly in such ways the spouse or the child by illness or other abnormal
behaviour achieves the attention of physician, parent or spouse and of society
in some instances! (12,13,14,21,22)

Whatever the dynamic influence which determine a physician's vocational choice
and operate within the doctor's immediate environment and in the family, a
multitude of compounding problems also operate and can predispose to substance
abuse.
These Include the tendency expressed by many physicians to deny
problems within themselves; this is often associated with the overt or covert
collusion of one's colleagues and/or family, who fail to see or will not see
the tension, distress and even behavioural disturbance of the sick physician.
This may represent a kind of misplaced love or friendship.
One might consider
that the real test of a relationship is that one is prepared to lose the
friendship or love of the person for whom one is concerned by expression of
the perceived need for help to that other person and even take more direct
action if necessary.
Overwork and fatigue are important influences which are
to some extent related to the style of work and the situation in which it
occurs;
they are also an expression of the personality for which the medical
.student and then physician has been selected.
Most physicians work hard and
(tend to overwork.
Few doctors would not begin early and finish late, i.e.
well beyond assigned and perhaps appropriate hours of employment.
In most
forms of practice, doctors work long hours and yet, all things being
considered, for many of them it seems that the need which is satisfied is to
work rather than to earn.
In fact nowadays excessive hours and generation of
extra income may produce financial rewards which prove simply uneconomic; this
serves just to highlight the mechanism.
Compounding problems for the physician are the development of any physical
illness, which tends to be denied, to be worked through or over, and easy access
to drugs becomes a problem.
Many cases of drug dependency begin when doctors
in a state of exhaustion, depression and/or physical discomfort from one cause
or another resort to medication to keep going, sometimes hypnotic/sedative
drugs and far too often, narcotics.

.../25

PhaAmabMztin No. 107

1986

25.

Underlying general problems which can have a marked influence on such matters
are the Indications of pre-disposing vulnerable personality, personal
development and family history which if further confirmed all raise questions
about selection for undergraduate training (20,23,24).
Additional complicati
factors are the lack of help at the undergraduate level to deal with emerging
The
problems and clearly emerging as a major concern, having female gender.
problems for female doctors are quite serious, the medical role may provide
greater difficulty for the female student and then doctor because of the
highly competitive nature of the training and work, the demands which the
female physician makes upon herself and the complex problems of role and role
diffusion in relation to practice of medicine and the domestic and other
responsibilities which female physicians may also assume.
For all doctors matters such as the assumed and assigned roles, the role model
with which one identifies as a student then young physician, the arduous
competitive nature of the training with limited opportunity (and often less
encouragement) for the student to engage In other activities or interests, the
lllusional sense of or wish for omnipotence, the fear of failure and the horriv
reality that ultimately we all must fail add to the difficulties of the doctor)
vocation.
Divorce is a particular problem for physicians, the divorced in the general
population are 3 times more likely to kill themselves than the married, wherea
*
divorced doctors are 13 times more likely to kill themselves than their marriei
colleagues.

Things which suggest existing or emerging problems amongst medical colleagues
(as for anyone else) which might need help and exploration include the
appearance of strain or obvious worry, decrease of efficiency and loss of
ambition, new hypersensitivity to criticism, sudden and unreasoning hostility
to almost any suggestion, undue argumentativeness and irritability, marked
change in habitual personality reactions, peculiar behaviour or mannerisms not
exhibited before", noticeable fatiguability, loss of weight, insomnia, and
apparently Inexplicable inappropriate disruption of domestic or other personal
relationships.
Doctors classically give the reasons for drug abuse as overwork, chronic
fatigue and physical disease.
Several conditions which must co-exist to
effect narcotic addiction in anyone, no less physicians include

a)

a predisposing personality

b)

the availability of drugs (an obvious problem for physicians)

c)

a set of other circumstances which bring these factors
together, plus

d)

some situation which operates to trigger the actual use and
to remove the inhibitions, for example stress/illness.

In considering what can be done to reduce or prevent such maladaptive
behaviour some have suggested 'better' selection of those who are to be
trained in medicine.
Several studies indicate that physicians who later
became drug dependent could have been spotted as vulnerable at the time of
selection or whilst undergraduates and helped at that time (23).
One
hesitates to say whether or not vulnerable persons should be excluded from
training or dismissed from medical school as our history includes too many
very creative and able persons who for one reason or another became drug
dependent for some while.
Had they not been allowed to complete training or
to continue or return to practise the profession might have been the loser and
much more the patients and the society which they served.
Certainly there
seems to be the need for good observation and adequate support systems within

.../26

PluuunabMeUn No. 107

1986

26.

the medical schools and throughout professional life the need for support from
colleagues and family, with adequate provision of consultative and treatment
facilities (24,25).

People handle stress in many different ways apart from the use of chemical
agents.
Common coping responses used by professionals include 10 common
techniques: changing to engrossing non-work or play activity such as reading,
community affairs, coaching sports, a variety of hobbies and outdoor activities:
analysing the stress producing situation and changing the strategy of attack
upon it, deciding what is worth worrying about and what is not, accepting less
perfection and delegating tasks when tensions build: working harder, working
longer hours, take on more responsibility: talking through with others on the
job, discuss with contemporaries and having a bitching session with one's peers:
changing to a completely different work task or job activity: talking through
with spouse: withdrawing physically from the situation for a while, taking a
break, engaging in physical exercise: trying to compartmentalise work and home
life, working hard on the job but when at home learning to blank out job
^problems:
building resistence to stress by regular sleep, regular exercise
rand good health habits.
Overall the most effective techniques seem to be the
last five which have been highlighted.

The basic survival kit for anyone, not least the physician, seems to include a
sense of self respect, an appreciation of human limitations and of one's own,
an ability to set priorities and to set limits, reasonable but not undue
attention to oneself, a capacity to recognize and accept the natural course of
events, the recognition of one's personal vulnerability and the development of
satisfactory dependence on significant others in one's family and amongst one’s
colleagues.
Doth in the direct interpersonal situation with drug dependent colleagues and
in general, one needs to have a supportive, caring role and not a critical
denigratory punitive and destructive one.

Many physicians who become dependent can be helped with good supervision,
appropriate control of the work situation and regular and random serological
and urinary controls to monitor drugs.
Some will need intensive psychiatric
help and this should be easily available (26,27).
Most of all every physician
and every student needs to bear in mind the classic first principals in this
area:-

1.

We are very well trained to take care of others and in
general we do that very well.

2.

We do not care well for ourselves and often take unkindly to
having this pointed out to us.

3.

We should never directly prescribe for ourselves any
preparation which has an Influence on our minds, hypnotic,
sedative, tranquillizing, stimulating or whatever.
The
use of such drugs should be at the discretion of an
appropriate colleague whom one is properly consulting.

■

If we were able to obey these rules this would help to minimize drug dependency
amongst us.
This would also be a further expression of our caring for those
placed in our charge for the use of narcotic/sedative/stimulant preparations
by ourselves, on ourselves, must carry the risk of some damage to our
professional judgement and skills.

.../27

PhaAnabiMeZin No. 107

1986

27.

ACKNOWLEDGEMENT

"THIS PAPER IS BASED ON VERBAL PRESENTATION ON DRUGS ANO YOUTH ALTERNATIVES
AND STRATEGIES GIVEN AT THE FIFTH ANNUAL CONFERENCE MELBOURNE JULY 1985 AND
SUBSEQUENTLY PUBLISHED IN AUSTRALIAN DRUG AND ALCOHOL REVIEW JANUARY 1986
ISSUE VOLUME 5. NO. 1.
THE AUTHOR IS GRATEFUL TO THE EDITOR OF THE REVIEW
FOR PERMISSION TO PUBLISH THIS ARTICLE."
Professor of Psychiatry
University of Melbourne
Department of Psychiatry
St. Vincent's Hospital
FITZROY. VIC. 3065. AUSTRALIA.
References:

1.
2.
3.
4.
5.
6.
7.
8.
9.

10.
11.
12.
13.

14.
15.
16.
17.

18.
19.
20.
21.
22.
23.

24.

25.

26.
27.

Registrar General U.K! 1978
Brit 3 Psychiatry 1977 131 1
3 Roy Coll Physic 1978 12 403-415
Dis Nervous System 1968 29 763
Arch Gen Psychlat 1973 29 800
3.A.M.A. 1974 228 323
3.A.M.A. 1976 236 1372
Am 3 Psychiatry 1964 121 358
Nadelson Carol C. 4 Notman Malkah T. (1983).
What is different for Women physicians, in. The
Impaired Physician, ed. Scheiber S.B. and Doyle B.B.
Plenum Medical Book Co. New York and London.
Preven D.W. (1983) Physicians suicide, in. The
Impaired Physician, ed. Scheiber S.C. and Doyle B.B.
Plenum Medical Book Co. New York and London.
Brit 3 Medical Psychology 40 333
Am 3 Psychiat 1965 122 159
Gerber Lane A. (1983) Married to their careers.
Tavistock. New York and London.
3. Religion and Health 1969 V 8:3
The Practitioner 1983 227 65
Shortt S.E.D. (1982) Psychiatric illness in physicians.
Charles C. Thomas.
Springfield. Illinois.
Webster T.G. (1983) Problems of Drug addiction and
Alcoholism among Physicians, in. The Impaired Physiciar
ed. Scheiber S.B. and Doyle B.B. Plenum Medical Book
Co. New York and London.
Health Commission of Victoria, Drug Dependency Office.
Personal Communication.
Psychiatry 1964 27 135
Genetic Psychology Monographs 1960 61 291
Am 3 Psychiatry 1967 123 1049
Arch Gen Psychiat 1961 4 357
Scheiber S.C. (1983) The Medical School Admissions
Committee. A preventive Psychiatry challenge, in.
The Impaired Physician, ed. Scheiber S.B. and Doyle B.B.
Plenum Medical Book Co. New York and London.
Nadelson Carol C., Notman Malka T. & Preven David W. (198
Medical Student stress adaptation and mental health, in.
The Impaired Physician, ed. Scheiber S.B. and Doyle B.B.
Plenum Medical Book Co. New York and London.
Doyle Brian B. & Cline David W. (1983) Approaches to
Prevention in Medical Education, in. The Impaired Physic!
ed. Scheiber S.B. and Doyle B.B. Plenum Medical Book Co.
New York and London.
3.A.M.A. 1982 247 2253
3.A.M.A. 1984 251 743

miilllimillllllimillHIH

erty of movement, bilateral resting tremor of the feet,
generalized cogwheel rigidity, and a stooped, somewhat
shuffling gait with loss of associated movements. Within
five days all clinical signs of parkinsonism disappeared.
A CT scan showed mild to moderate generalized cere­
bral atrophy. An electroencephalogram (EEG) was normal.
Liver function studies showed minimal elevation of biliru­
bin and serum glutamic-oxaloacetic transaminase (SGOT),
and the patient had mild hepatomegaly. Parkinsonian fea­
tures had been noted on two previous admissions.

Parkinsonism Provoked
by Alcoholism
P. L. Carlen, MD, FRCP(C),
tt§
*
M. A. Lee, MD, FRCP(C),
t§
*
M. Jacob, MD, FRCP(C),’t and O. Livshits, MD
t
*

Seven chronic alcoholics, aged 53 to 70, demonstrated
transient signs of parkinsonism provoked by alcohol
withdrawal or chronic severe intoxication. All showed
improvement or recovery when they abstained or de­
creased their alcohol intake for several days to weeks.
Animal studies have demonstrated impaired striatal
dopaminergic function during severe ethanol intoxica­
tion or withdrawal. Chronic alcoholism apparently can
exacerbate or uncover latent central dopaminergic
deficiency.
Carlen PL, Lee MA, Jacob M, Livshits O:
Parkinsonism provoked by alcoholism.
Ann Neurol 9:84-86, 1981

Patient 2
A 56-year-old man had drunk 3 to 4 quarts of gin per week
for the past twenty years. A month perior to admission he
had increased his intake to L bottle of gin daily. Two weeks
before admission he was noted to have a slow gait and
tremor at rest. His wife, a nurse, related that during two
prior drinking episodes the patient had shown similar signs
of parkinsonism, which resolved with abstinence.
Examination showed an emotionally depressed man with
slowed speech, resting tremor, and cogwheeling rigidity of
the right arm. He had a postural tremor in both arms. His
gait was wide based and he was generally bradykinetic. He
had palmomental and snout reflexes. Three days later, it
was noted that he had no parkinsonian tremor and his cog­
wheel rigidity had decreased. Nine days after admission, no
rigidity was noted and his bradykinetic gait had greatly im­
proved. Investigations in the hospital showed no biochemi­
cal evidence of liver disease. An EEG showed minimal ab­
normalities.

Patient 3

Acute alcohol intoxication has been reported to trig­
ger akathisia, dystonia, and cogwheeling in young
adults taking neuroleptics [7], suggesting that alcohol
can impair central dopaminergic mechanisms in hu­
mans. During the past three years we have observed
transient parkinsonism during alcohol withdrawal or
I chronic severe alcohol intoxication in seven chronic
alcoholics. Parkinsonism provoked by alcoholism has
not previously been reported.
Patient 1
A 53-year-old man with a ten-year history of alcohol abuse
(24 beers and several glasses of wine daily) entered the
hospital for alcohol withdrawal. He had been admitted for
alcohol withdrawal two and three years previously and
had had documented alcoholic liver disease for seven years.
One day after admission he was noted to have marked pov-

From the Departments of’Medicine and tPhysiology, University
of Toronto, the tAddiction Research Foundation Clinical Insti­
tute, and the § Playfair Neuroscience Unit, Toronto Western Hos­
pital, Toronto, Ont, Canada.
Received May 1, 1980, and in revised form June 27. Accepted for
publication July 5, 1980.

Address reprint requests to P. L. Carlen, MD, FRCP(C), Univer­
sity of Toronto, 33 Russell St, Toronto, Ont, Canada M5S 251.

A 62-year-oId woman who had been drinking up to 24
beers daily for twenty years had a one-year history of resting
tremor in the arms which was reportedly increased during
alcohol withdrawal. She was noted to have a shuffling gait,
cogwheel rigidity and resting tremor in the arms, an ex­
pressionless and flat facies, emotional lability, and de­
creased insight into her condition. She was diffusely
bradykinetic.
Four days after this visit, having maintained abstinence,
she was admitted to the hospital with an unsteady, shuffling
gait. Her parkinsonian signs had decreased. She had no
evidence of liver disease. CT scan showed moderate
ventricular and sulcal atrophy, and bilateral basal ganglia
calcification. She was reassessed six weeks later and osten­
sibly had not used alcohol. Signs of parkinsonism were
still present but were further diminished.

Patient 4
A 64-year-old man had drunk heavily for thirty years, in­
cluding a quart of whiskey per day and 24 beers per week
for the previous four months. Admission was prompted by
a seizure. During the first 48 hours in the hospital the pa­
tient experienced withdrawal symptoms, including a pos­
tural tremor that was controlled with chlordiazepoxide. On
the third day after admission he was noted to have a bilat­
eral pill-rolling tremor of the upper extremities with a fre­
quency of 3 to 5 per second. He had masked facies, pos­
itive glabellar tap, cogwheel rigidity of the arms, and

Reprinted from Annals of Neurology, Vol 9. No I, January 1981. Published by Little, Brown and Company, Boston, MA. Copyright© 1981 by the American Neurological Association; all rights reserved.
No pan of this reprint may be reproduced in any form or by any electronic or mechanical means. including information stocuge and retrieval systems, without the publishers written permission.

84

0364-5134/81/010084-03S01.25 © 1980 by the American Neurological Association

bradykinesia. His posture was stooped, and lie had a
shuffling gait with loss of arm swing. Gradually over the
next week, all clinical signs of parkinsonism resolved. A CT
scan demonstrated mild to moderate generalized cerebral
atrophy. The EEG showed mild, generalized slowing, and
liver enzymes were modestly elevated.
Six and twelve months previously, during brief periods
of alcohol withdrawal, he had noted a marked tremor which
was quite different from the pill-rolling tremor of the pres­
ent admission. However, he had also noted a slowness and
stiffness of movement during the first days of each with­
drawal episode.

Patient 5
A 66-year-old woman who had averaged 6 to 8 beers per
day since the age of 30 had a long history of tremor (prob­
ably of the postural or benign essential type) which was
decreased with alcohol intake and increased during with­
drawal. For two years prior to admission she had com­
plained of a pill-rolling tremor, particularly in the right
hand, which increased and gradually spread to both arms.
Six months before admission the patient noticed increased
abnormal involuntary movements of the tongue and lips.
There was no history of tranquilizer use.
On admission, two days after her last drink, the patient
was noted to have masked facies and a slowed, stiff gait
without associated arm swinging. Her gait was also ataxic.
The glabellar tap response was positive. She had a coarse
flexion-extension tremor of her fingers, greatest on the
right side, which decreased during voluntary movements.
Cogwheel rigidity was present in both arms. She had con­
stant lip smacking and repeated protrusions of her tongue.
Generalized hyperreflexia was present, but her plantar re­
flexes were flexor. She was disoriented to place and date
and had impaired recent memory. There was no biochemi­
cal evidence of liver disease. CT scan showed marked corti­
cal and generalized cerebral atrophy. Two weeks after ad­
mission the patient was started on Sinemet because of the
signs of parkinsonism. She improved after one week.
Sinemet was discontinued, and four weeks later she had a
normal gait, no rigidity, and almost no lingual-oral dys­
kinesia.

Patient 6
A 70-year-old man had abused alcohol since the age of 18,
particularly in the past ten years. Two years previously he
had been diagnosed as having alcoholic liver disease on the
basis of abnormal liver function studies, mild hepato­
megaly, and an abnormal liver scan. He was admitted with
severe alcohol withdrawal symptoms. His posture was
stooped, and he walked in short, shuffling, unsteady steps
with loss of arm swing. Over three weeks in the hospital his
gait improved but did not return to normal. A second ad­
mission four months later was for severe alcohol with­
drawal symptoms. Nine days after admission, neurological
consultation showed impaired fine motor movements,
bradykinesia, rigidity, stooped posture, and a shuffling gait
with loss of arm swing. A CT scan demonstrated moderate
cerebral atrophy. EEG showed mild generalized slowing.
Over the next two weeks his gait again improved but was

not completely normal. The patient had first noted a
shuffling gait two years previously and had been aware of a
deterioration of gait during previous episodes of alcohol
withdrawal.

Patient 7
For several months a 70-year-old woman had complained
of a progressive shuffling, slowed gait and impaired mem­
ory. Her husband had noted increased bradykinesia after
several drinks, which decreased by the next morning. She
had averaged at least 8 oz of vodka daily for many years.
Examination revealed impairment in orientation, recent
memory, calculation, and general knowledge. She had a
slowed gait with loss of associated swinging of the left arm,
resting tremor of the left arm, and decreased facial expres­
sion. She also demonstrated bilateral postural tremor and
mild intention tremor of the left arm, impaired tandem
gait, and mild proximal muscle weakness. Liver function
tests were normal. CT scan showed moderate diffuse cere­
bral atrophy.
Reexamination three months later, after she had reduced
her alcohol intake, demonstrated no resting tremor, a fluid
gait with associated arm swinging, and more expression to
her face. The'signs of dementia and cerebellar dysfunction
had also diminished.

Discussion
Although alcoholism-induced Parkinson disease has
not to our knowledge been reported previously, this
usually transient syndrome must not be rare. Our pa­
tients were all in the appropriate age range to de­
velop idiopathic Parkinson disease. None were re­
ceiving neuroleptic drugs. Patients 1, 2, and 4 had a
history of two prior parkinsonian episodes before
admission. Patients 2 and 5 had a history of parkinso­
nian tremor, and Patient 6 had shown a mild
shufflling gait one to two years prior to admission
(Table). Patients 1, 3, 4, and 6 developed their par­
kinsonism during the first few days of alcohol with­
drawal, Patients 2, 5, and 7 only during heavy drink­
ing; Patient 3 had both modes of presentation. Pa­
tient 5 also developed a lingual-oral dyskinesia while
drinking. Three patients demonstrated a withdrawal
syndrome along with their parkinsonism.
This syndrome differs from the chronic progres­
sive acquired hepatocerebral degeneration syndrome
described in chronic alcoholics with severe liver dis­
ease and portal-systemic shunting [9]. Most of those
patients have extrapyramidal neurological signs other
than parkinsonism. Although three of our patients
had mildly elevated liver enzymes and two had mod­
erate hepatomegaly, none had other signs of liver
disease and none had a history of hepatic encepha­
lopathy, which was present in 80% of the series of
Victor et al.[9].
The effects of ethanol on dopamine metabolism in
the basal ganglia may help to explain the syndrome

Case Report: Carlen et al: Alcohol-induced Parkinsonism

85

Parkinsonism Provoked by Alcoholism

Parkinsonism
Provoked during:

Patient No.,
Age (yr),
and Sex

Alcohol
With­
drawal

Chronic
Intoxi­
cation

Liver
Abnor­
malities

CT Scan

Recovery

1. 53, M
2. 56, M

+

-

+

Mild
None

Atrophy
Not done

3. 62, F

+

+

None

4. 64,M
5. 66, F

+

—
+

Mild
None

Atrophy and basal
ganglia calcification
Atrophy
Atrophy

Full, 5 days
Almost complete, 2
wk
Partial, 6 wk

6. 70, M

+

-

Mild

Atrophy

Full, 1 wk
Parkinsonism: full, 6
wk; dyskinesia:
partial, 6 wk
Partial, 7 wk

7. 70, F

-

+

None

Atrophy

Almost complete

we observed. A subhypnotic dose of ethanol reduces
dopamine turnover in the substantia nigra and caur
date nucleus in rats [1]. Increased striatal dopamine
release is seen in acutely intoxicated rats with
blood alcohol levels under 300 mg/dl; decreased
striatal release occurs with higher blood alcohol
levels [4]. Striatal dopamine release is also reduced
■during the first few days of ethanol withdrawal [4].
In mice, ethanol withdrawal is associated with di­
minished responsiveness of striatal dopamine-sensi­
tive adenylate cyclase activity [8].
These biochemical changes, if present in humans,
could help to explain why four of our seven patients
seemed to develop or greatly augment their signs of
parkinsonism during alcohol withdrawal. The reason
why other patients developed parkinsonism during
prolonged drinking episodes could be related to
higher blood ethanol levels, periods of relative with­
drawal, or other factors. We propose that our pa­
tients had underlying parkinsonian pathology, the
effects of which were intensified by chronic alcohol
intoxication and withdrawal. All the patients im­
proved with maintained abstinence. The six who had
CT scans showed cerebral atrophy, an expected
finding in chronic alcholics [2, 3, 5, 6]. Patient 3 also
had bilateral basal ganglia calcification. These findings
indicate that one should wait a few weeks before
starting antiparkinsonian medication in recently ab­
stinent alcoholics with newly diagnosed mild parkin­
sonism. Alcohol abuse would be expected to be det­
rimental to parkinsonian patients.
References
1.

86

Bacopoulos NG, Bhatnager RK, Van Orden LS III: The effects
of subhypnotic doses of ethanol on regional catecholamine
turnover. Epilepsia 8:1-20, 1967

Annals of Neurology

Vol 9

No 1

January 1981

Other
Comments
Two prior episodes
Two prior episodes
Pill-rolling tremor for
1 yr
Two prior episodes
Pill-rolling tremor for
2 yr, lingual-oral
dyskinesia for 6 mo
Two-year history of
mild shuffling gait

Carlen PL, Wilkinson DA: Alcoholic brain damage and revers­
ible deficits. Acta Psychiatr Scand (in press)
Courville O: The Effects of Alcohol on the Nervous System
of Man. Los Angeles, San Lucas Press, 1966, pp 1-102
4.
Darden JH, Hunt WA: Reduction of striatal dopamine release
during an ethanol withdrawal syndrome. J Neurochem
29:1143-1145, 1977
5.
Horvath TB: Clinical spectrum and epidemiological features of
alcoholic dementia. In Rankin JB (ed): Alcohol, Drugs and
Brain Damage. Toronto, Alcoholism and Drug Addiction Re­
search Foundation of Ontario, 1975, pp 1-16
6.
Lee K, Moller L, Hardt F, Aksel H, Jensen E: Alcohol-induced
brain damage and liver damage in young males. Lancet 2:759761, 1979
7.
Lutz EG: Neuroleptic-induced akathisia and dystonia triggered
by alcohol. JAMA 236:2422-2423, 1976
8.
Tabakoff B, Hoffman PL: Alterations in receptors controlling
dopamine synthesis after chronic ethanol ingestion. J Neu­
rochem 31:1223-1229, 1978
9.
Victor H, Adams RD, Cole M: The acquired (non-Wilsonian)
type of chronic hepatocerebral degeneration. Medicine (Balti­
more) 44:345-396, 1965
2.

3.

Propranolol and Chlordiazepoxide Effects on Cardiac
Arrhythmias During Alcohol Withdrawal
D. H. Zilm, Ph.D., M. S. Jacob, M.D., S. M. MacLeod, M.D., Ph.D.,
E. M. Sellers, M.D., Ph.D., and T. Y. Ti, M.D.
The pattern of cardiac arrhythmias and their treat­
ment. by propranolol and chlordiazepoxide, during
the first 48 hr of alcohol withdrawal has been stud­
ied. Prior to treatment, the incidence of serious and
life-threatening arrhythmias was found to be very
low and uncorrelated with most biochemical param­
eters. Propranolol treatment, while efficacious in
controlling arrhythmias, was limited due to its asso­
ciation with hallucinations. Chlordiazepoxide was
associated with poor early control of arrhythmias.
The combination of propranolol and chlordiazepox­
ide was found to perform best overall with substan­
tial reductions in arrhythmias and the fewest treat­
ment failures.

T IS KNOWN that cardiac rhythm abnor­
malities occur with greater frequency in
chronic alcoholics during intoxication1 and with­
drawal1'2 than would be expected in patients of
similar age without cardiovascular disease.
What is not known, however, is whether the
presence of such abnormalities represents an
increased risk to intoxicated and withdrawing
chronic alcoholics, whether such abnormalities
persist during alcohol withdrawal, and whether
factors can be identified that predispose chronic
alcoholics to arrhythmias, especially during
withdrawal. A randomized double blind clinical
investigation has been conducted to answer some
of the questions raised above and to evaluate the
efficacy of two medications, chlordiazepoxide
and propranolol, in modifying the pattern of

I

From ihe Human Responses and Biomedical Engineering
Laboratory, Clinical Institute, Addiction Research Founda­
tion. Toronto, Canada, Division of Clinical Pharmacology,
The Hospital for Sick Children. Department of Pharmacol­
ogy. University of Toronto, and Department of Pharmacolo­
gy'. University of Toronto and Toronto Western Hospital.
Toronto. Canada.
Supported in part by the Clinical Institute of the Addic­
tion Research Foundation.
Received for publication November 22, 1979; revised
manuscript received March 25. 1980; accepted April 17,
1980.
Reprint requests should be addressed to D.H. Zilm.
Ph.D., Human Responses and Biomedical Engineering
Laboratory. Clinical Institute. Addiction Research Founda­
tion. Toronto. Canada.
© 1980 by Grune & Stratton, Inc.
0145-6008/80/0404-0012501.00/0

400

occurrence of cardiac arrhythmias during with­
drawal. Chlordiazepoxide has been shown to be
a safe and effective therapy of alcohol withdraw’al;3,4 however, its effect upon electrocardiograph­
ic events in alcoholic population is not known.
Propranolol has been shown to be efficacious in
mild to moderate withdrawal, though the
response of cardiac arrhythmias in withdrawing
alcoholics has not been documented. Because of
its beta adrenergic blocking and quinidine-like
properties, propranolol may be potentially useful
in alcohol withdrawal where some arrhythmias
have been hypothesized to arise from increased
plasma catecholamine concentrations.1
MATERIALS AND METHODS
Seventy-two intoxicated male chronic alcoholics who
presented to the emergency department were admitted to the
intensive Care Unit (1CU) of the Addiction Research Foun­
dation Clinical institute. All patients had a 12-lead electro­
cardiogram (ECG) and chest x-ray and underwent a physi­
cal examination. On the basis of the admission ECG and
chest x-ray, patients with evidence of congestive heart fail­
ure, cardiac ischemia, and arrhythmias (except tachycardia)
were excluded as was any patient requiring emergency medi­
cal treatment other than for their intoxication. Following the
admission assessment, the monitoring of a lead II ECG was
commenced using an ECG telemetry transmitter (HP
78100A). The transmitted signal was received by a local
receiver (HP 78100A). the output of which was connected to
a standard patient monitor in the 1CU monitoring station
and to a 12-hr ECG tape recorder (Avionics, 385-A-12-H
Holier recorder). The preceding arrangement permitted
complete freedom of movement by the patient. 12-hr storage
of the ECG by a standard electrocardiographic recording
system (therefore, the generation of tapes compatible with a
playback system to permit reading of the ECG) and display
of the ECG to staff in the event of detection of life threaten­
ing cardiac-rhythms. In addition, the telemetry receiver
produces an alarm if either the transmitter battery fails or,
more importantly, if a lead falls off the patient. Constant
monitoring of the ECG permits continuous assessment of the
viability of the signal prior to recording thereby overcoming
problems of data loss experienced in a previous study1 using a
Holier recorder affixed on the patient.
During the initial ECG monitoring period, blood alcohol
concentrations (BAC) were estimated hourly by breath test­
ing until values reached zero. At this point, patients were
reassessed by a physician to determine their suitability for
continuing in the study. The nature of the investigation was
explained and willing patients gave consent to participate
further. Those with asthma, diabetes requiring insulin, or a

Alcoholism: Clinical and Experimental Research. Vol. 4, No. 4 (October). 1980

ANTI-ARRHYTHMIC DRUGS ALCOHOL WITHDRAWAL

hemoglobin of less than ]0 g/dl were excluded. Patients
receiving antiarrhythmia medications, phenytoin, proprano­
lol, or any benzodiazepine were not included.
Sixty patients who consented to participate and who
satisfied the admission requirements entered the second
phase (medication phase of the investigation). Prior to the
first medication, blood samples were drawn for determina­
tion of serum electrolytes (K, Na, Cl), blood CO2, creatine
phosphokinase (CPK), hydroxybutyric dehydrogenase
(HBD. SMA-12), complete hemogram
*
and plasma
catecholamines.5 Samples were drawn at 24 and 48 hr for
repeat testing of all biochemical parameters except catechol­
amines. The time of the last drink prior to admission was also
ascertained.
Patients were randomly assigned to one of four treatment
groups: (1) placebo; (2) propranolol, 40 mg; (3) chloridazepoxidc, 25 mg; and (4) propranolol, 40 mg and chlordiaze­
poxide, 25 mg. All patients received (double blind) one
capsule and one tablet every 6 hr for 48 hr. The placebo
group received placebo, identical in appearance to the active
drug in both capsule and tablet; the propranolol group
received a placebo capsule and propranolol tablet; the chlor­
diazepoxide group received chlordiazepoxide in capsule and
a placebo tablet and the combined therapy group received
chlordiazepoxide in capsule and a propranolol tablet. Blood
pressure and heart rale were measured 1 hr following each
medication.
The ambulatory ECG was recorded for periods 12-24 hr
and 36-48 hr following the first medication. All available
ECG tapes for the 60 patients who entered the study were
subsequently analysed on a beat-to-beal basis with an Avion­
ics 350 C playback apparatus. The individual who read and
scored the tapes was blind to the treatment assignment for
each patient. The system operates at 60 limes real lime and if
abnormalities are detected, the tape can be rewound slightly
and the section containing abnormalities played back at
normal speed for further analysis. The nature and incidence
of arrhythmias detected for each tape were recorded in a
summary.
The ECG summaries were read blindly by an independent
observer who assigned a “composite arrhythmia score” to
each 12-hr period based upon the type and frequency of
cardiac arrhythmias reported. The composite score was the
sum of the various component scores which could be assigned
to each ECG summary and which are shown in Table 1. The
.scores shown in Table 1 are derived simply from their rank,
which was proposed according to the perceived importance of
certain arrhythmias in alcohol withdrawal.1
The composite arrhythmia score forms a convenient
summary of arrhythmia patterns that are often different
among and within patients. It was not intended to provide a
rigorous predictor variable of arrhythmia risk to patients.
Sinus tachycardia was defined as a pulse rate of 100 or
greater. Persistent sinus tachycardia refers to increased heart
rate for more than 75% of the total recording time. Ventricu­
lar premature beats were defined as having a QRS morphol­
ogy different from sinus beats, not preceded by a P wave,

•Biochemistry and hematology determinations were by
standard clinical laboratory assays and techniques. Details,
if required, are available on request.

401

Table 1. Components of Composite Arrhythmia Score

Type
Normal
Transient sinus tachycardia
ST segment and T-wave changes
Persistent sinus tachycardia
Nodal rhythm, junctional or atrial
premature beats
Atrial flutter or paroxysmal persistent
atrial tachycardia
Unifocal ventricular premature beats (VPBs)
(infrequent, <3/12 hr)
Multifocal VPBs (infrequent)
Unifocal VPBs (frequent, >3/12 hr)
Multifocal VPBs (frequent, >3/12 hp
Ventricular tachycardia or life-threatening
conduction disturbances

Score
O

2
3
4
5
6
8
9
10

being premature and being followed by a compensatory
pause. Atrial premature beats were defined as preceded by a
P wave, having a normal QRS configuration and being
premature. Nodal premature beats were the same as atrial
premature beats, except that they were not preceded by P
waves.
Analysis of data was by one-way, and two-way analyses of
data with unequal numbers per treatment, Newman Keul’s
tests for differences between means6 and Student’s t tests (2
tailed) where appropriate.

RESULTS

During the premedication period, the ECG
recordings documented the occurrence and
frequency of arrhythmias in the period of declin­
ing intoxication and early withdrawal. Table 2
summarizes the type and frequency of cardiac
arrhythmias for the entire sample during this
initial premedication phase. From the sample. 12
patients could be identified who had high
composite arrhythmia scores, mainly due to the
presence of ventricular premature contractions.
Biochemical results for those 12 with high scores
were compared with the remainder who had
lower scores to determine if any biochemical test
existed that could identify those with more seri­
ous arrhythmias and, therefore, predict without
the aid of sophisticated long-term ECG monitor­
ing facilities, those for whom specialized treat­
ment might be anticipated. The results of the
comparison (Table 3) can be summarized by
stating simply that while some values were not
within the normal range, there was no statistical
difference between the two groups for values on
any biochemical test.
Of the 60 patients who entered the medication

402

ZILM ET AL.

Table 2. Summary of Incidence of Arrhythmias in Chronic
Alcoholics During Late Intoxication Period
and Early Abstinence

All arrhythmias
VPBs
Atrial or nodal premature beats
T-wave changes
Sinus tachycardia
Normal ECG
Atrial dysrhythmias
Sinus tachycardia
Persistent sinus tachycardia
Atrial premature beats
Nodal premature beats
Ventricular dysrhythmias
Unifocal VPBs
3-10 beats/12 hr
11-40 beats/12 hr
41-51 beats/12 hr
>51 beats/12 hr
Multifocal VPBs
Ventricular tachycardia

Number

Frequency

9
9
2
50
4

17
17
4
93
7

24
26
5
6

44
48
9
11

9
5
1
2
2
0

9
2
2
4
4
0

Frequency refers to the percentage number of incidents relative to the total number of tapes successfully read for this
premedication period (n =» 54).

phase, 47 completed it. The age range of these
patients was 27-65 yr (mean ± standard devia­
tion: 44 ± 9.4 yr). There was no statistical
difference in patient ages among treatment
groups. Two patients refused to stay for the

48-hr medication period and 11 experienced
adverse reactions while receiving medications
and were removed from the study to receive
appropriate alternative therapy. The 11 treat­
ment failures were distributed among the 4
treatment groups; however, the cause for the
failure was frequently specific to a particular
group. There were 4 failures in the placebo
group, all due to complications of alcohol with­
drawal; 2 patients developed severe withdrawal
necessitating pharmacotherapy and 2 had
seizures. There were 4 failures in the propranolol
group, all due to the development of severe
hallucinosis; most experienced both auditory and
visual hallucinations following 3-4 doses of
propranolol and all were agitated and disturbed
at this point. The 2 failures in the chlordiazepox­
ide group were a result of complications of
cardiovascular origin; 1 patient had a complete
heart block and 1 patient was discontinued
because of extreme hypertension. The single fail­
ure in the combined therapy group was due to
the development of hallucinations.
The 47 patients who completed the investiga­
tions were examined for the response of the 3
most frequently encountered arrhythmias prior
to and following the various drug treatments (see
Table 4). For each of the 3 types of arrhythmias,
no significant difference (chi square test) could

Table 3. Mean (± SEM) Results of Biochemical Testing Performed Just Prior to Medication for the Group With High
Composite Arrhythmia Scores and Group With the Low Scores

High

Biochemistry
Na
Cl
CO,
CPK
SGOT
BUN
HBD
Bilirubin
Total
Direct
Alkaline phosphatase
Plasma epinephrine
Plasma norepinephrine
Alcohol elimination rate
Initial blood alcohol concentration

Low

Normal Range
*

Scores

140 ± 0.7
4.1 ± 0.07
98 ± 1.4
24 ± 0.8
76§ ± 17
36§ ± 14
9± 1
183 ± 21

141 ± 0.6
4.1 ± 0.06
99 ± 0.7
25 ± 0.4
102§ ± 16
36§ ± 5
10 ± 0.6
192 ± 8

137-147 meq/liter
3.6-5.5 meq/liter
98-109 meq/liter
24-34 meq/liter
5-45 lU/liter
8-30 lU/liter
8-20 mg/dl
120-210 lU/liter

0.68 ± 0.10
0.20 d 0.04
36§ i 3
358§ d 88
*
828
± 117
212 ± 17
2083§ i 306

0.75 ± 0.06
0.23 ± 0.02
37§ ± 2
155§ ± 55
547§ ± 132
217 ± 11
2520§ ± 162

<1.0 mg/dl
<0.5 mg/dl
56-244 lU/liter
94-98 pg/mlf
278-286 pg/mlf
100-220 mg/l/hrt
0 mg/hter

•Values except where noted are from the Laboratory Manual of the Clinical Institute Addiction Research Foundation, Clinical Laboratory
Biochemistry Department. Values are from laboratory tests for annual examinations of healthy ARF employees.
•j-From Sole, M.J. (personal communication).
jFrom Shumate, et al.7
§Outside normal range.

ANTI-ARRHYTHMIC DRUGS ALCOHOL WITHDRAWAL

403

Table 4. Response as a Function of Treatment Group for
the Three Most Commonly Encountered Arrhythmias and
Composite Arrhythmia Score

Arrhythmia
Ventricular
(VPBs)

Period

Premed
12-24
36-48
Atrial or
Premed
nodal
12-24
36-48
Sinus
Premed
tachycardia 12-24
36-48
Arrhythmia
Premed
score
12.24
36-48

Placebo Propranolol
3
1
1
2
2
2
10

5.27
2.64
2.36

O
0

2
2
10
2
2
3.09
1.18
0.91

CDZ

Comb.

3
3
1
2
5
2
12
10
11
3.61
5.08
2.54

2
1
2
0
2
12
6
3
4.46
1.50
2.08

Premed refers to the initial taping following admission (see
text). 12-24 and 36-48 hr are the two 12-hr recording periods
following medication. Entries in the table (except Arrhythmia
score) are the number of patients with the associated arrhyth-

be found in the incidence of arrhythmias for any
treatment at any time following medication
compared with placebo except that, at 36-48 hr,
the incidence of sinus tachycardia for the chlor­
diazepoxide group was significantly greater than
placebo [x2 (corrected) - 4.02, p < 0.05]. As
noted in Table 4, however, there was a tendency
for chlordiazepoxide to be associated with a
higher incidence of ventricular and atrial arrythmias 12-24 hr following medication. In addition,
there was very little tendency of chlor­
diazepoxide to reduce sinus tachycardia even
when compared to placebo.
Table 4 also shows the mean composite
arrhythmia scores for each treatment group for
the 3 ECG recording sessions. As shown, there is
a marked tendency for scores to decrease
throughout the 48-hr withdrawal period. While
the effect as a function of recording session was
significant (F2;86 - 11.86, p < 0.001), chlordi­
azepoxide was associated with the only increase
in score at 12-24 hr relative to the premedica­
tion session. Chlordiazepoxide group scores were
significantly greater than those for all other
treatment groups (p < 0.05, by Newman-Keuls5
with treatments containing propranolol and p <
0.055 for comparison with placebo). By the 3648-hr period, however, all therapies performed
equally well. The response shown in the bottom
of Table 4 is consistent with the other informa­
tion shown in the table indicating that the rather
convenient method of constructing a composite

Placebo
■.... « CDZ
□—□ Propranolol

a__ a

01 7 13 19 25 31 37 43
Hours Post Medication
Fig. 1 Systolic blood pressures for the four treatment
groups as a function of time following the first medication.

arrhythmia scoring system does not greatly
distort the evaluation of the relative efficacy of
the drug treatments.
Blood pressure and heart rates were elevated
for all groups at the time of the first medication;
however, values declined towards normal levels
over the medication period. There was a highly
significant difference between groups for systolic
blood pressure (F3:4I - 4.83, p < 0.01), diastolic
blood pressure (F3:4I = 9.48, p < 0.0001) and
heart rate (F3:41 = 4.85, p <0.01) and, as shown
for blood pressure in Fig. 1, the difference
among groups could be attributed to the differ­
ence between treatments containing propranolol
and the other two treatments.
Following the first biochemical testing it was
found that CPK, SGOT, HBD, and alkaline
phosphatase tended to be elevated above normal
while the BUN tended to be subnormal. For all
treatment groups, CPK. SGOT, HBD, and
alkaline phosphatase decreased towards normal
levels over the 48-hr medication period, and
there was no difference between treatment
groups.
DISCUSSION

The sample of chronic alcoholics examined in
this investigation was representative of intoxi­
cated chronic alcoholics presenting to our hospi­
tal. The incidence and severity of cardiac
arrhythmias, therefore, represent those observed
in the terminal phases of ethanol intoxication
and early withdrawal. While the incidence of
some types of arrhythmias is clearly much
higher than would be expected for the nonalco­

404

holic population without cardiovascular disease,
there was no potentially life-threatening cardio­
vascular incident that could be attributed to
acute intoxication and withdrawal. As a result of
this finding it would be difficult to argue for the
profitability of instituting, into hospital care, the
intensive monitoring of the electrocardiographic
events of presenting chronic alcoholics unless a
diagnosed heart condition so indicated. Cardiac
arrhythmias have been shown to be more preva­
lent in late intoxication and withdrawal and
becoming less so by 48 hr in withdrawal. It was
found that no simple biochemical test was corre­
lated with the frequency or incidence of more
severe arrhythmias during the late stage of alco­
hol intoxication and early stage of withdrawal.
Thus, it may be true that while the occurrence of
cardiac arrhythmias may be related to the
presence of ethanol and elevated epinephrine
and norepinephrine blood levels as suggested by
Abbasakoor et al.,' the differences in severity
and frequency of electrocardiographic abnor­
malities cannot be accounted for by differences
in ethanol, epinephrine, and norepinephrine
levels. A likely explanation may be that the
observed differences among alcoholics is a result
of variable cardiac sensitivity to ethanol and/or
plasma catecholamine concentrations.
Both treatments containing propranolol were
associated with the greatest reductions in
arrhythmias, particularly early in withdrawal. In
addition, both treatments resulted in the greatest
decrease of elevated heart rates and blood pres­
sures corroborating the observations of Sellers et
al.3 Of particular interest and importance in this
investigation, however, is the very high incidence
of hallucinations in the withdrawing alcoholic
treated with propranolol alone (27%). Central
nervous system effects of propranolol, in particu­
lar, hallucinations, normally occur only occa­
sionally (1%)8-’ and are usually associated with
long-term propranolol therapy10'12 involving high
daily doses of the compound. The considerable
sensitivity of some of the alcoholics in this inves­
tigation raises the question of interaction of the
severe withdrawal state and propranolol. French
et al.13 demonstrated that 8 adrenergic receptors
become subsensitive during prolonged ethanol
ingestion and supersensitivity of 8 receptors is
known to occur approximately 72 hr in with­
drawal,14 possibly due to either an increase in
number or affinity of
receptors.15 Early in

ZILM ET AL.

withdrawal, a state exists whereby adrenergic
receptors are subsensitive,16 a condition that may
give rise to the clinical manifestation of some of
the signs and symptoms apparent in early with­
drawal.17 It is known, for example, that early in
withdrawal adrenergic antagonists increase sei­
zure scores caused by early withdrawal.18 It may
be likely, therefore, that the presence of a ftadrenergic blocking agent early in alcohol with­
drawal may be sufficient to exacerbate some
early signs and symptoms of withdrawal, espe­
cially hallucinations.
Chlordiazepoxide was found to be less effec­
tive in reducing arrhythmias within 12-24 hr
compared with either placebo or treatments
containing propranolol. During that period
chlordiaxepoxide was associated with an in­
crease in atrial arrhythmias and a failure to
substantially reduce the incidence of ventricular
arrhythmias and sinus tachycardia. In addition,
the two treatment failures that were the result of
cardiovascular complications occurred in pa­
tients who were receiving chlordiazepoxide. By
36-48 hr, chlordiazepoxide performs as well as
other treatments except that the incidence of
sinus tachycardia remains frequent. There is a
paucity of reports in the literature regarding the
role of chlordiazepoxide in cardiac arrhythmias.
What reports there are do not involve alcoholics
and generally comment on antiarrhythmic prop­
erties of the drug.19 Only one report exists20 to
imply that the benzodiazepine, diazepam, may
be implicated in arrhythmias. While the associa­
tion of chlordiazepoxide with atrial and ventricu­
lar arrhythmias is very difficult to account for,
there is some evidence to support the idea that
chlordiazepoxide may produce increases in heart
rate, or more correctly, antagonize a reduction of
heart rate that would occur normally (cf.
placebo group). Rao et al.21 reported slight
increases in heart rate following diazepam. In
addition, it can be noted that benzodiazepines
may have cholinergic blocking properties,
though such properties have hitherto not been
considered of any clinical importance.22
The combination of propranolol and chlordi­
azepoxide appears to go a long way towards
overcoming some of the treatment limitations
found in using the drugs separately. There was
only one treatment failure in this group and that
was due to hallucinations, very likely a result of
the presence of propranolol. The combination

ANTI-ARRHYTHMIC DRUGS ALCOHOL WITHDRAWAL

405

treatment was associated with significant reduc­
tions in arrhythmias, systolic and diastolic blood
pressures, and heart rate. There were no cardio­
vascular incidents such as those associated with
chlordiazepoxide alone. The mechanism by
which combination therapy is able to perform
better than each drug alone is difficult to specu­
late since the interaction of both compounds is
likely to be complex. Sellers et al.3 demonstrated
that while a combination of propranolol and
chlordiazepoxide was more efficacious than
placebo in ameliorating the signs or symptoms of
withdrawal, propranolol alone performed better.
It was noted, however, that the withdrawal
displayed by alcoholics in that study was mild to
moderate and that no incidents of hallucinations
were produced. In the present study, however,
more severe cases of acute alcohol intoxication
and withdrawal were included. With the demon­

strated risk of using propranolol in withdrawing
alcoholics, some of whom may be in severe
withdrawal, and with the limited effectiveness of
chlordiazepoxide in rapidly controlling cardio­
vascular parameters, the combination of pro­
pranolol and chlordiazepoxide may provide, in
appropriate patients, a more effective therapy in
withdrawal.
ACKNOWLEDGMENT
The authors ackowledge the considerable work of the staff
of the 1CU in assuring the successful conduct of this investi­
gation, and, in particular Roseanne Buski who brought all of
the vast amount of data together for analysis. We thank
Angelo Tesoro for performing the catecholamine assays and
Dr. E. Whiteside and Dr. C. Robertson for their participa­
tion and D. Durand for his help in setting up and maintaining
the telemetry recording system. We thank Karen Kaplan for
her expertise in implementing the computer analyses of the
data.

REFERENCES
1.
Abbasakoor A. Beanlands DA, MacLeod SM: Electro­
cardiographic changes during ethanol withdrawal. Ann NY
Acad Med 273:364-370, 1976
2.
Vetter WR, Cohn LH, Reichgotl M: Hypokalemia and
electrocardiographic abnormalities during acute alcohol
withdrawal. Arch Jnt Med 120:536, 1967
3.
Sellers EM, Zilm DH, Degani N: Comparative effi­
cacy of propranolol and chlordiazepoxide in alcohol with­
drawal. J Stud Alcohol 38:2096-2108, 1977
4.
Sellers EM, Kalant H: Drug therapy; Alcohol intoxica­
tion and withdrawal. N Engl J Med 294:757-762,1976
5.
Sole MJ, Hussain MN: A simple specific radioenzymatic assay for simultaneous measurement of picogram
quantities of norepinephrine, epinephrines and dopamine in
plasma and tissue. Biochem Med 18:301-307,1977
6.
Winer BJ: Statistical Principles in Experimental
Design. New York, McGraw-Hill, 1971, pp 191-195

7.
Shumate RP, Crowther RF, Zarafshan MA: A study of
the metabolism rates of alcohol in the human body. J
Forensic Med 83-97. 1967
8.
Zacharias FJ, Cowen KJ, Prestt J, et al: Propranolol in
hypertension: A study long-term therapy, 1964-1970. Am
Heart J 83:755-761, 1972
9.
Greenblatt DJ, Koch-Weser J: Adverse reactions to
propranolol in hospitalized medical patients: A report from
the Boston collaborative drug surveillance program. Am
Heart J 86:478-484, 1973

10.
Voltolina EJ, Thompson SI, Tisue J: Acute organic
brain syndrome with propranolol. Clin Toxicol 4:357-361,
1971
11.
Shopsin B, Hirsch J, Gershon S: Visual hallucinations
and propranolol. Biol Psychiatry 10:105-107, 1975

12.
Khur BM: Prolonged delerium with propranolol. J
Clin Psychiatry 40:198-199, 1979
13.
French SW, Reid PE, Palmer DS, et al.: Adrenergic
subsensitivity of the rat brain during chronic ethanol inges­
tion. Res Commun Chem Path Pharmacol 9:575-578, 1974
14.
French SW, Palmer DS: Adrenergic supersensitivity
during ethanol withdrawal in rats. Res Commun Chem Path
Pharmacol 6:651-662,1973
15.
Banerjee SP, Sharma VK, Khanna JM: Alterations in
/3-adrenergic receptor binding during ethanol withdrawal.
Nature 276:407-409,1978
16.
French SW, Palmer DS, Narod ME, et al: Noradren­
ergic sensitivity of the ccrebal cortex after chronic ethanol
ingestin and withdrawal. J Pharmacol Exp Ther 194:319—
326, 1975
17.
Wolfe S, Victor M: The physiological basis of the
withdrawal syndrome, in Mello NK, Mendelson JH (eds):
Recent Advances in Studies of Alcoholism. An Interdiscipli­
nary International Symposium, 1970
18.
Goldstein DB: Alcohol withdrawal reactions in mice:
Effects of drugs that modify neurotransmission. J Pharmcaol
Exp Ther 186:1-9, 1973
19.
Greenblatt DJ, Shader Rl: Benzodiazepines in clini­
cal practice. New York, Raven, 1974, pp 145-146
20.
Barnett JS, Hey EB: Ventricular arrhythmias asso­
ciated with the use of diazepam for cardioversion. JAMA
214:1323-1324
21.
Rao S, Sherbaniuk, RW, Prasad K, el al.: Cardiopul­
monary effects of diazepam. Clin Pharmacol Ther 14:182—
189,1973
22.
Droppieman LF, McNair DM: Screening for anti­
cholinergic effects of atropine and chlordiazepoxide. Psychopharmacologia 12:164-169,1968

HVA. '

ALCOHOL AND DRUG ABUSE AT BMHC
Marc Galanter, M.D.

I.

Teaching:

The Division serves as the principal vehicle for teaching in the
area of alcoholism and drug abuse at the College of Medicine. These
disease areas are most pressing, since they affect 10% of the popula­
tion, and constitute 53% of the total social cost of psychiatric and
mental disorders.

Training begins at the undergraduate level with a module in the
first year of the Human Behavior sequence. During the psychiatry
clinical clerkship, a weekly seminar and patient interview sequence is
conducted at Bronx Municipal Hospital Center for student clerks. This
module emphasizes the acuisition in skills of clinical interviewing of
the substance abuser, diagnostic issues, and the selection of appropriate
treatment modalities relative to the variety of abuse syndromes. In
addition, electives on both clinical and research issues are available to
first and fourth year students.
On the post-graduate level, psychiatric residents are offered a
structured sequence of experiences. Lecture series are given in the
first, second, and third post-graduate years, emphasizing issues relevant
to the trainees' work at that level. Thus, in the PGY I year, this is done
in relation to the emergency room experience, emphasizing issues of
diagnosis, evaluation of occult addiction, and management of acute in­
toxication and withdrawal. Seminar series in subsequent years deal more
with issues of long-term treatment.
Central to the residents' training is the provision of a sequence
of individual supervision sessions for each of the psychiatric residents
in both the first and third PGY years. In the first year, six sessions
of individual supervision are centered around the emergency service; in
the third year, individual supervision sessions focus on patients presenting
in the long-term treatment services of the ambulatory clinic and on the
liaison service. In the fourth year elective experiences are offered,
generally involving the combination of clinical administration and super­
vised research activities.

The Division has also offered fellowships with an emphasis on
clinical administration and research. Publications emerqin.q_f.rom these
fellowships have focussed primarily on the evaluation and treatment of
addictive illness in the general hospital setting.

Training for social work students and interns is also provided,
with the placement of two to four interns from Hunter College and
Yeshiva University social schools for each academic year.

The Division has also been the site of a federally-funded Career
Teacher Program in Alcohol and Drug Abuse. This activity has served
to provide a national focus for organizing and disseminating teaching
information in the substance abuse area. This past year, this has
culminated in the American Medical Society on Alcoholism appointing the
Division’s Director as Chairman of the Committee, which will undertake
the establishing of criteria for training in the credentialling of
physicians in the alcoholism field.

II.

Clinical Activities:

The Division is centered at the Comprehensive Alcoholism Treatment Center
of the Bronx Municipal Hospital Center, where some 500 patients each year are
treated on a twenty-bed acute inpatient unit. After their need for detoxifica­
tion is first addressed, patients are integrated into the long-term treatment
program. The C.A.T.C. has 500 patients in active treatment and provides
15,000 patient visits each year, group and individual therapy being primary
modalities. The program also maintains an active vocational and recreational
therapy program, in addition to the medical care described above. A variety
of special rehabilitation modalities are maintained, including women's groups
to meet specialized needs during the course of treatment, and a self-help
program geared to developing communal assistance for social rehabilitation
and abstinence.

The Division provides liaison activities, dealing directly with the phy­
sicians responsible for general care of drug abusing and alcoholic patients
at Bronx Municipal Hospital Center. We have found that 24% of these patients
are diagnosable as alcoholic, and large numbers as drug abusers. Most have
come to the hospital for treatment of the consequences of this primary disease,
and it is essential to initiate rehabilitation during the phase of general
medical care. Supervision of psychiatric residents who serve as liaison
officers is a primary aspect of this.

The following statistics for the 1984-5 year are relevant.

1.

Inpatient department

Beds: 20.
Mean length of stay: 10.

Number of admissions: 620.

Sex ratio,male/female: 84%/16%.
Age range

18-20: 1%

21-34: 38%

35-49: 25%

50-64: 17%
65 and over: 19%

2.

Outpatient department
Total number of patients treated: 489.
Patients carried over from prior year: 402,

New patients for year: 262.

Sex ratio, male/female: 73%/27%.

Ethnic groups
Caucasian 20%.

Black 42%.
Hispanic 38%.
Treatment modality

Individual therapy: 10% of patients, 1083 visits.

Group therapy: 95% of patients, 10,289 visits.

Family counseling: 10% of patients, 756 visits.

Research Activities

A variety of research activities are ongoing, in areas directly related
to alcoholism and drug abuse and in allied fields.

Project areas are listed

below along with the parties principally responsible for their implementation.

1.

Self-help treatment for alcoholism (Marc Galanter, M. Dv).

This project

funded by the Commonwealth Fund is directed at investigating an innovative
approach to alcoholism rehabilitation.

The treatment relies on self-help

techniques and a sizeable input of patient direction into clinical activities,
allowing for diminished staffing and lower cost.

3.

Neuroendocrine studies on alcoholics and diabetic patients (Jacob Jacoby, M.D.,
A number of projects focus on neuroendocrine abnormalities in medical

Ph.D.).

illnesses such as diabetes, and in syndromes secondary to chronic alcohol abuse.
Coordination here is undertaken with the Departmental preclinical laboratories

and with the Department of Medicine.
3.

Ethnic characteristics of alcoholic and borderline patients (Ricardo Castaneda,

M.D.).

Evaluation of the incidence of different pathologic syndromes, including

the borderline personality disorder, are examined in relation to the different
ethnic groups treated in the program.

Consideration of relative treatment

success in the alcoholism program for different ethnic groups is also being
undertaken.
4.

Verbal production in psychoanalytic sessions (Georges Moroz, M. D.).

The

transcripts of psychoanalytic patients are analyzed for repeated themes and
structures.

This allows for an understanding of cognitive and affective issues

which emerge in the course of the therapeutic experience and also assist in

understanding the nature of the therapeutic process.
5.

An evaluation of the "Recovery" self-help program (Marc Galanter, M. D.).

With support from the Recovery self-help organization, an evaluation is underway
to ascertain the way in which this self-help program aids chronic psychiatric

patients.

The need for professional help and pharmacotherapy are examined in

relation to parameters of group involvement.
6.

Psychology of religious cults (Marc Galanter, M. D.).

The psychological

outcome of long-term membership and marriage in the Unification Church is
examined.

Correlates of improved emotional well-being and enhanced conformity

to group demands are examined in relation to scores on standardized psychological
instruments.
7.

Recent Developments in Alcoholism (Marc Galanter, M.D., Editor).

This book

series, with volumes released annually, overviews recent research findings.

The current volume addresses combined alcohol and drug problems, typologies of
alcoholics, the withdrawal syndrome, and renal and electrolyte problems.

M
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A'

ALCOHOLISM
Dr .0 .M .Francis
Director
St.Martha's Hospital
BANGALORE-560009
Drinking has been in existence from time immemorial

but it was not much of a problem.

Fermented juices were

taken occasionally; the alcohol content was low.

enness was infrequent and socially looked down

Drunk­
upon in

our country.

Today, alcoholism is a major problem in -the country.

There arc at least 3 million alcohlics in India.

It is

a problem for the individual (causing many diseases like

cirrhosis of liver and being a risk factor for other

major diseases such as heart disease), the-family (broken
or unhappy families) and the society (crimes, fights,
accidents and loss of productivity).

It was because of

the realization that alcoholism is a major problem that

prohibition became a major policy of our Independence
movement.
The problem of alcohol abuse is both urban and rural.

The Indian Council of Medical Research study covering a
number of urban centres induding Bangalore found that
20$ of urban consumers of alcohol are totally dependent
on it.

Problem drinking is very high in industries, varying

between 5$ and 15$.

With the large number of large .scale

industries in ihe public and private sectors in Bangalore,

the problem is one of high concern.

The economic costs

of alcoholism are very substantial.

In the developed

countries, the Employees Assistance Programme for
Alcoholism has been introduced successfully.

It augurs

well that the Managements and trade unions in Bangalore

are now seized of the problem.

contd.2

2

W>io is an alcoholic?

A person who has become physically, physiol ogically
or psychologically dependent on alcohol is an alcoholic.
There is a compelling urge or craving for alcohol.

The

body adapts itself to alcohol. There is tolerance.
There is dependence. Withdraw^ produces symptoms which
can be severe.

Alcoholism is an illness, manifested by

behavioural and clinical disorders.

It is generally

progressive but can be arrested.

Factors leading to alcohol abuse
Any type of person can become an alcoholic.

Some

people are more prone to become problem drinkers alcoholic personality ? childhood delinquency ? familial.?

.genetic ? Certain factors can precipitate alcohol abuse -

stress, loss of job, death of spouse, sudden improvement
in income.

A pre-existing psychiastric problem like

depression may lead to alcohol abuse.

Alcohol causes aggressive, silly behaviour.
is unsteadiness of gait and slurred speech.

There

Difficulty

is experienced in carrying out even simple tasks.

Vision is impaired as also hearing.

Alcohol can cause

acute drowsiness, deep sleep and coma.
Early identification of problem drinkers

It is necessary to identify ihe "hidden alcoholic".
Management is hopefully much easier at that stage than

after the person has become a chronic alcoholic.

are many indicators available.
absolute.
useful.

There

No single indicator is

But a composite group of indicators can be

Among them are psycholigical, clinical and

laboratory manifestations.

contd.3

1.

Psychol orical

(1 )

The first one is a hi story, including drinking
habits - frequency and quantity (how often ? how
much ?) Usually Hie person gives a reliable

>

a newer to ih c frequency
often unreliable.

(ii)

but the quantity is

Heavy drinking (about 60 g/

day of ethanol) indicates problem drinking.
Increased toleranee to alcohol. She person
meeds more and more alcohol to get the same

effect.
(iii)

Drinking quickly, gulpi ng the first drinks,

skipping meals while drinking.

(iv)

Concern or worry about drinking but unable to
stop or reduce drinking.

The family also gets

worried about the drinking.

(v)

Intellectual impairment.

To a keen observer

who knows the person well, this may be the first

indicator.
(vi)

Work impairment is an indicator.

(vii)

Accident prone at the workplace and elsewhere.

(viii)

Absence from work.

Change in friends, keeping company with heavy

(ix)

drinkers.
2.

Clinical

(i)

3.

Hand tremor may be one of the earliest symptoms.

(ii)

Alcoholic fetor by day.

(iii)

. Nausea and vomiting in the morning.

(iv)

Signs and symptoms of acute or chronic

(v)

Hepatomegaly and evidence of impairment of liver

(vi)

functions
Scars on ihe body (due to accidents and fights).

pancreatitis

Laboratory
There are many markers which can point to alcoholism.

(i)
(ii)

Gamma glutamyl transpeptidase (GGT)
Serum glutamic oxaloacetic transaminase (SGOT)

(iii)

"

alkaline phosphatase

(iv)

"

glutamic pyruic transaminase (SGPT)

- contd.4

(v)

- 4 Mean corpuscular volume (MCV)

(vi)

Serum high density lipoprotein cholesterol (HDL-C)

(vii)

Abnormal transferrin

(viii)

Random blood alcohol level

Chronic alcoholism
Chronic alcoholism is indicated by

1.1.
2.
3.
2.1.

2.
3.
3.1.

high/frequent consumption of alcohol

withdrawal symptoms; black-outs
physical violence
battered child ren/wife

psychosomatic complaints, depression or anxiety in spduse
divorce/separation
loss of sense of responsibility
absenteeism

4.

prone to accidents

4.1.

liver disease - cirrhosis of liver

2.

malnutrition

3.

pancreatitis

4.

gastritis; peptic ulcer

5.

congestive cardiac failure

6.

neurological disorders

5.1.

2.

W

impaired work performance

2.
3.

anxiety

depression

3• suicide attempt
6.1.

4

loss of friends

2.

change of friends (drinking)

3.

loss of interest in recreation

7.1.
debts
2.
poor living conditions
Treatment
Alcoholism can be treated.

and multi-step.
1.
2.

The management is multidimensional

The objectives of treatment are

management of the acute episode of intoxication and
detoxication,

breaking the dependence on alcohol,

contd.5

3.

treating the alcohol withdrawal reactions,

4.
5.

remedying the chronic health problems due to alcohol,
changing the life-style, attitude and personality

6.

characteristics, and
providing support to the individual and the family

to cope with the situation.

Motivation
One of the important requirements for the success of
treatment is motivation to seek help and willingness to
undergo treatment.

Many persons are desirous of breaking

the habit but the motivation may not be strong enough.
have to build up motivation.

We

Team effort

Treatment should involve the psychiatrist, clinical

psychologist, social worker and (in industries) the personnel
welfare officer, as also an understanding and supportive
family and in industries, management.
Counselling
Good counselling can be effective.

It must emphasise

responsibility, personal health, work and interpersonal

relationships.
Educational material;

Good educational material, appropriate to tie level of
the person must be made available.

Good literature must be

produced as also audiovisuals.
Relaxation methods can help to allay tension and anxiety and
contribute to better treatment.
serve
Family therapy:Drink!ng behaviour might/as an

adaptive

function for the individual or the family. Alcoholism could
be a symptom of larger family problems. Family members can

and should provide support to wean away the problem drinker.
contd.6

- 6 Counselling of the

There is also need to help the family.
family members is needed .

Group therapy
Interaction with others who are also dependent on

alcohol can help.
their problems.

Members of the group share and discuss

One successful group therapy was through Alcoholic

Anonymous, founded in 1935 "by Bill W, who was an alcoholic
It arose from a long

(real name: William Giffith Wilson).

talk for hours with another alcoholic: Dr.Robert Smith.

By talking together and sharing their weaknesses in giving

*

up drinking, the two men found that the urge to drink passed
off. Alcoholics Anonymous has g$o6\wn to at least a million

members throughout the world.

Combining family and groups can be helpful.
couples group therapy is to be tried.

Multiple

The difficulty is in

finding couples and groups comparable in age, education,

socio-economic status and severity of alcoholism.
Work therapy is worth trying as part of the total treatment.

Detoxification: During the acute stage, there is need for
hospitalization.

treated.

If there are complications, they must be

Management of ihe acute alcohol intoxication and

.

the concomitant withdrawal syndrome will depend on

(i)

patient's condition

nutritional
(ii)

status

sererity
(iii)

of alcohol dependence, and

overall
(iv)

medical evaluation.

Treatment of complications
The most important and direct morbidity caused by

alcohol is cirrhosis of the liver.

Mortality due to cirrhosis

in different countries is closely related to the amount of

alcohol consumed, irrespective of the type of beverage.

The

risk factor for development of cirrhosis is given by the

product of the average daily consumption of alcohol multiplied

.contd.7

- 7 by the period of consumption at that level.

Fatty

degeneration of liver and alcoholic hepatitis may be seen.

Pancreatitis (acute and chronic) can be caused by

alcohol.

Gastritis is another clinical manifestation.

Anaemia and clotting disorders can occur.

Neurological

diseases affecting central and peripheral nervous system
may be seen.

The heart may be affected by cardiomyopathy.

Vitamin deficiencies may occur.
Pharmacotherapy of chronic alcoholism.
Treatment with drugs does not have an important place
in the management of chronic alcoholism.

In the initial

stages, there may be a place for anxilytic drugs and

antidepressants.

So also drugs are useful to control with­

drawal symptoms.
One drug which is useful is disulfiram (antabuse).

It causes an aversion reaction when alcohol is taken.
Disulfiram blocks the oxidation of alcohol at the acetaldelyde
stage, raising its concentration in the blood by 5-10 times,

and causes reaction.

125 - 250 mg of the drug is administered

per day or once in 5 days (the effect often lasts for a week).
Taking as little as 7 ml of alcohol can bring about the

reaction. Care should be taken as the side-effects and /
contra-indications are many and the reaction can be severe.
Disulfiram action was discovered accidentally,

Two

Danish Scientists took the drug themselves to assess its
safety as a vermifuge. While on disulfiram, they went to

a cocktail party with disastrous results. They inferred
that the drug might be useful in preventing alcohol consumption.

Other drugs like calcium carbamide and metronidazole
and other aversion techniques are being tried.

Research
Research is needed if we are to solve our problems in

the future.

"If you do not think of the future, you cannot

have one".

There are many areas of research.

contd.8

8
1.

Survey of alcohol use - licit and illicit

- youth; different socio-economic

groups

- employed persons

- industries
- extent of alcoholism in the
population
2.

Control measures

- legal
- educational
- social

- limiting use of alcohol
- limiting problems arousing out of

use of alcohol.
- cause of spread of alcoholism.

3.

Preventing alcohol abuse

4-

Identifying the problem

- factors governing use of alcohol.
drinker - fevelopment of markers of alcohol
consumption

5.

Adverse effects of

alcohol use

- individual
-r family
- society
- at the work place

6.

Mechanism of tolerance to alcohol

7.

Drinking and accidents- on the roads

8.

Alcohol and diseases

- in the factory
- liver

- cardiac
- neurological
- psychiatric
9.

Treatment

10.

Follow-up

- psychological
- pharmacological
- individual
- family
- group
- low cost interventions
- Evaluation of recovery
- Prevention of relapses
- Employee assistance programmes

t

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April 10, 1987

Mrs. W Ramakrishnan
5/9 Milton Street, Cooke Town
3AKGAL0RE - 560 00$
Dear Mrs. Ramakrislman,

Sub: Request for setting up a Ward for Alcoholics
Ref: Your letter dated March 21, 1987
I am thankful to you for your letter and the concern you have
expressed in your letter. I would have lilted to give a completely positive
response to your suggestion as alcoholism is an important area where help is
needed and can 00 given.

We are having plans to start a unit to deal with alcoholism under
our proposed family care centre. . Unfortunately the two qualified and experienced.
persons (one with a counsellor with Doctorate from ITD-HIAIIS and another a
Psychiatrist who had been working at St. John’s Medical College Hospital) whom
we had identified as the possible persons to be in charge of the Unit are no
longer available in the city.
We shall continue ’to look for others and, if we find suitable persons,
we would like to start the Unit. We would not like 'bo take up responsibility
till we are able to discharge it well.
because

We have not been thinking of putting up a new ward for the purpose,
(1) Our emphasis was to be on prevention and education, and

(2) ' e do not have the resources to put up a new ward and
we are unable to re-assign one of the existing wards for
the purpose.

. . . With regards,

!

Residence :
5/9, Milton Street, Cooke Town
BANGALORE-560 005 @562161

,

office:

w.

Reserve Bank of India
Nrupathunga
Road
BANGALORE- 560 002

•

24.3.198?

The Director (Shri C.M. Francis)
St. Rar tha ’ s To spi tai,
nrupathunga Road,

BAY GALORE.
Dear Sir,
Request for setting up a Ward
for Alcoholics.

I wish to bring these few lines for your consideration
and necessary action.

In Reservo Bank of India a number of employees have got
themselves addicted to alcohol thus xn ruining themselves

physically and mentally and their jobs are also at stake.
In' the past few years many premature deaths due to excessive
consumption of alocohol have rendered their families homeless
with no hope of a bright day in their lives.
St. Johns Radical hospital and Nimhans have been
providing medical assistance as they have equipped •
themselves with a ward which has rendered phychiatric
treatment as well as by administration of anti-aouse
drugs to alcoholics and in many cases the victims have
improved/got rid of their addiction and have been cured
and have been leading happier and better lives thereafter.

Your hospital being ax in the heart of the City
would facilitate such people immensely if a ward is set
up for the purpose. We have about 200 severe cases which
would be referred to you from time to time and I am sure
if your hospital establishes a ward on these lines, the
service rendered to such addicts would help the victims
to live longer, cleaner and better lives making a better
society.
I hope you would consider the project and do the
needful in the matter.

Thanking you,

Yours fai thfully,

(MRS. W. RAMAKRISHWA.V)

r\K T.T. RANGANATHAN CLINICAL RESEARCH FOUNDATION
3 D'Monte colony, Madras 18

WHO ?........................ ME ?
(For family members, relatives and friends of Alcoholics)

In order to determine whether or not, the Alcoholism of
another person affects you, it is well to check over a List of Twenty
questions and answer TRUTHFULLY each one of them.
1.

Do you lose sleep because of a problem drinker ?

2.

Do mo st of your thoughts revolve around the problem drinker
or problems that arise because of him or her ?

3.

Do you exact promises about the drinkirg which are not kept?

4.

Do you-make threats or decisions and not follow them
through ?

5-

Has your attitude- changed toward this problem drinker
(alternating between love an! hate) ?

6.

j

Do you mark, hide, dilute and/or empty the bottles of
liquor or medication ?

7 •/

Do you think that everything would be O.K. if only the
problem drinker would stop or control the drinking ?

8.

Do you feel alone - fearful - anxious - angry and frustrated
most of the time ?

9-

Do you find your moods fluctuating wildly - as a direct
result of the problem drinker's moods and actions ?

10.

do you feel responsible and guilty about the drinkirg
problem ?

11.

Do you try to conceal, deny or protect the problem drinker ?

1^

Have you withdrawn from outside activities and friends
because of embarrassment and shame over the drinkix^
problem ?
1

*
13

Have you taken over many chores and outlets that you would
normally expect the problem drinker to assume - or that
were formerly his or hers ?

14.

Do you feel forced to try to exert tight control over the
family expenditure with less and less success - and are
financial problems increasing ?

15-

Do you feel the need to justify your actions and attitude
and, at the same time, feel somewhat smug and self-righteous
compared to the drinker ?

16.

If there are children in the house, do they often take sides
with either the problem drinker or the spouse ?

-2-

17-

Are the children showing sigjixs of emotional stress, such
as -withdrawing - having trouble with authority figuresrebelling - acting out sexually ?

10.

Have you noticed physical symptoms in yourself, such as
nausea/ a 'knot' in the stomach/ ulcers/ shakiness/sweating
palms /bitten finger nails ?

19-

Do you feel utterly defeated - that nothing you can say or
do will move the problem drinker ? Do you believe that
he or shee can't get better ?

20.

Where this applies, is your sexual relationship with a
problem drinker affected by feelings or revolution; do
you 'use' sex to manipulate -or refuse sex to punish
him or her 2

(YES'\
exist.

s indicates that Alcoholism
ANGES in the person\answering

T.T. RANGANATHAN CLINICAL RESEARCH FOUNDATION (Regd)
No.6 Cathedral Road, Madras 600 086

DRINKING

-

THE KEY QUESTIONS

IF you have any questions about your drinking or if someone else is
concerned about YOUR drinking, even though YOU are not, the Following
information will help you to identify the problem.

WHO.................... ME ???
IN order to determine whether or not a person has drifted from
'Social' drinking into 'Problem' drinking, it is well to check over a List
of Test Questions and answer TRUTHFULLY each one of them. No body else
can do it for you.
1.

Do you lose time from work due to Drinking 7

2.

Is drinking making your home life unhappy ?

3.

Do you drink because you are shy with other people ?

4.

IsjDrioking_affectingyour reputation?

5.

Have you ever felt Remorse after drinking 7

6.

Have you ever gotten into financial difficulties as a result of
drinking 7

7.

Do you turn to lower'companion
drinxing 7

and an inferior environment when

8.

Does your drinking make you careless about your family's welfare 7

9.

Has your ambition decreased since Drinking ?

10.

Do you crave a Drink at a definite time daily ?

11.

Do you want a Drink the next morning 7

12.

Does Drinking cause you to have difficulty in sleeping ?

13.

Has your efficiency decreased since Drinking ?

14.

Is Drinking jeopardising your job or business ?

15.

Do you Drink to escape worries or troubles ?

16.

Do you drink alone 7

17.

Have you ever had a complete loss of memory as a

18.

Has your Physician ever treated you for Drinking 7

19.

Do you Drink to build up your self-confidence ?

20.

Have you ever been to a hospital or institution on account of Drinking 7

result of Drinking 7

If you have answered 'YES' to any 'ONE' of the questions, there is a
definite warning that 'YOU WAY BE ALCOHOLIC'
If you have answered 'YES' to any 'TWO', the chances are that 'YOU ARE
ALCOHOLIC' .

If you have answered 'YES' to any 'THREE' or more, 'YOU ARE DEFINITELY
ALCOHOLIC'.

ONLY YOU CAN DECIDE:
Rsme.-.b'”', ALCOHOLISM is a 'Progressive' disease; it never gets better while
Drinking continues, only worse. And, if unchecked, leads to INSANITY or a
PAINFUL and PREMATURE DEATH.

FAMILY ENV C.RO1_',®NT_SCAIE

INSTRUCTIONS
There are 90 statements in this
about families. You are to dec:

let,’ They are statements
e wjl ich of these statements are
fall e• Make all your marks on
the separate answer sheets. If yot”’ th. nk
statements is TRUE
or mostly TRUE of your family, make
ab®11^
(True). ir you tl Lak the statement i s
mostiy FaLSE of
your family, make an X in the box labs lleu
1
'
T

F

Family members often keep their feelin'7s t'-'
themselves.

T

F

3.

We fight a lot in our family.-

T

F

4.

We don't do things on out’ own very often ii our family.

T

F

5.

We feel it is important to be the best at
whatever you do.

Family members really help and suppo
2.

6.

c-

another.

We often talk about political and social problei. 's •

T

F

\ T

F

\\F

We spend most weekends and evenings at home.
8.

Family members attend Religion and/worahip
places fairly often.

T

9.

Activities in our family are pretty carefully
planned.

T

10.

Family members are rarely ordered around. .

T

11.

We often seem to be killing time at home.

T

12.

We say anything we want to around home.

T

13.

Family members rarely become openly angry.

T

F.

14.

In our family, we are strongly encouraged to
be independent.

T

F

15.

Getting ahead in life is very important in
out' family.

16.

Normally go outside home to attend recreational/
entertainment programmes.

17.

Friends often come over for dinner to
visit

18.

We don't say prayers worship in our family.

T

F

‘

F

19.

We are generally very .heat a ;ia orderly

20.

There aie very few r Zles t 3 follow in our £amily.

21.

It is hard to get /thin- s uone, at d home
without upsetti’ /g some 3ody.

23 *

'
/F
throw things /

get so angry they

24.

We think th/^gs ov x £or outselves in our family.

25.

How much r ,<oney a person-makes is not very
importan t to v ' /
Learnin-4 abou' new and different things is
very . .mport-' nt £n our family.

26.
27.

Nobocyy in r Jr family is active in sports,
•i
e le igue, bowling, etc.

28.

We /often talk about the religious meaning of
r u3pea- ous / festive! days.

29.

It's c Eten hard to fine things when you need
then in our household;

30 .

T.ie re £s one family member who makes most of
* ,'ie decisions.

->1.

' .j)iere iS a feeling of togetherness in our
family,

32

we cell each other abovr orr personal problems.

■’ . 3.

Family members hardly ever lose their tempers.

34.

We come and go as we want to in our family.

35.

We believe in competition and "may the best
man win" .

36.

We are not that interested in cultural
activities.

37.

We often go to movies, sports events, camping eta

38.

We don't believe in heaven or hell.

39.

Being on time is very important in our family.

40.

There are set ways of doing things at home.

41.

We rarely volunteer when something has to be
done at home.

42.

If we feel like doing something on the spur of
the moment we often just pick up anu go.

43.

Family members often criticize bach other

T

F

44.

There is very little privacy in our family.

T

F

45.

We always sttive to do things just a little
better the next time.

T

F

intellectual discussions.

46.

We rcr?.ly ?.a-

T

F

47.

Everyone in our family has a bobby or two.

T

F

48.

Family members have strict ideas about what is
right and wrong.

T

F

49.

People change their minds often in our family.

T

F

50.

There is a strong emphasis on following rules
in our family.

T

F

F

51.

Family members really back each other up.

T

52.

Someone usually gets upset if you complain
in our family.

T

F

53.

Family members sometimes hit each other.

T

F

54.

Family members almost always rely on themselves
when a problem comes up.

T

F

55.

Family members rarely worry about job promotions,
school grades etc.
F

56.

Someone in our family plays a musical instrument.

T

57.

Family members are not very involve^ in recreational activities outside work o. school.

,,

58.

We believe there are some things you just have
to take on faith.

_

F

59.

Family members make sure their rooms are neat.

T

F

60.

Everyone has an equal say in family decisions.

T

F

61.

There is very little group spirit in our family.

T

F

62.

Money and paying bills is openly talked
about in our family.

T

F

63.

If there's disagreement in our family, vx
we try hard to smooth things over anu Keep
the peace.

T ■

F

64.

Family members strongly encourage each other to
stand up for their rights.

T

F

65.

In our family, we don't try that hard to succeed.

T

F

- 4

66.

Family members sometimes attend lessons for some hobby
or interest.
T

F

67.

Family members often go to learn/acquire something new.
T '

F

68.

in our family each person has different ideas about what
is right and wrong.
T
F

69.

Each person's duties are clearly defined in our family
T

70.

We can do whatever we want to in our family.

T

F

71.

We really get along well with each other.

T

F

F

we are usually careful about what we say to each other.
T
F
73. Family members often try to one-up or out-uo each other.
T
F
74. It's nard to be by yourself without hurting someone's
feelings in our household.
T
F

72.

75,"Work before play" is the rule in our family.

F

T

Listening Radio/Stereo/gramophone is more important than
reading in our family.
T
F
77. Family members go out a lot.
T
F
76.

78.

The religious books are very important books in our home.
E
F

79.

Money is not handed very carefully in our family.

T

F

80.

Rules are pretty inflexible in our household.

T

F

81.

There is plenty of time and attention for everyone in our
Family.
T
F

82.

There are a lot of spontaneous discussions in our family
T
F
in our family, we believe you won't ever get anywhere by
raising your voice'.
T
F

83.

84.

we are not really encouraged to speak up for ourselves in
our family.
T
F

85.

Family members are often compared with others as to how
well they are doing at work or school.
T

F

Family members really like music, art anu literature.
T
F
87. Our main form of entertainment is listening Rauio/Stereo/
Gramophone.
T
F

86.

88.

Family members believe that if you sin you will be punished.
T
F

89.

Generally we maintain our home neat and clean.

T

F

90.

You can't get away with much in your family.

t

f

-Pleas® check ( ) the -answer below that best -describes your
feelings, behaviour, -and experiences related to a parent’s
alcohol use. Take your time -and be as accurate as possible.
"aaier

Age-

Sex ?

Educations

Religions

daste:

Occupation:

Ifibditle J
Status:

Position, in the
family?
Eaat±.iy^a£k-g-rydnd>- •

Ham®

Relationship

Education

06'cUpati^n-

InSdnie'

a.

Drinking parenfs namo-S

Occupation.:
Income?

Duration of alcohol intakSs
Treatment undergoes:
Diagnoses:

"[. Have you ever thought or known that one of your parents
had a drinking problem?

Yes/no

2. Because of a parent's drinking have yOU Qv&r
(a) lost sleep
(b) worried
(c) cried
Id) all the above
(e) none
(f) others “Specify

3. Did you ever encourage one of your parents id stop
drinking?
If yes - How?
If no, why?
* Kindly elaborate on your answers whenever possible.
If .more- than.o.ne item applies, list it-1,2, 3

4.

Because your parent was drinking did .you ever fdel
(a)
alone
(b)
seared’
(nervous
d) angry
e)
none of the above
f)
all the above
g)
others -specify

i

5,

When your parent was drinking did you ever
(a)
argue
(b)
abuse
(c)
fight
(d)
others - specify

6.

Because of a parent s drinking did you ever
(a)
threaten to run away
(b)
hurt yourself
■ (c) threaten suicide
(d> others - specify

7.

Has a problem drinking parent e while drinking ever
(a)
yelled at you
(b)
hit you
(c)
threatened yoy
(d)
others - specify

8.

Have any of your a family members been threatened when
a parent was drinking?

If yes - Who?
How?
9. Have you heard your parents fight when one of them was
drunk?
fes/ No
xf yes - About what did they fight

10. Bid you ever protect another family member from a parent
who was drinking ?
Yes/ No
If yes
■Whom and How?

11.

Haye you ever taken a parent's bottle of liquor and
(a)
hide it
(b)
empty it
(c)
broken It
(d)
other's specify

12.

*
13

Jo your thoughts revolve around a problem drinking
parent ?
Always^ Sometimes/ Rarely
Ro you think about the .ifficulti.es caused by your
parent's drinking ?
Always/ Sometimes/ Rarely

14. Rid. you over wish that a drinking parent would
(a)
moderate his drinking
(b)
drink rarely
(c)
stop drinking
(d)
others — specify
Did you ever feel that you were the cause for your
parentis drinking?
Yes/ No
If yes - Why?

1b. Due to alcbhol use do you ever fear about your parents
Atting (a) divorced
(b)
separated
17.

Because of parent's drinking problem were outside
activities ever
(a)
withdrawn from
(b)
avoided)

18.

Have you ever stayed away from frinnas because a parent’s
drinking problem caused
a5 embarassment
shame
b)
rid- ’ cult
c)
d)
others - specify

19.

In the midd le of an arguement or fight between a problem
drinking parent and your other parent did you ever
(a)
intervent
(b)
take sides
(c)
feel caught
(d)
others - specify

20.

Do you think that your parent dramk alchol because of
(a) you
(b) sisters/brothers
(c other parent
(d) family members
(e)
others - specify.

21.

Do you feel that a problem drinking parent did not
really love you?
Yes/ No
If yes - Why?

22.

What. do you think about a parent's drinking?
(a) resent
(b) dislike
(c)
hate
(d)
indifferent
(e)
like
(f0> others - specify

23.

Because of a parent's alcohol use, have you ever
■vorried about a parent's
(a) physical health
(b) emotional well-being
(c)
social status

24.

Have you ever been blamed fora parent’s drinking?

25.

Do you think your father is an alcoholic ?

26.

Do you compare and want your home life to be-like
that of your friends without drinking parents?

27.

Because of drinking has your parent ever made prom'
which could not be kept ?
T
x-j
<->
Yes/ No
If yes, now often?

28.

About the alcohol related issues in your family
did you ever speak with a
(a) priest
(b) friend
(c)
other family members
(d)
brothers/sisters
(e)
non-drinkihg parent
(f)
others - specify

If no, Why?

29.

Did you ever fight with your brothers and sisters
about a parents drinking?

30.

'io avoid the drinking parent do you
(a) stay away from home
(b) come late
(c)
stay in your room
(d)
others - specify

31.

Do you avoid tne other parent’s reaction to drinking?
Yes/ No

If yes, why? How?

32.

Did you ever take over the chores and responsibilitie
at home that e were usually done by a parent before
he or she developed a drinking problem?

33.

Did you ever consult a professional about your
parent’s alcohol problem?

Never/ sometimes/ often/ rarely/ always

(a) psychiatrist
(b) psychologist
c social worker
medical doctor

THANK YOU for your cooperation.

SOCIAL ASPECTS OF ALCOHOLISM 1

By
Mrs. Lalita Bhatti, M.S.W., D.P.S.W.2

The recognition of the role of socio-psychological factors in causing and

maintaining alcoholism has brought e change in the disease notion of alcoholism
as a physical entity.

Recently there has been an acceptance of the term

'Problem drinking' instead of 'Alcoholism'.

It is argued that problem drinking

places emphasis upon behaviour rather than on the person and thus,avoids the
more permanent label alcoholism, which tends to be attached to thepperson.

This

shift is mainly due to the fact that the popular aporoaches likt>-constititional,

psychological and sociological^ cannot help to understand and treat alcoholism

«

independent of each other.
Two facets of Social Aspects -

The workers who strongly ahdere to the constititional aoproch do not give

any importance to the social factors in understanding the etiology of alcoholism.

Most of them, of course, agree that alcoholism could be an exogeneous stress on
the family and social milien of the alcoholic.

During the third decade of this

century, Knight (1937) and Chassell (1938) stressed the importance of understanding

the total family in order to understand individual drinking behaviour.

Meeks

(1976) comments, 'drinking may indicate stress or dysfunction in,a social system,

may be secondary to dysfunction in a social system', seems to be quite appropriate.
He is of the opinion that 'some alcohol problems may reside as much as in social

structures and processes as in people'.
Socio-cultural theory of Alcoholism -

Most of the epidemiological surveys have, demonstrated that the incidence

of drinking have a significant association with age, sex, social status, conicity,
degree of urbanization, quality of marital and family life.

sociological and demographic variables.

These are all

On the'other hand, in the field of

psychological research no unique personality type or a unique nosological
group have shown definite correlation with alcoholism (Roebuck & Kessler, 1972).

Therefore, as pointed out by Cahalan etal (1969), 'Whether a person drinks at

all is primarily a sociological and anthropological variable rather than a

psychological one', needs a very special consideration.

1.

Paper presented at Seminar on Alcoholism organised by the
Deot. of Psychiatry, St. John's Medical College & Hospital
and *
ndian Psychiatry Scciety, Karnataka State Branch, on
6-6-1983.

2.

Department of Community Medicine, St. John's Medical College,
Bangalore - 34
,2

1

-:2sTwentieth century is the age of positivism and anxiety.

The technological

advancement'.- in the European and Western Society have brought a severe degree of

monotomy in lift.

This has affect d the youth very much.

He finds himself

as an empty snell - his family as an empty, shell - his whole system as an
empty shell..

Ke is in constant search of relations and significant, others.

He is desperately searching meaning of life.
acculturation of society.

This is an indication ’of

Whenever a society is undergoing acculturation the

culturally ir.ducsd tensions will reach to an “untolerable level.
lead to existential doubts.

These tensions

Roebuck & Kessler (1972) believe that ’the choide of

alcohol to relieve these is determined by ,(1) attitudes towards alcohol and

(2) the availability of substitute means of satisfaction or tension release.
A similar review is expressed by Cahalan (1970) and he contended that higher
rates of problem drinking in lower socio economic group might be due to fewer

opportunit- s/for recreation and tension release.
Family .of ■, .coholics The behavioural scientists believe that Alcoholics’ family of orientation

is one of ■' -.o very important factors in understanding the problem of alcoholism.
In this reg’-fd several attempts have been made to explain the various socio­

psychologic-1 tenets of family life.

Most , of the work in this field is based

on the gen..al system theory wherein the family has been considered as an

open system.

The expression of 'abusive drinking' as per the family system,

is considered as a sign of stress within the family.

Often it is seen

drinking i.: .-. family sterte r.3 a -ubstitute in the absence of usual coping
> intact families j
mechanisms. , The other view with regard to the abusive'drinking/is that it
maintainstn ■. family as a system.

Alcoholism brings stability rather than

disruption -_n .the. interactional behaviour in certain families.

Jackson

(1954) reported the following sovon stages in the adjustment of the family
to alcoholism.

1.

Attempts to deny the problem

2.

At: empts to eleminate the problem

3.

Disorganization

4.

At' ompts to reorganize inspite of the problem

5.

E;- Tts to escape the problem

6.

Reorganization of the family

7.

R:cove;y and reorganization of the whole family.

Parent ch: !d relations in the families of alcoholics Wittman (:939) has given an account of the parent child relationship.

According io her the alcoholics have oversolicitors mother and a comparatively
3

4
”

3

stern, fobidding father; the later, the person who inspired and awe or fear
and who displayed inconsistant tendencies of severity and indulgence, thus

producing in the child a feeling of insecurity and helpless dependance.

Shiela Daniel also found that alcoholic parents were not consistant in their
actions towards children.
’
Parental drinking attitudes -

Jackson and Connor (1957) have shown that alcoholics came more frequently
from houses in which one parent drank - usually the father.

With regard to

the families of alcoholism in the Indian set up according to Bhatti (1982)
Channabasavanna & Bhatti (1981) and Channabasavanna and Bhatti (1983) most
of the alcoholics belong to anomic families. According to them majority of the

cases came from the families having unhealthy communications, poor concern and
lack of leadership.

The individual members have their own way of life, style

of interaction and personal convictions which are often idiosynoratic.

They

are highly individualistic and do not bother about other family members.

They hardly have any discussion and no common ways are adopted to achieve the
In extreme cases, except living under common roof the family

family goals.

members have nothing else in common.

These are called the anomic families.

Anomic families contribute heaily for alcoholism and drug addiction.
In such families, the individual self is given the highest importance by
the family as such.

Often in such families regular leader of the family moves

out quite frequently and in his/her absence some other family member accepts the

leadership.

Such acceptance of leadership is always to fill the gao.

Therefore

the leader is quite mild, non-commital, highly indecisive, rarely enters into
any kind of discussion and leaves everything to others; such a leader pretends

to be a broad minded leader.

Also in such families due to the permanent incapn.oi?

incapacitation or the death of the actual leader, some member of

is forced to accept the leadership.

confusing in these families.
overadherence.

the family

The patterns of communications are quite

There is always an atmosphere of imposition and

When the leader conveys the messages they are interpreted in

comparison with the way the messages were being conveyed by the original

leader.

At times the messages are quite contradictory.

The messages reflect

more often the covert meaning which remains a guess work for the receiver.
In such families the leader does not posses the role of a leader, still

plays the role of a leader.

The roles are allocated but not accepted.

patterns of reinforcement are usually temporary in nature.

use of negative patterns of reinforcement.

The

Such families make

In crisis, such families turn

to governmental and voluntary agencies’.
,4

5

Schematic analysis of family system of alcoholics

Type of family

-Anomic type

Type of self

-Individual self

Type of leadership

-Marginal and/or stop-gap
leadership

Type of communication

-Messages without any meaning and
misinterpretation of the messages

Type of role

-Cognitive discrepancy .and
discrepancy of role

Tyoe of reinforcement

-Through coercion and punishment

Type of social support systei -Tertiary social support system

Social class and alcoholism
In general survey results indicate that percentage of drinkers increase with

increasing social status.

On the other hand rates of heavy drinking, heavy

escape drinking and problem drinking among drinkers are highest in lower
status groups.
The middle and lower upoer class might be expected to have high rate of

alcoholism because of the tensions and insecurity brought about by high speed of
living, industrial and commercial activity and high pressures in life.

The

lower classes would be expected to have high rates because of their supposed
lack .of controls on drinking.

One problem that confronts researchers who study

the association between drinking patterns and social class is the matter of

social class criteria.

Sociologists utilise different methodologies and criteria

in the stratification area.

The four most frequently used indicators of

social class are income, education, occupation and some combination of these.

Cahalan etal (1969) found that heavy escape drinkers had relatively lowerincom^B
irc~.:.-

■ .problem

drinking related to age, sex and urbanization.

Men in all

age groups have a higher frequency of drinking problems than do women.
Cahalan holds that role differences between men and women explain men's heavier
drinking.

The frequency of drinking problems in the aggregate among men was

found to be -highest among those in their twenties, significantly lower among

those in their

thirties and forties, and tapering off among those in their

fifties. The degree of urbanization is related in certain ways to drinking

behaviour, depending upon two variables - age and socialstatus. In conslusion,
I would like to reitrate that the research in the field have established

that the etiology of alcohol abuse and aocoholism is multifactorial.

Equally, it is proved beyond doubt that the management outcome is always
better when the family of an alcoholic has participated actively in the
treatment programme-well that is the relevance of social factors in alcoholism.
5

5

References;-

1. Bhatti R.s.,

Family Therapy in Alcoholism paper presented at
the International Consultation on Christian
Response to the Alcohol and Drug. Problem - 1982
Whitefield (in press)-

2. Cahalan, Don

Problem Drinkers - San Franoisco,
3ossey - Bass - 1970.

3. Cahalan, Don, Cisin, Ira, H,
end Crossley, Helen Fl
American Drinking Practices’, New Burnswick, N.3.
Rustgers Centre yaf Alcohol Studies - 1969.
'

A. Channabasavanna S Fl
Bhatt i R S .

The families of drugs abusers and their
contribution in the psychosocial tratment of
addicts - oaper presented at the 3rd Conference
of Drug Addicition, 1981, New Delhi

5. Channabasavanna, S Fl
Bhatt i, R S

Family Thesapy of Alcohol addicts - paper
presented at the 35th Annual Conference of
Psychiatry, 1983, Bombay (in press)

6. Chassel.3.

Family Constellation in the etilogy of
essential alcoholism, Psychiatry 1938

7. Jackson O.K

The adjustment of the family to the crisis of
alcoholism. Quarterly Journal of studies on
Alcohol - 1959.

8. Dackson, Joan K and
Conner, Ralpha

Attitudes of parents of alcoholics, moderate
drinkers, and nondrinkers toward drinking.
Quarterly Journal of studies on Alcohol 1414s December 1953.

9. Knight R

The dynamics and treatment of chronie alcohol
addiction, Bulletin oft he Flenninger
clinic, 1. 1937.

10. Fteeks D E

Family Therapy in Alcoholism Interdisciplinary
Approaches to an Enduring Problem, Eds. RE,
Tarter, AA, Sngerman, Addison - Wesley
Publishing Company, Massachusetts 1976.-

11. Roebuck 3 . B
Kessler.R.G

The etiology of Alcoholism Constititional,
Psychological and Sociological Approaches
Charles C Thomas Publisher Springfield Ilthois
USA- 1972
Impact of Alcoholism on wives and children.
■Paper presented at the International
Consultation on Christian Response to the
Alcohol and Drug Problem 1982 - Whitefield
(in press)
Developmental Characteristics and Personalities
of Chronie Alcoholics. 3ournal of Abnormal
and Social Psychology 34; July 1939.

12. Shiela Daniel •

13. Whittman, .Flary Phyllis

CAIM
Chemical Addiction Information Monitoring

CAIM TREATMENT CENTRE

For the treatment of Alcoholism,

Addiction to cocaine, heroin,
barbiturates, amphetamines, or

abuse of prescribed medications.

318, 15th Cross. Sadashivanagar, Bangalore - 560 080. Phone : 363438

Chemical Dependency
The loss of control and craving for alcohol or other
mood-changing drugs is a treatable illness. It can happen

to anyone, regardless of circumstances of person, back­
ground, race, sex, income profession or education.
Alcohol, cocaine, minor tranquilizers, barbiturates,
heroin, amphetamines, LSD or mescaline, or abuse of doctor

prescribed medication, can cause disease or ill-health
and dysfunctioning of the body, mind, emotions, spirit

(values) and relationships with family, occupation, and

society at large.

TWO CLINICAL - MEDICAL FACTS
One

:

The pathologies (problems) that develop as the
result of the misuse of any of the mind-altering

or mood-changing drugs are roughly the same.
Two

:

The Recovery Process is essentially the same,
regardless of the type of mind-altering or mood­
changing chemical.

TREATMENT SERVICES

The C A I M Treatment Centre of Bangalore is an
intensive, extensive 12-step centered service for the

treatment of the disease of chemical dependency.

The

treatment methods include an in-patient program of variable
length stay as indicated; as well as out-patient services

individualized to the patient's needs.

Counselors function

with physicians to meet the medical and psychosocial needs
of participants.

Family Therapy
Recovery requires that family members learn
how to communicate with each other and deal

openly with their feelings.

Family Therapy is an

integral part of any treatment plan, as the
disease of Co-Dependency exists within the family

system.

O-O
£ ,
/
I

Restoring the Body, Mind, Emotion,
Spirit and Relationships

Goal

The program of the Chemical Dependency
Recovery Centre is specifically focused and
designed to restore the chemically dependent
person and their family members to optimal health
and functioning of Body, Mind, Emotion, Spirit
(Values), and Relationships.

Achieving that Goal
In order to accomplish that clear goal of lasting

recovery (getting clean and sober and practicing to stay

that way comfortably), active participants in our program
go through, or work on, seven areas or processes :

1.

BODY
Detoxification safely; optimize physical health.

2.

MIND
Learn about the disease of chemical dependency;
and choose new ideas and attitudes over dysfunctional

old ideas and belief'systems.
5.

EMOTIONS

Choose to learn how to identify, clarify and express
feelings.

4.

SURRENDER
Choose to learn how to use the superior haetvc or

surrender.

Learn to improve the quality oF. •

ance of having the disease of chemical depetxAtoc^.

5.

PERSONALITY AND CHARACTER

Choose t« identify what aspects of your own personality
or character have interfered - until now - with your

ability to choose your own recovery, holistic health

and happiness.
6.

RELATIONSHIPS

Choose to restore healthy relationships to yourself,

to others (family, job, society), and to the natural
HEALING POWERS of the Universe.

7.

PROGRAM OF RECOVERY

Choose to learn how to use the most effective long­
term Program of Recovery for your own benefit, to

ensure your own lasting recovery, once you leave

the hospital.

Ways we can be of service :

*

We provide Family Intervention and Help.

*

We maintain an Open Door Policy and Practice which

Call 363438/385622/385234/385915

says that we are available to help anyone suffering

from the disease of chemical dependency or co-depen­
dency, family and friends, regardless of circumstances.
*

We provide Education, Information, and Referral Ser­
vices 385622/363438/385913/385234

*

Speakers, seminars, and training provided

to the general community, professional

groups, and service organizations.

, full-scale implementation

*

of an Employee Assistance Program (including per­
sonnel. training) .at your: agency, ombusinessnby an
experienced EAP Consultant.

*

On-going Therapy meetings and numerous self-help

meetings on the unit,
RECOVERY begins with a single phone call ’

' /

363438/385622/385234/385913

ADMISSION to the CAIM Treatment Centre is facilitated
with an absolute minimum of bureaucratic fuss and delay.

"The good is too often the enemy of the best"

Bill W.

Criteria for the Diagnosis of Alcoholism
BY THE CRITERIA COMMITTEE, NATIONAL COUNCIL ON ALCOHOLISM

These criteria were compiled by a committee
of medical authorities from the National
Council on Alcoholism to establish guidelines
for the proper diagnosis and evaluation of this
disease. Criteria are weighted for diagnostic
significance and assembled according to
types: Physiological and Clinical (including
major alcohol-associated illnesses) and Beihavioral, Psychological, and Attitudinal. Be­
cause early diagnosis is helpful in treatment
and recovery, manifestations are separated
into their earlier and later phases. There are
brief discussions of recurrent and arrested
alcoholism, cross-dependence, and the types
ofpersons at high risk of alcoholism.
he problem of alcoholism has been re­

ceiving increasing interest in the past few
T
years. Extensive treatment programs are

being mounted, hospitals are beginning to
accept patients for treatment, labor­
management programs are attempting to
identify alcoholic employees to give them
special benefits and rehabilitation, third-party
payments are being afforded by insurance
carriers, and courts are making special dis­
position for rehabilitation. Therefore, it is
important to establish a set of criteria for the
' diagnosis of alcoholism. To this end, the Na­
tional Council on Alcoholism established a
committee1 to prepare a set of criteria, to
submit it for criticism and documentation by
other experts, and to publish it for the guid­
ance of those involved in the diagnosis of al­
coholism.
Editor's Note: These criteria are being published
simultaneously in the Journal and in Annals of Internal
Medicine by agreement of the Editors and the National
Council on Alcoholism. See page 214 for an editorial
by Morris Chafetz, M.D.
Reprints of this article may be obtained from the Pub­
lications Division, National Council on Alcoholism,
Inc., 2 Park Ave., New York, N. Y. 10016, for $1 each.
Remittance must accompany orders under $5. There is a
ten percent discount for orders of 50 or more copies.

' Members ofthecommiltee are listed in Appendix 1.

Amer. J. Psychiat. 129:2, August 1972

At the outset, it became apparent that we
had undertaken a formidable task, for, de­
spite a great deal of work in the past, much of
the literature is burdened by anecdotal ma­
terial and special assumptions made a priori,
and there is a dearth of scientifically con­
trolled observations on the natural course of
the disease. In addition, people of many dis­
ciplines have made observations from their
own points of view, which may be hard to rec­
oncile, and there are not a few who, by their
definition of disease, have eliminated alco­
holism from the category of disease. But any
tendency to withdraw from the field was
overcome by the urgency of the task, and the
committee herewith presents the results of its
deliberations.
Diagnostic criteria may serve several pur­
poses. They may be used to ascertain the
nature of a disease from a cluster of symp­
toms. This was not the main goal of the
committee. They may be used to promote
early detection and provide uniform nomen­
clature, both objects of this endeavor. Criteria
may be used to prevent overdiagnosis. This is
important because of the psychological, fi­
nancial, legal, and therapeutic implications in
a diagnosis of alcoholism for the life of the
patient. Criteria may be set for treatment
purposes. Beyond indicating that a need for
treatment exists, the committee believes that
any indication of different modalities of
treatment, except in broad terms, is beyond
the scope of its mandate. Criteria may be set
for prognosis; at present the prognosis for al­
coholism is obscure.
Mainly, the committee expects the criteria
to be used to identify individuals at multiple
levels of dependency. The committee has en­
deavored to use objectively reproducible data
that are obtainable from the patient, his im­
mediate family, or his associates. These data
have been weighted for their diagnostic sig­
nificance. We have included material that
would differentiate degrees of severity and
that would allow for progression of the
disease, where that exists, without prejudging
[41]

128

the possibility that cases of alcoholism may
exist in which progression is not a factor. All
but one consultant believed that, in alcohol­
ism, there generally is a progression of the
disease, although this might not necessarily
be reflected by continually increasing drink­
ing. Many consultants have exhorted us to
concentrate more on “early manifestations.”
The reader will note a separation into early,
middle, and late effects, which is a general
guide. Our first intent, however, is that the
person who is diagnosed as having alcohol­
ism surely fits into that category.
The Nature of Alcoholism

The committee was unanimous in defining
the disease of alcoholism as a pathological
dependency on ethanol, as it is classified un­
der Section 303.2 in the Diagnostic and Sta­
tistical Manual of Mental Disorders, second
edition, of the American Psychiatric Asso­
ciation.
Aside from the legal difference between the
distribution of alcohol and that of other
drugs, there are important scientific differ­
ences. A drug is defined in two senses: it is a
substance of use in medicine, and it is a habit­
forming substance. It generally produces its
effect in small quantities. Although alcohol
does produce an effect with small quantities,
it differs from other drugs in both senses in
that large quantities over a long period of
time are necessary for it to become habit­
forming.
Another difference between alcohol and
other drugs, particularly those of the opiate
class, is the relative risk of addiction. Many
people drink, but only ten percent develop
the psychological and physiological depen­
dency on alcohol that can be categorized as
alcoholism. With opiates, the risk of phar­
macological addiction is considerably higher.
Many alcoholics believe that they were alco­
holics from their first drink, that their re­
action to alcohol was different from that of
others. These retrospective data are suspect
until and unless a clear difference is estab­
lished between these individuals and others.
Family incidence of alcoholism and other
factors may indicate a portion of the popu­
lation at high risk.
Whether anyone who drinks a sufficient
quantity over a sufficient period of time will
develop alcoholism, whether a specific bio­
142]

DIAGNOSIS OF ALCOHOLISM

chemical or psychological difference leads to
alcoholism, or whether both conditions (with
other as yet undetermined factors possibly
turning the balance) are necessary to cause
alcoholism has not yet been established.
Thus, whether there is a continuous or dis­
continuous progression from drinking alco­
holic beverages to dependency on alcohol has
not yet been clearly decided. Animal data
suggest that anyone who drinks enough over a
sufficiently long period of time will develop
the signs of alcoholism. In the free state,
however, neither all humans nor all animals
choose the paths that lead to this condition.
In establishing criteria for diagnosis, the
committee wishes to avoid prejudging these
issues of etiology.
On the other hand, once alcoholism is es­
tablished, there is general consensus on its
manifestations, and the committee thus feels
it is appropriate to describe it as a disease, in
agreement with the American College of
Physicians, the American Medical Associa­
tion, the American Psychiatric Association,
and other bodies. Alcoholism fits the defini­
tion of disease given in Dorland's Illustrated
Medical Dictionary, 24th edition:
A definite morbid process having a characteris­
tic train of symptoms; it may affect the whole
body or any of its parts, and its etiology, patholo­
gy, and prognosis may be known or unknown.

Partial and intermittent forms of alcoholism
pose some problems that will be treated
separately. Isolated episodes of inebriation,
even if they generate unfortunate conse­
quences, are eliminated.
Divisions of Data

Data are assembled according to the type
of material they represent. Therefore, there
are separate data “tracks”—Track I:
Physiological and Clinical, and Track II:
Behavioral, Psychological, and Attitudinal.
The Track II data are grouped together be­
cause behavioral manifestations, the easiest
to determine and most objective to recognize,
imply attitudinal and psychological man­
ifestations.
There is no rigid uniformity in the progress
of the disease, but, since early diagnosis
seems to be helpful in treatment and recov­
ery, manifestations are separated into “ear­
ly,” “middle,” and “late.” In addition to
identifying early and late symptoms and

Amer. J. Psychiat. 129:2. A ugust 1972

129

national council on alcoholism
TABLE 1
Major Criteria for the Diagnosis of Alcoholism
---------- ‘
DIAGNOSTIC
CRITERION
LEVEL
TRACK I. PHYSIOLOGICAL AND CLINICAL
A. Physiological Dependency
1. Physiological dependence as mani­
fested by evidence of a withdrawal
syndrome1' when the intake of alcohol
is interrupted or decreased without
substitution of other sedation.
**
It
must be remembered that overuse of
other sedative drugs can produce a
similar withdrawal state, which should
be differentiated from withdrawal from
alcohol.
a) Gross tremor (differentiated from
other causes of tremor)
b) Hallucinosis (differentiated from
schizophrenic hallucinations or
P
other psychoses)
c) Withdrawal seizures (differentiated
from epilepsy and other seizure
disorders)
d) Delirium tremens. Usually starts
between the first and third day
after withdrawal and minimally in­
cludes tremors, disorientation, and
hallucinations.*
2. Evidence of tolerance to the effects
of alcohol. (There may be a decrease
in previously high levels of tolerance
late in the course.) Although the degree
of tolerance to alcohol in no way
matches the degree of tolerance to
other drugs, the behavioral effects of a
given amount of alcohol vary greatly
between alcoholic and nonalcoholic
subjects.
a) A blood alcohol level of more
than 150 mg. without gross
evidence of intoxication.
b) The consumption of one-fifth of a
gallon of whiskey or an equivalent
amount of wine or beer daily, for
more than one day, by a 180-lb.
individual ***
3. Alcoholic "blackout" periods. (DifB
ferential diagnosis from purely psy­
chological fugue states and psycho­
motor seizures.)
B. Clinical: Major Alcohol-Associated Illnesses.
Alcoholism can be assumed to exist if
major alcohol-associated illnesses develop
in a person who drinks regularly. In such
individuals, evidence of physiological and

CRITERION
psychological dependence should be
searched for.
Fatty degeneration in absence of other
known cause
Alcoholic hepatitis
Laennec's cirrhosis
£•
Pancreatitis in the absence of cholelithiasis
Chronic gastritis
’
’
Hematological disorders:
Anemia:
hypochromic,
normocytic,
macrocytic, hemolytic with stomatocytosis, low folic acid
Clotting disorders: prothrombin eleva­
tion, thrombocytopenia
Wernicke-Korsakoff syndrome
Alcoholic cerebellar degeneration
Cerebral degeneration in absence of
Alzheimer's disease or arteriosclerosis
Central pontine myelinolysis ) diagnosis

DIAGNOSTIC
LEVEL

Marchiafava-Bignami's
f possible
disease
J postmortem
Peripheral neuropathy (see also beriberi)
Toxic amblyopia
Alcohol myopathy
Alcoholic cardiomyopathy
Beriberi
Pellagra
TRACK II. BEHAVIORAL. PSYCHOLOGICAL.
AND ATTITUDINAL
All chronic conditions of psychological
dependence occur in dynamic equilibrium
with intrapsychic and interpersonal conse­
quences. In alcoholism, similarly, there are
varied effects on character and family. Like
other chronic relapsing diseases, alcoholism
produces vocational, social, and physical
impairments Therefore, the implications of
these disruptions must be evaluated and
related to the individual and his pattern of
alcoholism. The following behavior patterns
show psychological dependence on alcohol
in alcoholism
*.
1. Drinking despite strong medical con­
traindication known to patient
2. Drinking despite strong, identified,
social contraindication (job loss for
intoxication, marriage disruption be­
cause of drinking, arrest for intoxica­
tion, driving while intoxicated)
3. Patient's subjective complaint of loss
of control of alcohol consumption

2
1
2
2
3'

3
3
2
1
2
2
2
2
3
2
2
3
3

*See SeixasM).
*Some authorities term this "pharmacological addiction."
*For equivalent amounts in wine and beer, see Appendix 2.

signs, each datum was graded according to its
degree of implication for the presence of al­
coholism. Of course, some of the more defi­
nite signs occur later in the course of the ill­
ness. But this does not mean that people with
earlier signs may not also have alcoholism.
Various terminologies for these signs have
been suggested; we propose to weight them
and group them into three “diagnostic lev­

Amer.J. Psychiat. 129:2, August 1972

els,” with those weighted as “1” being the
most significant.

Diagnostic Level 1. Classical, definite, ob­
ligatory: A person who fits this criterion must
be diagnosed as being alcoholic.
Diagnostic Level 2. Probable, frequent,
indicative: A person who satisfies this
criterion is under strong suspicion of alcohol[43]

130

DIAGNOSIS OF ALCOHOLISM

ism; other corroborative evidence should be
obtained.
Diagnostic Level 3. Potential, possible,
incidental: These manifestations are common
in people with alcoholism, but do not by
themselves give a strong indication of its ex­
istence. They may arouse suspicion, but sig­
nificant other evidence is needed before the
diagnosis is made.

physical examination, and other observa­
tions, plus laboratory evidence, must fit into a
consistent whole to ensure a proper diagnosis.
Minor criteria in the physical and clinical
tracks alone are not sufficient, nor are minor
criteria in behavioral and psychological
tracks. There must be several in both Track I
and Track II areas.
Psychiatric Diagnosis

Diagnosis

It is sufficient for the diagnosis of alcohol­
ism that one or more of the major criteria are
satisfied, or that several of the minor criteria
in Tracks I and 11 are present; see tables 1
and 2. If one is making the diagnosis because
of major criteria in one of the tracks, he
should also make a strong search for evidence
in the other track. A purely mechanical se­
lection of items is not enough; the history,

After a suitable evaluation, a separate
psychiatric diagnosis should be made on
every patient, apart from the diagnosis of al­
coholism. Patients may suffer from schizo­
phrenia, latent or overt; from manicdepressive psychosis, obsessive-compulsive
neurosis, recurrent depression, anxiety neu­
rosis, or psychopathic personality; or have no
psychiatric constellation differing from
normal. The diagnosis should properly be

TABLE 2
Minor Criteria for the Diagnosis of Alcoholism
CRITERION

DIAGNOSTIC
LEVEL

TRACK I. PHYSIOLOGICAL AND CLINICAL
A Direct Effects (ascertained by examination)
1.
Early;
Odor of alcohol on breath at time of
medical appointment
2.
Middle
Alcoholic facies
Vascular engorgement of face
Toxic amblyopia
Increased incidence of infections
Cardiac arrhythmias
Peripheral neuropathy (see also Major
Criteria, Track I, B)
3.
Late (see Major Criteria, Track I, B)
B. Indirect Effects
1.
Early:
Tachycardia
Flushed face
Nocturnal diaphoresis
2.
Middle:
Ecchymoses on lower extremities, arms.
or chest
Cigarette or other burns on hands or
chest
Hyperreflexia, or if drinking heavily,
hyporeflexia (permanent hyporeflexia
may be a residuum of alcoholic
polyneuritis)
3,
Late:
Decreased tolerance
C.
Laboratory Tests
1.
Major—Direct
Blood alcohol level at any time of more
than 300 mg./100 ml.
Level of more than 100 mg./100 ml. in
routine examination
2.
Major—Indirect

[44]

DIAGNOSTIC
LEVEL

CRITERION
Serum osmolality (reflects blood alco­
hol levels): every 22.4 increase over
200 mOsm/liter reflects 50 mg./
100 ml. alcohol
Minor—Indirect
Results of alcohol ingestion:
Hypoglycemia
Hypochloremic alkalosis
Low magnesium level
Lactic acid elevation
Transient uric acid elevation
Potassium depletion
Indications of liver abnormality
SGPT elevation
SGOT elevation
BSP elevation
Bilirubin elevation
Urinary urobilinogen elevation
Serum A/G ration reversal
Blood and blood clotting:
Anemia: hypochromic, normocytic.
macrocytic, hemolytic with stomatocytosis, low folic acid
Clotting disorders:
prothrombin
elevation, thrombocytopenia
ECG abnormalities
Cardiac arrhythmias; tachycardia: T
waves dimpled, cloven, or spinous;
' atrial fibrillation; ventricular prema­
ture contractions; abnormal P waves
EEG abnormalities
Decreased or increased REM sleep.
depending on phase
Loss of delta sleep.
Other reported findings
Decreased immune response
Decreased response to Synacthen test
Chromosomal damage from alcoholism

'J b

Amer. J. Psychiat. 129:2, August 1972

SXCDFLnfcfj

131

national council on alcoholism

made in the dry state, since alcohol is anxiety­ becomes aware that physiological and psy­
producing and can also bring out psycholog­ chological dependency exist. At this point
ical mechanisms and traits that are not ap­ periods of “going on the wagon” may occur,
parent without alcohol. In particular, the with a resulting intermittent or recurrent
hallucinatory behavior induced by alcohol pattern of drinking. For most drinkers, there
withdrawal is not to be equated with schizo­ are lesser or greater periods of time when,
because of circumstances or the acute effects
phrenic hallucinatory behavior.
of alcohol, drinking is not possible. This pat­
Alcoholism with Intermittent or
tern is not inconsistent with other drug de­
pendency situations, in which interruptions of
Recurrent Drinking
use are commonplace and have been accepted
Intermittent or recurrent drinking may without the necessity of making a separate
represent a phase in the course of alcoholism. category for them.
This pattern should be noted separately. The
Even with a “steady” pattern of alcohol
same criteria control the diagnosis. In some use, there are marked fluctuations in the
individuals there are recurring episodes of blood alcohol level during each day. The pa­
inebriation that become more frequent over a tient with an alcohol problem, given free
period of years until a daily drinking pattern choice, does not, as one might assume, keep
emerges. In many individuals daily drinking drinking to maintain a steady blood level of
increases until the individual himself slowly alcohol. It has been observed that men who
TABLE 2 cont.'d
Minor Criteria for the Diagnosis of Alcoholism

CRITERION
TRACK II BEHAVIORAL. PSYCHOLOGICAL
AND ATTITUDINAL
A. Behavioral
1. Direct effects
Early:
Gulping drinks
Surreptitious drinking
Morning drinking (assess nature of
peer group behavior)
Middle:
Repeated conscious attempts at
abstinence
Late:
Blatant indiscriminate use of alcohol
Skid Row or equivalent social level
2. Indirect effects
Early:
Medical excuses from work for
variety of reasons
Shifting from one alcoholic beverage
to another
Preference for drinking companions.
bars, and taverns
Loss of interest in activities not
directly associated with drinking
Late:
Chooses employment that facilitates
drinking
Frequent automobile accidents
History of family members under­
going psychiatric treatment; school
and behavioral problems in children
Frequent change of residence for
poorly defined reasons
Anxiety-relieving mechanisms, such
as telephone calls inappropriate in
time, distance, person, or motive
(telephonitis)
Outbursts of rage and suicidal
gestures while drinking

Amer. J. Psychiat. 129:2, August 1972

IIAGNOSTIC

CRITERION
B

2

2
2
1
2

2
2
2
2
3
3

3
3

2
2

DIAGNOSTIC
LEVEL

Psychological and Attitudinal
1. Direct effects
Early:
When talking freely, makes frequent
reference to drinking alcohol, people
being "bombed.” "stoned.” etc., or
admits drinking more than peer
group
Middle:
Drinking to relieve anger, insomnia,
fatigue, depression, social discom­
fort
Late:
Psychological symptoms consistent
with permanent organic brain syn­
drome (see also Major Criteria,
Track I. B)
2. Indirect effects
Early:
Unexplained changes in family,
social, and business relationships;
complaints about wife, job, and
friends
Spouse makes complaints about
drinking behavior, reported by patient
or spouse
Major family disruptions
*
separation.
divorce, threats of divorce
Job loss (due to increasing inter­
personal difficulties), frequent job
changes, financial difficulties
Late:
Overt expression of more regressive
defense mechanisms: denial, projec­
tion. etc.
Resentment, jealousy,
paranoid
attitudes
Symptoms of depression: isolation.
crying, suicidal preoccupation
Feelings that he is "losing his mind"

2

2

2

3

2
3

3

3
3
3
2

[45]

132

were incarcerated for public intoxication for
three-month periods had a total yearly alco­
hol intake and a total time available for
drinking that may have been less than that of
the “normal” drinker. Yet these men report­
ed withdrawal signs and symptoms upon ces­
sation of each drinking spree. Thus, there is
in some cases an apparent persistence of the
“alcohol addiction memory.” The conditions
that cause withdrawal signs and symptoms
are not as yet fully understood.
Thus, where the practitioner has a patient
whose drinking pattern consists of intermit­
tent or recurrent drinking and in whom the
appropriate diagnostic criteria are satisfied,
the condition should be diagnosed as alcohol­
ism (with the qualification as to pattern
added if it seems important).

DIAGNOSIS OF ALCOHOLISM

Concurrent A.A. attendance with full par­
ticipation
Concurrent self-administered and profes­
sionally guided deterrent medication
Resumption or continuation of work with­
out absenteeism
No traffic violations
No substitution of other drugs
Although the committee did not choose at
this time to assign definitive time values for
any of these considerations, the recovery or
remission gains in its validity with a pro­
gressively longer time. For abstinence alone
to be the criterion, without other therapeutic
activity, there needs to be a longer time peri­
od than if abstinence is combined with other
criteria.
Alcohol Use

Alcoholism: Recovered, Arrested, or
in Remission

Since alcoholism is relapsing and chronic,
there are very few authorities who claim a
complete cure. But there are many patients
who, after a time of complete sobriety, have
reordered their lives in a rehabilitative way
and are completely able to perform complex
and responsible tasks. There are also a few
patients who have returned to "social” drink­
ing or who have infrequent “slips” but who
still function as rehabilitated persons.
Although these diagnostic criteria are not
devised as a guide to prognosis, it is the opin­
ion of the committee that a history of alco­
holism in the past, followed by a significant
recovery, should be taken into account as a
guide to treatment, employment, and resto­
ration of rights and privileges previously de­
nied because of active alcoholism. Some
members of the committee believed that total
abstinence would not, in the future, turn out
to be an absolute, final necessity for recovery
from alcoholism. However, it was agreed that
total abstinence, as a measure of recovery,
arrest, or remission, was usually more easily
measurable, definitive, and generally accept­
ed than a change from “dependency” to “so­
cial” drinking. Thus, the committee agreed
that the following considerations should de­
termine the diagnosis of recovered, arrested,
or remitted alcoholism:
Duration of abstinence
Concurrent active treatment program
[46]

Diagnostic terms that define conditions
that fall short of alcoholism are necessary
because of the effects of alcohol on behavior.
Although the term alcohol abuse has wide
currency, we prefer alcohol use, accompany­
ing this term with a description of effect. This
leaves the term “abuse” for such situations as
child abuse, animal abuse, or self-abuse,
where there is an animate object of the abuse,
and does not anthropomorphize alcohol,
which, after all, is a chemical (the “neutral
spirit”). The term misuse, we believe, also
carries an unnecessary moral implication.

Alcohol Use with Inebriation

Intoxication may be mild, moderate, or
severe, or may lead to coma. Although alco­
holics are frequently obviously intoxicated,
mere intoxication is not sufficient for the
diagnosis of alcoholism. Indeed the physician
should be cautious in making a diagnosis of
alcohol intoxication on the basis of a stag­
gering gait, slurred speech, other neurologi­
cal signs, and an odor of alcohol on the
breath. In such cases, one must be sure to
rule out diabetic acidosis, hypoglycemia,
uremia, impending or completed stroke, and
other causes of cerebral impairment. An
alcohol breath test, determination of blood
alcohol level, or serum osmolality measure­
ment may assist in making a diagnosis of al­
cohol intoxication. A history from the pa­
tient and from family members or friends is
usually helpful but must in itself be subject
to evaluation. Alcohol intoxication must be
Amer. J. Psychiat. 129:2, August 1972

NATIONAL COUNCIL ON ALCOHOLISM

133

thought of in any person in coma; in addi­
tion, barbiturate and other sedative intoxi­
cation must be investigated: cross-dependence
and cross-tolerance are common.

drugs, barbiturates, or “minor” tranquilizers
in an attempt to control the anxiety generated
by heavy alcohol use or in the mistaken im­
pression that pharmacological control of the
anxiety will stop the alcohol use. Such cross­
Alcohol Use with Pathological Intoxication
dependence is so common that it must be in­
In some individuals a small amount of al­ vestigated in any person suspected of alco­
cohol will evoke violent, aberrant behavior. holism.
Pathological intoxication is an idiosyncratic
In addition, the life-style of persons who
response to alcohol and is separate from al­ seek pharmacological "highs” is associated
coholism.
with heavy alcohol use pari passu with other
psychoactive chemical materials. Such per­
Alcohol Use: Reactive, Secondary.
sons are at risk of alcoholism, and patients
or Symptomatic
being investigated for the diagnosis of alco­
I Reactive, secondary, or symptomatic al­ holism should also be evaluated for use of
cohol use should be separated from other these materials.
Treatment programs for the use of other
forms of alcoholism. Alcohol as a psychoac­
tive drug may be used for varying periods drugs engender a significant proportion of
of time to mask or alleviate psychiatric “instant alcoholics” who, having relinquished
symptoms. This may often mimic a prodro­ the other drugs, turn to alcohol and experi­
mal stage of alcoholism and is difficult to ence an unusually rapid onset of dependency.
differentiate from it. If the other criteria of Thus, patients in this category should also be
alcoholism are not present, this diagnosis screened for alcoholism, and attempts should
must be given. A clear relationship between be made to prevent its onset.
the psychiatric symptom or event must be
present; the period of heavy alcohol use Persons at High Risk of Alcoholism
should clearly not antedate the precipitating
Epidemiological and sociological studies
situational event (for example, an object
loss). The patient may require treatment as show that the following factors indicate high
for alcoholism, in addition to treatment for risk for the development of alcoholism. There
the precipitating psychiatric event: one may is not complete agreement on the extent of
be able to confirm the diagnosis only in risk for each factor.
retrospect.
• A family history of alcoholism, includ­
ing parents, siblings, grandparents, uncles,
A Icohol and A nxiety
and aunts (2).
• A history of teetotalism in the family,
The effects of alcohol on the rising slope of
the absorption curve parallel the four stages particularly where strong moral overtones
of anesthesia, and thus excited or uninhibited were present and, most particularly, where
behavior may be shown with mild inebria­ the social environment of the patient has
tion. But it also has been documented that, changed to associations in which drinking is
with large doses over a prolonged period of encouraged or required (2).
• A history of alcoholism or teetotalism
time, alcohol produces anxiety. Whether this
bimodal effect occurs as a regular result of in the spouse (2) or the family of the spouse
any amount of alcohol is currently being in­ (3).
• Coming from a broken home or home
vestigated. The progressive rise of anxiety
with continued heavy drinking is responsible with much parental discord, particularly
for many of the effects listed as minor where the father was absent or rejecting but
not punitive (4).
criteria.
• Being the last child of a large family or
in the last half of the sibship in a large fam­
Cross-Dependence
ily (3).
• Although some cultural groups (for ex­
Cross-dependence (or “cross-addiction") ample, the Irish and Scandinavians) have
may begin iatrogenically or spontaneously been recorded as having a higher incidence of
with the use of any of the sedative class of alcoholism than others (Jews, Chinese, and
Amer. J. Psychiat. 129:2, August 1972

(47]

DIAGNOSIS OF ALCOHOLISM

134

Italians) the physician should be aware that
alcoholism can occur in people of any cul­
tural derivation (5-7).
• Having female relatives of more than
one generation who have had a high inci­
dence of recurrent depressions (8).
• Heavy smoking: heavy drinking is often
associated with heavy smoking, but the re­
verse need not be true (9).

8. Winokur G: Genetic findings and methodological
considerations in manic-depressive disease. Brit J
Psychiat 117:267-274, 1970
9. Pollack S: Drinking Driver and Traffic Safety Proj­
ect, vol I. Los Angeles, Public Systems Research In­
stitute, University of Southern California, 1969

Recording the Diagnosis

Chairman: Samuel C. Kaim, M.D., Director, Staff
for Alcoholism and Related Disorders, De­
partment of Medicine and Surgery, Veterans
Administration

If alcoholism as defined above is present,
the diagnoses should be stated in this order:
Alcoholism: intermittent use, recurrent
use, steady use (early, moderately advanced,
far advanced)
Psychiatric diagnosis
Physical diagnosis
If major criteria or a sufficient number of
minor criteria are not met, the diagnosis
should be:
Suspected alcoholism; psychiatric diagno­
sis; physical diagnosis
Other diagnoses that can be made:
Alcohol use: reactive, secondary, or symp­
tomatic; psychiatric diagnosis; physical diag­
nosis
Alcohol use with inebriation
A description of the physical diseases as­
sociated with alcoholism and their diagnosis
will be the subject of a separate communica­
tion.

APPENDIX 1

Criteria Committee, National Council
on Alcoholism

Henry Brill, M.D., Director, Pilgrim State Hospi­
tal
Luther A. Cloud, M.D., Associate Medical Direc­
tor, Equitable Life Assurance Society of the
United States
David H. Knott, M.D., Ph.D., Director, Alcohol
and Drug Dependence Clinic, Tennessee Psy­
chiatric Hospital and Institute
Charles S. Lieber, M.D., Professor of Medicine,
Mount Sinai School of Medicine, and Chief,
Section of Liver Disease and Nutrition, Bronx
Veterans Administration Hospital
William M. Mclsaac, M.D., Ph.D., D.Sc., Di­
rector, Texas Research Institute of Mental
Sciences
Jack H. Mendelson, M.D., Professor of Psychia­
try, Harvard Medical School, and Director,
Psychiatry Service, Boston City Hospital
James Rankin, M.B., B.S., Director, Institute for
the Study of Addiction, Addiction Research
Foundation, and Associate Professor of Medi­
cine, University of Toronto
REFERENCES
Anthony Reading, M.D., Assistant Director, Psy­
chiatric
Liaison Service, Johns Hopkins Uni­
1. Seixas FA (ed): Treatment of the Alcohol With­
versity School of Medicine
drawal Syndrome. New York, National Council on
Richard S. Shore, M.D., Director, Bureau of Al­
Alcoholism, 1971
coholism, San Francisco Department of Public
2. Guze SB, Tuason VB, Gatfield P, et al: Psychiatric
Health
illness and crime with particular reference to alco­
Harold N. Willard, M.D., Associate Professor of
holism: a study of 223 criminals. J Nerv Ment Dis
134:512-521, 1962
Internal Medicine, Yale University
3.
Barry H, Blane HT: Birth order as a method of Steven J. Wolin, M.D., Clinical Associate, Labo­
studying environmental influences in alcoholism.
ratory of Alcohol Research, National Institute
Ann NY Acad Sci 197:172-178, 1972
on Alcohol Abuse and Alcoholism (Saint Eliza­
4.
McCord W, McCord J: Origins of Alcoholism.
beths Hospital)
Stanford, Calif, Stanford University Press, I960
5.
Perceval R: Alcoholism in Ireland. J Alcoholism Ex Officio: Irvin E. Hendryson, M.D., Professor of
Surgery and Assistant Dean, University of New
4:251-257, 1969
6.
Whitney ED (ed): World Dialogue on Alcohol and
Mexico School of Medicine
7.

Drug Dependence. Boston, Beacon Press, 1970
Snyder CR: Alcohol and the Jews. Glencoe, Ill, Staff: Frank A. Seixas, M.D., Medical Director,
National Council on Alcoholism
Free Press, 1958

[48]

Amer. J. Psychiat. 129:2, August 1972

NATIONAL COUNCIL ON ALCOHOLISM

135
APPENDIX 2

Whiskey Equivalents of Consumption of Wine and Beer
Equivalents are based on:
0.8 quart = one-fifth gallon
32 ounces = 1 quart
Whiskey contains 43 percent ethyl alcohol
Fortified wine contains 20 percent ethyl alcohol
Table wine contains 12 percent ethyl alcohol
Beer contains 4 percent ethyl alcohol

|

Person's
weight
(pounds)

Whiskey
(quarts)

Fortified
wine
(quarts)

Table
wine
(quarts)

(quarts)

(12-oz.
bottles)

220
200
180
160
140
120

1.0
0.9
0.8
0.7
0.6
0.5

2.0
1.9
1.7
1.5
1.3
1.0

3.6
3.2
2.9
2.5
2.2
1.8

11.0
9.7
8.6
7.5
6.5
5.4

29
26
23
20
17
14

Amer. J. Psychiat. 129:2, August 1972

Beer

[49]

ArW .

i i '/7z *v z

- ^L_Jl, CT-

Ufc

k

■ ILA, y. (^_J-Z 19^^^^10-517
’ T . (j^A-t—Jh

|CQP'

t

j M.
>£&<&

P^c/^kJ

^■nrcry

4v^>.J V< p -A.& V £- i ■ r

JU
•; 5V C^)Ui.y VM -

6^U>e^

MH
7 ro-TSCT

Est^A-clBhincf a central consulting service
In organisations where medical facilities exist, it

would be desirable to establish a consulting service as an additional
component, The central,

onsuiting service can preferably be situated

at the industrial medical centre. A consultant psychiatrist from a

general hospital may be coopted into the programme. The physician
in-charge of the industrial medical centra, the welfare officer or

the social worker and a clinical psychologist, along with represent­
atives of the labour unions would form the rest of the team.
Ihe central consulting service would ensure the coopera­

tion of the management and labour unions, educate th > work force

along with their families, and supervisory personnel. It would also
raSdteiH maintain the administrative liaison between other conrminity

facilities (e.g., the Halfway Hbme) and th? general hospital, and
periodically evaluate the cost effectiveness of th? programme.

identification of tly problem drinker
Many of the earlier industrial programmes relied on the

signs and symptoms of alcoholism for th- identification of the
problem drinker. lbwever, training the work supervisors to detect

such signs and syn^jtoms have been found to be impractical. .'foroover,
the supervisors are usually reluctant to label an employee as an

alcoholic, and often do not report their findings. Tn most instances,
problem drinking will manifest itself in impaired work performance
and absenteeism. Apart from this, simple biochemical evaluations
and self rating questionnaires are available for early detection of

problem drdnkingjcfctk xriLth liigh reliability and validity.

referral and cocumentation
Cnee the problem drinker is identified, a series of corrective
interviews are conducted motivating Iiirn to seek help on their own.

When the offer is accepted, he may be evaluated by the clinical
psychologist, social worker and the physician at the central consulting

service, to assess his motivation, factors maintaing the problem

drinking and the extent js of physical morbidity, ffe and his family
are informed about the method of treatment and their cooperation

sought. The welfare officer is approached for necessary assistance

regarding leave from the job for detoxification.

BMwyification »nd management duri.no the early phase
Two to three weeks of admission on an average is required

during tills phase. Detoxification, initiation oi counselling for the
individual and his family, identification end treatment of major

psychiatric disorders and medical complications ar? conducted at
tills stage. At the end of the hospital stay, the individual is

either returned to the factory for resuming active duty immediately,
or send to the halfway home if prolonged cure is required.

Fpll^w up and maintenance of abstinence

It is known that frequent follow ups results in a higher

probability of success in Mtarfat abstinence of alcohol. The most
efficient follow up may lie conducted at the work place. Those
who drop out from the follow up may quickly be identified and
their families contacted by the social worker. The problem drinkers

are to bra regularly followed up for at least one year, since the

maximum rel-spses are seen to occur in this time.

rhe ?iaifww:y home

A portion of the problem drinkers would have deteriorated
sufficiently to warrant additional, more technical and graded care

for rehabilitation. They are to be referred to the halfway home
after discharge from the hospital, where they may have to stay

for three to six weeks months.

personnel.
The medical officer of the industry’s medical centra would

primarily assist in th? integration of the programme in the existing

medical service of the industry, and provide supportive medical

management from time to time. lie would also initiate training of
otiler personnel and health education programme which are integral

parts of ths project. In course of time the industry’s medical team
would assimilate sufficient technology to maintain the project on

their own.

The clinical psychologist provides the important therapeutic
management and gives the continuity to the programme at it’s various

stages, and at different locations of treatment. Once the project is
started the emphasis of the educational and motivational programmes

shift to the families of the problem drinkers. In addition,development

of documentation systems, counselling the individuals and their
families, carrying out follow up of cases and periodic evaluation

of the programme are to be dealt with by the psychologist.
The social worker primarily brings about attitudinal

changes at the beginning of th3 programme, through meetings of labour

unions and the management, and meetings of family groups. This is

essentially a programme of health education, ^part from this the
social worker c n facilitate the liaison with section supervisors

in the identification of cases and maintain liaison with the halfway

home. rv.ring follow up he conducts homo visits in order to detect

sricl motivate dropouts, and keep track of the public opinion of

the program® among the different categories of workers in the

industry and their families.
Additional staff ar® recruited as and when required

according to the necessity of th? moment and availability of
facilities.

CONCLUSIOjL.
. Employee Assistance Programme for Alcoholism have been

able to successfully control alcohol related loss of productivity
among the industrial workers. This method also has an inherent

advantage in that ths population catered for is immobile and thus
available for easy identification and follow up. Finally the

cost effectiveness is considerable in terras of productivity to
th? industry, relief of problems to the family, reduced expenses

related to consumption of alcohol, and management of alcohol
related medical problems. Hewever, in most programmes the referral

rates tend to be high in the early phase of the operation, when
it is easy to identify the most troublesome and chronic problem

drinkers, but decline once these employees have been treated.

Somasundaram 0, The alcoholic industrial worker, Indian Journal
of Psychiatry, 1976, 18, 165-175.

Tbit S, Skinner H A, Israel Y, Early identification of alcohol
abuse i 2 : Clinical and laboratory indicators, Canadian

cedical Association Journal, 1981, 124, 1279—1295.
Walker K, Shain M, Employee assistance programming : In search

of effective interventions for the problem-drinking employee,
British Journal of Addiction, 1983, 78, 291-303.

Problem drinking in industries varies between 5 to 15 percent,
according to various surveys conducted in India

In recent years,

professional attention has increasingly been directed to the workspot
as a potential locus for identifying the problem drinker, itost

problem drinkers have jobs. They can be identified relatively early
by the evidence of impaired x-Jork performance and other simple tools

for early detection

Occupationally oriented progranvne, offering

help rather than dismissal, yield the highest reported rates of
successful recovery from problems related to alcohol.
In developed countries, the Employee Assistance Programme

for Alcoholism (KAPA) has been introduced, based on recognition of

■tbe adverse effects of problem drinking on productivity, social

consiousness on the part of the management and specific awareness
of th ? drinking problem within the industry. It has been very sucess-

ful in organisations of large or medium size, employing more than
1000 x;oxkers 3. The vrorfc place is viewed not merely as an agency
of referral but also as an active force in the rehabilitation

process.

PJk

- t> 2_

INDUSTRIAL AuCOrOl.ISM AND LOSS OF PRODUCTIVITY 8

A STRATEGY FOR INTERVENTION

DR. M.J THOMAS
*

DR. M.C MAYAMMA **

* CONSULTANT PSYCHIATRIST,
**

ST. JOHN’S MEDICAL COLLEGE,

CONSULTANT CLINICAL PSYCHOLOGIST,

BANGALORE

Patrick Bucknell

152
(e) two and one half grammes of a preparation,
mixture, extract or other material containing not
less than one-fifth of one per cent of morphine or
a salt of morphine or any proportion of
diacetylmorphine or an ester of morphine or a
salt of an ester of morphine;
(/) 5 grammes of barbitone or a salt of barbitone or
(g) 5 grammes of cannabis (Amended, 46 of 1978,

alone or contained in a preparation, mixture,
extract or other material; (Added, 46 of 1978,
(A) 10 tablets or capsules containing any proportion
of any dangerous drug,

shall, until the contrary is proved, be presumed to have
had such dangerous drug in his possession for the

Detention
order.

progress made by such person and the
likelihood of his remaining free from
addiction to any dangerous drug on his
release, and shall then be released.
*
(3)
Before a detention order is made in
respect of any person, the court shall
consider a report of the Commissioner on
the suitability of such person for cure and
rehabilitation and on the availability of
places at addiction treatment centres, and if
the court has not received such a report it
shall, after such person has been found
guilty, remand him in the custody of the
Commissioner for such period, not exceed­
ing three weeks, as the court thinks
necessary to enable such a report to be

(4)
When a court makes a detention
order, it may, where the circumstances of
the offence so warrant, order that no
conviction shall be recorded.
(5)
The Commissioner shall, in his
report under subsection (3), inform the
court whether or not a detention order has
previously been made in respect of the
person to whom the report relates.
5. (1) The Commissioner may order
that a person released from an addiction
treatment centre shall, for a period of
twelve months from the date of his release,
be subject to supervision by such organisa­
tion or person as he may specify and shall
while under such supervision comply with

4. (1) Where a person is found guilty
of a relevant offence and the court is
satisfied that in the circumstances of the
case and having regard to his character and Supervision
previous conduct it is in his interest and the order.
public interest that he should undergo a
period of cure and rehabilitation in an
addiction treatment centre, the court may,
in lieu of imposing any other sentence,
order that such person be detained in an
addiction treatment centre.
(2) A person in respect of whom a
•pedfy.
drtrnrinn order is
shall be detained in
(2)The Commissioner may at any time
an addiction treatment centre for such a
period, nor less than six months and not
more then eighteen months from the date of
such order, as the Commissioner may •The periods in subsection (2) have been reduced to 4 months
determine, having regard to the health and

Bntuh JmhuI ofUdutxm 10 (19S3) 153-162
© 1913 Society for ibc Study of Addiction to Alcohol sod

Alcoholism and the Nature of Outcome
Anita Duckitt, David Brown, Griffith Edwards, Edna Oppenheimer, Margaret Sheehan and
Colin Taylor
Addiction Research Unit, Institute ofPsychiatry, 101 Denmark Hill, London SES

A great deal ofprevious work has been directed to conceptual and methodological issues relating to descriptions of‘outcome’ in
studies of career, natural history, and treatment ofalcoholism. There is still no consensus even on basic measures of drinking
behaviour which would allow comparison between reports, and the ‘dynamic
*
of relationships between variables remains
obscure. This paper uses data from a 10-12 year follow-up of 68 interviewed male alcoholics to explore simple and partial
correlations between outcome variables, relating both to the total follow-up period and the 12 months prior to interview. In
several instances significant correlations arefound between outcomes in different domaines, but the levels ofcorrelation which
are reached suggest that outcome cannot be conceived as a simple unitary dimension, while the pattern ofpartial correlations
begins to reveal the underlying dynamic of relationships. Outcome may need to be conceived not just in terms of end points or
scores, but in terms of the processes in which the individual becomes caught up.

Introduction
Research on alcoholism treatment and on the career and
natural history of the alcoholic share a fundamental
concern with definition and measurement of ‘outcome
*.
But it is now generally recognised that what may once
have appeared a relatively straightforward and unitary
concept in reality poses many complex questions.
These questions have over recent years been widely
debated [1,2] but have not as yet achieved sufficient
clarification for different research workers commonly to

social adjustment and mental and physical health should
in addition be recorded. [2,5,6]. Measurements of degree
of dependence on alcohol have begun to be employed
[7,8]. There is a recognition also of the possible
disjunction between these different measures, with debate

analysis therefore poses many difficulties due to the
disparate nature of the data which is collated [3,4]. This
is not to undervalue the research advances which have

Attention has increasingly been given to refinement in

predictive of change in other areas [5,6,9,10]. Early
studies often tended to use measures which compounded
drinking and social adjustment [11], whereas the recent
trend is to keep the basic measures of different elements

acknowledgement that continuous as well as categorical
descriptions may have to be explored, and with ‘normal
(both theoretical and practical) it is urgent that a wider drinking’ thus a possible outcome [9]. It is evident that the
range and complexity of possible drinking outcome
meaning and measurement of outcome. Outcome is a patterns cannot be easily be subsumed simply under such
conceptual and methodological issue in its own right, and headings as 'drinking' and ‘abstinent’. There arc some
to continue with studies which explore the significance of
predictor variables or the efficacy of different treatments
without the nature and measurement of outcome first present. Others may be recorded in terms of a relatively
being better resolved, is to build on insecure foundations. short time-base, while career studies often also seek to
Turning briefly to some account of those advances on integrate data relating to a particular dimension over a
long period of time. A relatively constricted Svindow of
rather than employing drinking behaviour as the sole observation’ pertaining only to the recent past can have
advantages relating to accuracy of recall but a restricted

A. Duckia, D. Brown, G. Edwards, E. Oppenheimer, M. Sheehan and C. Taylor

sampling of fluctuating behaviour (eg. drinking examined seperately — firstly the 12 months prior to
behaviour) can on the other hand be too narrow and interview and secondly the entire follow-up period of
10-12 years (mean 11.3 years). These time periods will
Il should also be admitted that the word ‘outcome’ itself subsequently be referred to as the ‘12 month’ and the
in some ways invites misunderstanding. In the classic ‘entire follow-up’ periods. Guidelines were developed for
scoring
all individual items where relevant. Information
sense the ‘outcome’ of a fixed time-base clinical trial has
meaning, but in studies of career and natural history minting to illnesses, hospital admission and criminal
‘outcome
*
is never complete until the subject’s eventual offences were obtained from extensive record searches.
death — we are otherwise observing only an arbitrary Data was also obtained wherever possible independently
from collaterals, but this information will not be discussed
segment of a continuously unfolding story.
On the basis of previous work we thus have, as it were, in the present paper.
a map which outlines many of the questions which have to
be further explored, but the details of the mapping are still Data relating to the 12-monlh period
in many areas vague. Furthermore, the current tendency
to deploy multiple outcome measures though representing 1 Drink behaviour
Three measures of drinking behaviour were used.
an important advance, is still really evidence only of a
(a) Categorisation by frequency and quantity. The
catch-all empiricism — we have not so far been able at all
drinking behaviour of each individual was assessed
closely to approach a dynamic understanding of the why
by determining the number of weeks out of 52 the
of any relationship between different aspects of outcome
patient spent in any of four categories. The highest
or to disentangle the nature of intervening processes. Our
level of drinking on any day of the given week
map lacks the roads and railways.
decided the category to which the entire week was
A preliminary report on the characteristics and overall
assigned. The four categories of drinking were
long-term outcome of the cohort we will discuss in this
defined thus:paper has been published elsewhere (8]. Hereour aimis not
(i) Weeks containing any day on which the
to givean ‘outcome report’ in the conventionalsense, but to
patient exceeded 10 pints of beer or its
use these data to illustrate and examine some of the basic
equivalent (200gm absolute alcohol).
issues which are posed by this type of research. Conceptu­
(ii) Weeks containing any day where 5 pints of
ally we are particularly interested in the significance of
beer or its equivalent (lOOgm) was exceeded,
degree of dependence on alcohol [13] as mediator between
but not more than 10 pints (200gm).
drinking behaviour and other variables. Whether our
(iii) Weeks containing any day where up to 5 pints
findings would generalise to other patient groups is a
of beer of its equivalent (lOOgm) consumed,
question only to be resolved by further exploration.
but this level was not exceeded.
(iv) Weeks of total abstinence.
Method
(b) Summary drinking score (SDS). The information
Sample
categorised above was condensed into a con­
The present study originated in 1968-70 when the
tinuous score. Points were awarded as follows:Addiction Research Unit conducted a controlled trial in
0 was given for each abstinent week out of the 52.
which 99 married, male alcoholics were randomised
1 point for each week at the « 5 pints of beer (or
between ‘treatment’ and ‘advice’. These patients were
equivalent) level.
originally followed-up 12 months [14] and 24 months [15]
2 points for each week at the >5 < 10 pints of beer
after their intake to the study. Between March 1980 and
(or equivalent) level.
April 1982 efforts were made to contact the surviving
3 points for each week at the > 10 pints of beer (or
members of this cohort. It is to data from this 10-12-year
equivalent) level.
follow-up that this paper refers. Of the original 99
(c) Alternative drinking category. Subjects were
subjects, 18 had died and 68 of the remaining 81 were
tricoromiscd into a ‘Good’ group, an ‘Equivocal’
group and a ‘Bad’ group. This summary classifica ­
tion was originally employed by Orford and
Edwards [14] and is included here for the purpose
Overall strategy of the enquiry
of comparison. In essence, outcome was con­
Data were collected by a semi-structured enquiry, and by
sidered ‘Good’ if the patient reported five or fewer

Alcoholism and she Nature of Outcome

155

weeks containing any episode of 200 gm (10 pints) 5 Socio-medtco assessment
intake or more. Outcome was considered ‘Bad
* if
Addition of the previous two scales created a ninerhe patient had 26 or more weeks containing any
point summary of the individual’s socio-medical
lOOgm (or more) per day drinking (five pints).
status. A point was scored for each of the following:Between these two extremes all other cases were
No imprisonment in the last 12 months
considered ‘Equivocal’.
No attempted suicide in the last 12 months
No problems with drugs in the last 12 months
Married for last 12 months (minimum)
'Troubles’ associated with alcohol abuse
Had worked 11 months out of the preceding 12
This was a ten-point scale developed in rhe original
No evidence of depression in last 12 months
study [14]. It consisted of the following equally
Has an N score on the EPI less than 1 sd. above
weighted items relating to adverse experiences over
normal
the previous 12-month period:Lives in his own or rented accommodation
Suffered morning shakes
Has a Purpose-in-Life score greater than 1 sd. below
Morning drinking
normal
Inability to stop drinking till drunk
Vomited or had nausea in the mornings
Passed out when drinking
Entire Follow-Up Period
1 Drinking behaviour
Lost time (even half-a-day) from work
Drank secretly
For each year (or part year) of ±e follow-up period the
Pawned own or wife’s possessions or household
number of months spent in each of the three
categories, Abstinent, Social Drinking and Troubled
Got family into debt of £50 or more.
Drinking, was recorded. Social drinking was defined
These ten items fall into two categories. The first six
as untroubled drinking for at least three consecutive
items may be described as ‘dependence ’ symptomatol­
months and not exceeding five pints on any drinking
day.
ogy while the remaining four are social problems
experienced as a result of alcohol abuse.
Abstinence was the time spent in total sobriety.
‘Troubled’ subsumed any drinking outside these two
categories.
Social adjustment
A four-item scale gave points related to marriage,
criminality, employment and accommodation. For 2 The ‘Total Drinking Data’ (TDD)
each of the following one point was given (i) if the
For each year or part year the number of months spent
patient was married for the last 12 months regardless
in troubled drinking were calculated and averaged.
of whether or not it was the same marriage as in 1968/
Each individual could thus receive a score between 0
70; (ii) if he had not been in prison during the last 12
and 12. A more detailed examination of these data will
months; (iii) if he had been employed for at least 11
be given in a forthcoming paper.
months ofthe previous twelve; (iv) ifhe currently lived
in his own home (either owned or council rented) as
opposed to living in lodgings, a hostel or being of no 3 Mental health
This was assessed by a three-item score relating to any
fixed abode.
episode of depression, suicide attempt or drug abuse.
As for the twelve-month score a point was scored for
Menial health adjustment
the absence of each of these problems.
This comprised five items. A point was scored
respectively for absence ofdepression, absence ofdrug
problems and absence of suicide attempt, all within 4 Physical health
the last 12 months. A point was scored unless the
The three items contributing to this category were (i)
patient bad a Purpose-in-Life (PIL) score more than
reported brain damage, (ii) peptic ulcer, (iii) any major
1 standard deviation below the ‘normal’ range [ 16] and
chronic or life threatening diseases including cirrhosis.
similarly unless he had an EPI score on the N sub-scale
This information largely derived from hospital notes,
greater than 1 standard deviation above ‘normal’ [17].
rather than interviewer report.

A. Duckin, D. Brown, G. Edwards, E. Oppenheimer, M. Sh^Bm and C. Taylor

Alcoholism and the Nature of Outcome

Table 4. Twelve months prior to interview: Social and Mental Adjustment. Percentage
Scale

Item

Social Adjustment
N = 68

Married for last 12 months
Not been imprisoned in last 12 mths
Employed at least 11/12
Own (or Council rented) home
No depression in last 12 mths
No problems with drugs in last 12 mths
No suicide attempts in last 12 mths
•Normal’ P.I.L. score
‘Normal’ EPI score (N)

Mental Health
N-65

5 Severity ofAlcohol Dependence Questionnaire (SADQ)
This self-completion questionnaire was used here to
physiological dependence during the entire follow-up
period [18].

The N of the tables listed below varies from 59-68 due to
1 Twelve Month Follow-up: Raw Scores
(a) Drinking behaviour categorised by weeks spent in each
offour categories. For each of the four drinking
levels the distribution of subjects by number of

particular level is given in Table 1.
(b) Summary drinking score (SDS). Results by this
Subjects appear to split fairly evenly within the
four bands, with 25 per cent scoring zero.

between categorisation by this approach and the
SDS was 0.9 (pC.OOl, one-tailed).
(d) Troubles associated wuh drinking. The rates of
endorsement for the individual items of this scale
are given in Table 3. When the individual scale
scores were examined the distribution was as
follows: 48 per cent of patients (32) scored 0
Troubles; 23 per cent scored 1-3 Troubles; 29 per
cent (19) four or more Troubles. The results
suggest that upwards of 50 per cent of subjects had

previous 12 months. For those subjects experienc­
ing any Trouble at all, the mean count was 4.2 and
the median 4.
(e) The adjustment score. For Social Adjustment and
Mental Health rates of endorsement for individual
items are shown in Table 4. The distribution for
Social Adjustment scores was 0,3 per cent; 1,16.4
per cent; 2,25.4 per cent; 3,32.8 per cent; 4,22.4
percent (n=67). As regards mental health, Table 4
Table 3. Troubles with drinking experienced during the 12
months prior to interview (n = 67). The endorsement of the

Endorsement
70.6
95.6
51.5
35.3
93.8
89.2
86.2

*2
66

suggests that only small percentages of subjects
had shown overt evidence of impairment as
per cent. Distribution for the summary
indicated by depression, drug problems or suicide
Psychosocial Adjustment Scale is given in Table 5,
attempt while larger numbers showed maladjust­
which suggests a skewing toward better outcome
ment as judged by scores on the EPI N Score and
with relatively few subjects (13.2%) scoring 4 or
Purposc-in-Life inventory. Complete data on
less on this 10-point scale.
Mental Health Adjustment was available on only
59 subjects and corrected scores were therefore
calculated when only one item was missing (n=65) 2, Twelve-month Period: Correlation Between Measures
Table 6 shows the correlation matrix for the various
the missing item being replaced by the mean score:
measures of outcome discussed above: in this analysis
the distribution was then 1, 4.6 per cent; 2,10.8
we have employed only the one drinking measure
(SDS) because it correlated highly with the other
Table 5. Twelve months prior to
drinking measures. This table shows that consumpinterview; distribution of patients by
Psycbo-Sodal Adjustment Scores.
Summation of scores on mental health
Drinking Score, correlates significantly with
‘Troubles’ (.55) and with social functioning (-.30)

between drinking behaviour and twelve-month
Mental Health Adjustment docs not reach rignifjrance

9-10
20
adjustment are significantly correlated.
Table 6. Twelve month follow-up: simple correlations between measures
SDS
Troubles
Mental Health
Social Adjustment
SDS
TroubW

"'5

-0.35"

Mcnul health
Sochi adjustment

_"M

-0.41""

••■indicates p< 0.001; **
p<0.01; *p<0.05.
SDS is Summary Drinking Score.

A. Duckitt, D. Brown, G. Edwards, E. Oppenheimer, M. Sheehan and C. Taylor

Table 8. Entire follow-up penod: simple correlations between measures. Notation for significance as
in Table 7. TDD is Total Drinking Dau.
TDD
Mental health
Physical health
SADQ
TDD
0.06
Mental health
N.S.
0.09
-0.07
Physical health
N.S.
N.S.
0.01
SADQ
*
-0.28
***
-0.39
N.S.

Social Adjustment

Mental Health

Trouble Score split into Dependence Score (DS) and Social
Troubles (ST). One-tailed significance levels are quoted.

Tn order further to understand these relationships:
relationship between the four outcomes measures can

pair of variables controlling for the effect of all other

between the given pair. [21,22].
This diagram reveals the position of ‘Troubles’ as a
Social Adjustment or Mental Health on the one hand

relationship as suggested by the simple correlation
analysis, but a relationship that only exists through the
variable ‘Troubles’. The partial correlations for these
two variables with SDS are -.07 and .03 respectively

Alcoholism and the Nature of Outcome

We do not have SADQ scores specifically for the
twelvc-month period but only ‘worst ever’ scores
related to the whole follow-up. However among the
items which comprise the Troubles score there are six
items which may be taken as related to the dependence
concent (see p. 156). When the partial correlations are
run with these six items as a Dependence Score (DS)
Troubles (ST) score, the relationships arc then as in
Figure 2 with DS in a mediating position although its
relationships with Mental Health and Social Adjust­
ment do not reach signficance.

3 Entire Follow-up Period: Raw Scores
(a) Mental health. Endorsements for each of the three
items in the upper part of Table 7 relate to mental
health over the entire period the of the follow-up.
Roughly one-third of subjects (with overlap) had
experienced difficulties in each one of the three
areas ofdepression, drug abuse or suicide attempt,
while one-third had experienced no difficulties of
analysis shows more clearly the subtle relationship of
this type.
the links between distinct areas offunctioning that was
(b)
Physical
health. The lower section ofTable 7 shows
not apparent in the simple correlation. It is not the
that 13 per cent of subjects had sustained brain
level of drinking per se which impinges adversely on
damage, 13 per cent had contracted a peptic ulcer
adjustment, but drinking that leads to ‘troubles with
and 22 per cent had experienced a variety of other

diagram. The lack of significant relationship between
drinking and Mental Health that was seen in the

.19
-.41
-22
major illnesses during the entire follow-up period.
(pc.09)
(pc.001)
(p<.061
However, 61 per cent had experienced none of Ten Year
------- SADQ--------- Mental------- Physical
these health problems.
Drinking Data
Health
Health
Entire Follow-up Period: Correlation Between Measures
The simple correlations computed for the data on the
entire follow-up period reveal that only the depen­
dence measures (the SADQ) correlates with any of the
other measures (Table 8). The SADQ shows a
significant relationship with drinking behaviour
summated over the follow-up period (the Total
Drinking Data or TDD)
*,
and with Mental Health
Adjustment for the same period. The physical health
of this sample on the available measure appears to have
no relationship with drinking or any other variable,
but we are of course dealing with the physical health
only of the survivors of the original sample.
The data was then examined using the same partial
correlation technique described above, and again a

Note 1 * This relationship holds even when the QF element in
the SADQ is dropped out. The relationship therefore is not

12 Month Dau

Tabic 7. Entire Follow-Up Period: Mental and Physical Health.

Mental Health
Mental Health
N-67
Physical Health
N-67

No depression in whole F.U. period
No suicide attempt in whole F.U. period
No drug abuse in whole F.U. period
No brain damage
No peptic ulcer during F.U.
No major health disorders

Endorsement
68.7
67.2
68.7
86.6
86.6
77.6

Social Adjustment

SDS
Troubles

Mental
Health
0.52
(p< 0.000)
0.38
(p< 0.001)
0.01
N.S. (0.47)
-0.19
(p<0.06)

more illuminating picture of the relationship between
variables emerges (Fig. 3).
simple chain. The link between drinking and
dependence (SADQ) is weak but still apparent. The
links between dependence, and impaired mental
health is highly significant, and the relationship
between mental and physical health just failed to reach
significance.

Correlations Between Measuresfor 12-Month and Entire
Follow-Up
Finally, the correlations between the 12-month
outcome variables and the entire follow-up period
variables were calculated (Table 9). Five simple
correlations attained significance (p>.001) including

10 Year Dau
Drinking
Physical
Dau
Health
-0.07
0.08
N.S. (0.28)
N.S. (0.26)
-0.35
0.11
(p< 0.002)
N.S. (0.19)
0.74
0.11
(p< 0.001)
N.S. (0.19)
0.43
0.06
(p< 0.001)
N.S. (0.33)

SADQ

—0.39
(p<,001)
-0.17
(p<.09)
—0.31
(p<.005)
0.26
(p<.02)

A. Duckitt, D. Brown, G. Edwards, E. Oppenheimer, M. Sheehan and C. Taylor
the correlations between long-term mental health and
12-month mental health .52; long-term mental health
and 12-month social adjustment .38 drinking over the
entire follow-up and drinking over the last 12 months
(-67).

Discussion
The results section of this paper might be regarded as a
sort of ‘statistical essay’ directed to an examination of the
relationship between outcome variables. With such an
essay it is proper to remember the possible shortcomings
in the quality of the data. There must undoubtedly be a
certain amount of ‘noise in the system’. It could
comfortingly be argued that for any significant relation­
ships to be perceived through this ‘noise
*
is evidence of
their inherent robustness, but on the other hand there is
a possibility that rhe correlations may be inflated by the
individual who is willing to admit one socially undesirable
crudeness of some of the scales we have employed should

very much ‘summary’ variables. They may fail to

drinking — a heavy weekend drinker would not be
implications for subsequent correlations with degrees of
dependence. For the total drinking data as we focus on the
amount of time spent drinking (rather than quantity
consumed) on any occasion the effect would be to depress
the score of the ‘binge
*
drinker which would have the
effect of slightly weakening the correlation between

as heavily dependent as the consistent consumers. The
correlation may be of a lower observed magnitude than
perhaps it should be. It seems wise therefore to interpret
these results with caution, and see them as pointing
toward useful leads for further work rather than at this
stage to firm conclusions.

between different drinking levels. For instance, in
relation to the heaviest drinking level 54 per cent of
subjects spent no time at all in this band while 22 per cent
spent 40-52 weeks at this level; the remaining 23 per cent
were however spending some lime in this category. The
distributions for the intermediate levels of drinking
(>5s£ 10 and «S5 pint equivalents) suggests that drinking
but that such behaviour is rather difficult to sustain, with
only 12 per cent ofsubjects reporting 40-52 weeks at these
levels. The distribution for abstinence again shows

spending no time in this category, 36 per cent spending
40-52 weeks at this level and 36 per cent spending some
bur lesser time abstinent.
The overall conclusion which thus emerges is that to .
conceptualise the integration of drinking outcome simply
in terms of ‘abstinent’ or ‘drinking
*
would be very
inadequate. For analytical purposes it is necessary to
develop some sort of summary descriptions, but the
essentially empirical nature of present solutions to this
problem must be admitted—we are segmenting drinking
behaviour in terms of convenient cutting-points rather
than along the boundaries of any naturally occurring
typology (if such exists). The Summary Drinking Score
(SDS) employed in this presentation appears though to
provide a useful continuous measure; that categorisation
by levels on this score should correlate highly with the
Good/Equivocal/Bad (see p.154), might be seen as
supporting its vailidity.
As already mentioned fuller discussion of the data for
drinking behaviour over the entire follow-up will be given
elsewhere. Here though the high correlation (.74) between
the measures for drinking behaviour relating to the entire
and twelve-month periods should be noted. This suggests
a considerable stability in group behaviour over time, but
with only 45 per cent of variance accounted for it is also a

completely reflect behaviour over the longer period. This
will focus on three issues — the measurement of drinking conclusion is in broad agreement with recent major
behaviour, the distinctiveness of and simple correlations outcome studies [2,7,12].
between multiple outcome variables, and finally a
Conceptually the measures which we employed to
consideration of the hints which emerge as to the complex
underlying relationships between these variables.
them a number of different approaches to integration of
outcome over time. The TDD score is an example of a
The Measurement of Drinking Behaviour
deliberate crude attempt to summarise fluctuating
Turning first to a consideration of 12-month drinking behaviour and data which could not otherwise be easily
outcome, the data given in Table 1 make it apparent that handled statistically. Measures of mental and physical
any simple categorisation ofoutcome must be imposed on health essentially tot-up the occurrence of events, while
a very considerable real-life diversity of drinking patterns the 'worst ever’ SADQ score reflects ‘integration’ in terms
— the real picture is of very varied apportionment of time of. maximal experience of a given variable over time.

Alcoholism and the Nature of Outcome

Similar diversity can be found in the basis ofmeasurement be very tentative. Turning to the data for the entire period
over the twelve month period. When looking at patterns (Fig. 3) there is a suggestion that a dependence measure
of correlation the fact that we are employing conceptually (SADQ) may hold a mediating position between drinking
rather varied approaches to integration should be born in behaviour and adverse consequences. There is
congruence between the shorter and longer term findings.

Simple Correlations between Multiple Outcome Measures
The results at several points confirm the existence of
significant correlations between outcome variables, as
regards the 12-month period (Table 7). The relationships
which are displayed are in accord with what would
intuitively be expected — the positive correlauon for
instance between SDS and Troubles and the negative
correlation between SDS and Social Adjustment. At this
level of analysis it would certainly not be possible to
maintain that the way in which patients drink is unrelated
to what otherwise happens to them but the degree to
which variables arc independent also deserves emphasis:
there are evidently different dimensions of outcome,
although they may correlate. Furthermore, SDS docs not
correlate significantly with Mental Health. The
inadequacy which would result from employing only one
dimension is underlined, and the conclusion to be drawn
from our results are in this respect much in accord with the
findings of previous investigators [2,5,6].
The picture which emerges for the entire period (Table
8) is that the drinking measure (TDD) agains fails to
correlate significantly with the measure of Mental Health,
or in this instance Physical Health — a meaningful Social
Adjustment scale could not be constructed for this longer
time period.

The Underlying Relationships Between Variables
In the introduction to this paper we referred to our present
understanding of ‘outcome’ in terms of analogy to a map
which is still lacking much detail on lines of communica­
tion. In Figures 1,2 and 3 we have perhaps some very
tentative indication as to how the exercise in mapping
might be further approached — outlines no doubt as
indistinct as any early exercise in cartography. Whatever
the shortcomings in detail the important conclusion may
though be that there is some son of intelligible dynamic
to be unravelled in these relationships. Figure 1 for
instance raises the question why drinking itself (SDS)
does not bear directly on Mental Health and Social
Adjustment, but only through the mediating relationship
with the conglomerate of Troubles. Further analysis (Fig.
2) hints that a more central position in the network of
relationships may be held by dependence (DS) but give
the imperfect and post-hoc nature of the dependence
measure which is being employed the conclusion can only

The Way Forward
advance in the understanding of outcome must be highly
dependent on design of a reliable and valid basic set of
measures, and preferably such as to commend themselves
very generally to research workers and allow more
comparability between studies.
Equipped with such tools there might be some
possibility of taking further the sort of ‘mapping’ which
can begin to show the underlying relationship between
variables. A true understanding of the nature of outcome
is probably still quite considerably beyond our grasp. A
categorisation of outcome which is dose to the natural
events may have to approach the unravelling of diverse
processes of outcome — rather than dealing only in
artificially constructed scores. For example, the person
who is heavily dependent, or who has suffered severe
impairment in some sector of adjustment (or who has
sustained multiple disadvantages, and be caught up in a

these terms outcome would be categorised not just on the
dynamic career path along which the individual is moving
[19]. We need further to delineate the nature and
characteristics of these ‘outcome pathways’ and capture
the sense of movement.
Appendix
Shows the distribution of Psycho-Medical scores for the entire
follow-up period.
Score
%
N
Mental Health
0
23.9
2
38.8
4
34.3
N = 67
Physical Health
0
10.4
28.4
3
61.2
N = 67

1 Moos, R. H., Craniate, R. C., Finney, J. W. (1982). A
conceptual framework for alcoholism treatment evaluation.
In E. M. Pattison and E. Kaufman, (eds.) Encyclopedic
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162

A. Duckitt, D. Brown, G. Edwards, E. Oppenheimer, M.

2 Vaillant, G. E. (1983). The Natural Huwry of Alcoholism.
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treatment versus no treatment.Journal ofStudies an AIcohol,
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269-271.
10

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*
two-yean
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485-502.

Edwards, G. and Gross, M. M. (1976). Alcohol
dependence: provisional description of a clinical syndrome.
British Medical Journal, 1, 1058-1061.
Orford, D. J. and Edwards, G. (1977). Alcoholism. Oxford:
Oxford University Press.
Orford, J., Oppenheimer, E. and Edwards, G. (1976).
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(1979). The development of a questionnaire to measure
severity ofalcohol dependence. BritishJournal ofAddiction,
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Edwards, G. (1984). Drinking in longitudinal perspective:
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Stockwell, R., Murphy, D., Hodgson, R. (1983). The
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145-155.
Whittaker, J. (1982). GLIM Syntax and simultaneous tests
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Britui Journal rfAdduium 80(1985), 163-171
© IMS Society for the Study of Addicuoo to Akobol tad other Drugs

Drug Use and Religious Affiliation, Feelings and Behaviour
Edward M. Adlaf
*
and Reginald G. Smart
*
Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada
Summary
The present study examined the relationship between religious affiliation, intensity of religious feelings, frequency of church
attendance on the one hand, and on the other, drug use among a sample of adolescent students (N = 2,066). Six drug-use
measures were employed: alcohol use; cannabis use; non-medical and medical drug use; hallucinogenic use; and polydrug use.
Thefindings indicate that, religious-affiliation ofstudents was insignificantly related to drug use. The only exception to this rule
wasfor alcohol use, in which case non-affiliated students used less frequently than did Protestant or Roman Catholic students.
Church attendance exhibited a stronger negatives effect on drug use than did religiosity; however, the effect of the latter had
greater impact among females than among males. Overall, the impact of both variables increased as the drug examined moved
towards the upper end ofthe licit-illia drug continuum. Finally, many of the results varied according to students’ gender and

Introduction
It seems intuitive that an individual’s religious beliefs and
control. Indeed, social-learning theory would postulate
this to be the case; that is, connections to conventional
institutions, such as the church, should provide exposure
to and reinforcement of normative behaviour [1]. This
hypothesis, much to the chagrin of many, was not
confirmed by Hirschi and Stark [2]. They found no
relationship between frequency of church attendance and
delinquent behaviour among a sample of adolescents.
This finding, in violation of conventional wisdom, kindled
further research in the area. Burkett and White [3] later
confirmed Hirschi and Stark's findings; however, they
suggested that religion may differentially affect the
various components of delinquent behaviour. In par­
ticular, they found a moderately strong negative
relationship between church attendance and the use of
alcohol and marijuana. This differential effect has been
confirmed more recently [4].
Most studies indicate that religious participation
measured by frequency of church attendance is
negatively related to both alcohol and marijuana use
[3-7J. The exceptions to this rule arc Kandel et al. [8] and
Kane and Patterson [9]. They found no relationship and
a positive relationship, respectively. Other studies

and do not necessarily reflect those of the Addiction Research
Foundation.

indicate that religious beliefs, in contrast to affiliation, are
negatively related to drug use [5,7,10].
To date, several of these investigations have restricted
their examination to alcohol use [5, 10]. Others, in
addition, have examined marijuana use [6, 7, 11]. Few
studies, however, have considered the impact of religious
factors on other substance use, whether it be illicit use or

that proscriptions against substances used for medical
purposes should be less related to religious factors than the
case of illicit-type drugs. Yet, few studies have entertained
this hypothesis.
Moreover, despite the complexity and the number of
confounding factors, only a handful of the studies
employed multivariate techniques [6, 5, 10]. Certainly
sophisticated multivariate techniques, in and of them­
selves, are not necessarily superior, for in the absence of
theory results can become uninterpretable. At the same
lime, however, to disregard multiple independent
variables, in which theory dictates or suggests a
relationship, is also questionable. One of the factors
occasionally omitted from analysis is gender, an especially
important variable if one suspects differential socializa­
tion processes. Elifson et al. [4] for instance, found
differential gender effects in explaining delinquency.
They hypothesized that closeness to mother plays a major
role in this difference and suggested that their results
support Bardwick and Douvan [12], who contend that
females arc more likely to become strongly attached to

Hll

Dr L. R. H. I hew

International Review Series: Alcohol and Alcohol Problems Research

6.

India

D. Mohan
*
and H. K. Shanna2
'Aiwcialc Profcsior and Head of the Psychiatry Deparitnem, 7 Research Ol/tcer, Deparinienl of
Piythiairy, All India Iminute of Medical Scuncei, New Delhi-110029.

Summary
Indian society, which was once a model for abstinence n gradually becoming modernised. Asa result of this, synthetic alcoholic

theme emerges. Training programmes art conspicuous by their absence, at are treatment facilities Similarly, work on alcohol
m the voluntary sector hat a lung history focused primarily on prohibitum. However, in the 1980s some positive steps are being
considered. These include the establishment of the' Working Group on Alcohol and Drugs' and the policy to establish ‘Advanced

were being used, both legal and illegal. It also took into
account much hearsay evidence on the alleged advene
recommendations. However, it neither commissioned any
research nor identified any areas in which future research
even nith a broad framework of social and public health
policy should be carried out. It piously stated that alcohol
consumption had still not reached alarming proportions,
that the final issues were an impediment to enforcing total
alternative sources lor state financial resources. It also
suggested that in those states which were finding
enforcement difficult due to economic reasons, 50 per cent
of the loss in revenue would be compensated by the federal
govetnment.
effective right from Independence, this thread was not

alive until 1976. when it was Mill a part ol the stated
government policy, but then disappeared liont political
commitment, following the brief experience of the Janata

A
V

International Review Strut:
to poliucal dissension within it, the policy could not "Be
implemented. It Mill remain
*
a point of speculation as to
whether these policies could have been implemented had
the Government served its full (erm of office. In retrospect
H is laitly obvious that governmental concern alxiul
reduced availability, or policy development canted vety
belle conviction with the intelligentsia economic planners
and health functionaries.

(a) *,Fundin ’ ugenaeJ
In India the major national funding agencies arc:
id Indian (Council ol Social Science Research (ICS.SR)
(n) Indian Council of Medical Research (ICMR)
(in) Indian National Science Academy (INSA)
(iv) Council for Scientific and Industrial Research (CS1R)
(v) Indian Agriculture Research Institutes
These funding agencies support research on an ad hoc
basis in their respective areas Some of them also have
established specific cent res for research under their control
ui identified areas of national iirq>ortancc. The ICMR
under it has many National Institutes (c.g. the National
Institute on Nutrition) and Advanced Centres (c.g. the
Advanced Centre in Biological Psychiatry). The CSIR has
similarly developed a string of laboratories to carry out
long-term research The INSA supports basic research in
all fields including medicine. More recently the Govern­
ment of India has also constituted a Department of Science
and Technology (DST) to sujscrvisc, oversee and co­
ordinate research in space, oceanography and other frontier
areas. In all die above funding agencies, ad hoc projects are
sanctioned based on approval by peer group review and in
for specific problems.
Unfortunately if the research policies of these funding
agencies are reviewed, it becomes evident that they have
had no coherent research diicc'lion. The ICMR and the
U SSR, should have drvclo|>cd joint research jmiIicic* and
ptogiamines However. this was not implemented, as it

and public health consequence
*.
The only ray ol hope is
the ‘Working Groupon Alcohol and Drug Dependence,'
which the Government has now constituted to formulate
long term research activities under die Central
Prohibition Committee, which still has to give its

(b) Reuarch uctivilut within the preterit jrumewurk
Proposals for ad hoc grants in alcohol research have
originated mainly in the late seventies and early eighties.
Most of the activity has been confined to the posl-doctorat ■
thesis work in departments id psychiatry across four major
centres id naming and some departments ol sociology m
other universities. Those have mostly been surveys of a
specific target group, either in terms of psychiatric
where alcohol has been included as one of the incidental
drugs. Only two studies (one post-doctoral thesis and one
project specifically funded for research on alcohol) have
publications in the aica have Iweii included in the
bibliography and the funded studies summarised in
Tables 1 and 2. Obviously these studies do not in any way
reflect the national picture or a co-ordinated effort. They
arc listed, as they may mark the beginning of sustained
interest in this area in tune to come.
Work on alcohol in the voluntary sector has had a long
and varied history. The All India Prohibition Council
(AIPHC) is the longest active organisation in this field.
The origin of the group liad a lol in common with the
philosophies of the political movement, and some of its
activities were aimed at enforcing prohibition and
increasing abstinence through picketing; However,
research was never one of its aims. The work by this
organisation, spanning over 50 years, is the only lasting
influence in the alcohol movement in this country.
Indeed, it encompasses the whole of a review chapter on
alcohol for the Encyclopaedia of Social Work (4 J.
Other voluntary organisations (such as Alcoholics
Anonymous (AA)) which have flourished in the West,
have had a very chequered history in India. They never
really caught on m an organised fashion. The only
organisation in addition to the above mentioned group
*
is
the recently funded private organisation, the TTK

show if its ambitious piugiammc
*dcvchip

over the yeais

future direction
*
ilopctully, with increasing urbanisation and rapidly
expanding alcohol production, alcohol research will
become a priority issue. Reference has already been made

multidisciplinary, will make formal recommendations
regarding continuous research on policy planning, social

Central Prohibition Committee. Another promising
possibility would be the development of an 'Advanced
Centre on Alcohol and Drugs' which has been rccomrncn-

binding 1 hr ratlin it view on wniolugiml as|>r<ia id
alcohol research relets only to piuliibttmii |l|

alxitil the muses for lack of tcsmich, policy and funding

The hr»t 11 its close association with the political and moral
movement reflected in the prohibition approach. The
second major reason is that il did not appear as an issue of
rnmediate or remote concern in national health policy: it

tlic scientific community ha* lacked both the expertise and
funding from the concerned agencies. It 11 our hope (hat
this picture will soon change.

Dm E. (1981). 7
Al IMS, New Delhi, 149-160.
U.S .nd Tongue, H (lids ), AIIMS, New Delhi, I6l-I6l’

global concern of the health planner* both al nauonal and

immediate problems, c.g. communicable diseases,

planning prevenuve activities, in problems such as
whx'h will bear (run in decade
*
to come. This blind spot
persists despite World Health Assembly resolutions and
various reports that arc periodically issued from the
Division of Mental Health, WHO Headquarters. Perhaps
this indifferent response by nauonal governments 1$
relkcuve of WHO
**
own lack of conviction in the area of
akohol related problems.

if
l j s

AllMS, New Delhi, 185-197.

K. and Baja), J. S. (1984). 'Alcohol ibuic in

(1977). 'Drug abuv among college studenu: An interim

Family TWerapy: Development,
Issues, and Approaches
THE DEVELOPMENT

OF FAMILY

THERAPY

Family therapy has-gradually gained widespread acceptance as a
psychosocial intervention technique since its recorded beginnings
nearly 30 years ago. Four‘recent reviews serve as a valuable
social history on the development of family therapy. Haley's
(1071a) chronological account covers important events in the field
and the evolution of the theoretical bases of family therapy. Fox
(1976) focuses on important issues--theories, techniques, ctt.ics,
assessment, outcome, and training—and the individuals associated
with them; other sections of the review are devoted to prominent
figures such as Murray Bowen and Theodore Lidz. Guerin (1976)
presents a similar developmental history but couches it in the
context of the geographical regions associated with different
theoretical concepts. Stanton (1979) presents a comprehensive
and updated review of this field. The reader with a particular
interest in the historical development of family therapy will find
these sources excellent supplements to the brief review presented
in this report.
Historically, accounts of treating whole families in therapy began
to appear in the mental health literature in the early 1950s.
These accounts reflect the influence of such pioneers in family
therapy as Frieda Fromm-Rcichmann (Haley 1970), Nathan Ackerman
( 1958. 1966a, 1966b), and Gregory Bateson and his colleagues
(1956). Fromm-Reichmann's work in the late 1990s pointed to a
greater improvement in schizophrenic children when their mothers
were included in the therapeutic process. This led others to
speculate about the role of the father as well as the mother in the
development of mental and emotional problems.
Bateson and his
colleagues soon began to include both parents in their clinical
research on the causes of mental and emotional problems. By this
time, Ackerman was already quite experienced in working with
families. In the early 1930s, he incorporated into clinical practice
his belief that many emotional and mental problems originated in
and could be treated within the family. His first writings on the
subject were not published until 1958, but knowledge of his work
through other channels greatly influenced the practice of many
prominent family therapists.

Th« Influence of ihnse diversely oriented pi eeliliiincHr en I
researchers enabled two broaderand Interrelated theoretical
developments to further the growth of family therapy. These are

learning (lipniy and ayalaina Iheitiy,

The principles of learning theory (Bandura 1969; Hawkins et al.
1966; Wolpe 1958) are viewed as particularly relevant to family
therapy because of their emphasis upon changing behavior, estab­
lishing a similar set of operations for behavioral change, and
evaluating therapy outcomes.
A vital aspect of this learning
theory orientation is that it permits each family member to monitor
how his or her behavior has changed and how this change affects
lire behavior of another family member (Patterson 1971; Patterson
et al. 1968; Stuart 1969).

The concerns of systems theory—e.g., homeostasis, communication
patterns, deviation processes—were adapted to the therapeutic
process by Hoffman (1971), Jackson (1957), and Watzlawick and
his colleagues (1967).
In applying these concerns to family
therapy, the primary emphasis has been on helping family members
understand that no member acts in isolation, that the actions of
each member affect the actions of other members. Helping family
members realize and understand this interdependence of behavior
among themselves has been a major goal of the systems-oriented
family therapy. This therapeutic process seeks to counter and
interpret the situation which most often brings a family to the
therapy, that is, the symptoms of the one ", . . identified patient,
whom the family labels as 'having problems' or 'being the problem'"
(Mlnuchln 1979).
Other theoretical movements have influenced family therapy also,
but seemingly to a lesser extent than learning theory and systems
theory (Haley 1971b). Accounts of these other movements appear
in Fox (1976), Haley (1971a), and Guerin (1976).

FAMILY THERAPY ISSUES AND APPROACHES
Currently, there arc many family therapy approaches and tech­
niques, but there is, as yet, no universally accepted definition of
family therapy. Still, there are grounds of common agreement.
One, qbyiously, is that the therapist should focus on the family
rather than on the individual. Further, each lamily member is to
be equally considered in the therapeutic process. Less universal,
but quite common, is the practice of avoiding medic.il twins such
as treatment, patient, mental illness, and therapy. This Is done
to reduce identification with the medical model of treatment and
its accompanying designation of one individual as the source of
the family's problems.

Family therapists seem to agree, therefore, that if therapy is to
be successful, an "identified patient" cannot be the focus of
treatment. This leads to numerous Ijnportant questions concerning
the process involved in the identification of one family member as

the problem" or the "deviant" one--a process that takes place
before therapy. Because the family therapist can only evaluate
and help the family dual will, lh« results of i|lp process, rfttlW
limn Ils development, ll Is <■«..<.!,t|„| f„t (|„, therapist to understand
the conditions most conducive to the development of the designation
of a deviant individual in the family. A number of theoretical
assertions have been suggested to help therapists understand
these conditions or issues:
1.

It is helpful if the family is viewed as a system. When this
occurs, the problem or deviant behavior of any one family
member is not viewed as an isolated act but may be viewed as
either caused by the behavior of other family members or as
resulting in changes in the behavior of other family members
(Jackson 1957; Watzlawick et al. 1967).

2.

The deviant behavior of one family member should not be
considered as a random or inexplicable set of occurrences but
as a behavior that fulfills a function. For example, a child's
deviant behavior might function to draw the family's attention
away from the family's feeling of being scorned by the larger
community (Vogel and Bell 1960).

3.

What may be considered as "deviant" behavior by one family
may not be considered so by another family.

0.

The causes and ellecls of deviant behavior In a family should
not be viewed In Isolation; several levels of the family system
may be involved. Hoffman (1971) suggests that amplifying
behavior on one level of the system (e.g., a child's defiance)
may inhibit further deviance on another level (e.g., tension
between parents that may break up the family). He and
others (Buckley 1968; Nett 1968) believe it is unfortunate
that therapists sometimes fail to view some deviant behavior
as potentially beneficial on at least some level (such as a
child's deviant behavior functioning to reduce tension, keeping
the family together).

Most therapists agree that there is a deviance process similar to
that described above. .illliougb different therapists use different
terminologies in speaking of the process. And most agree that
involving the whole family in the therapeutic process is the most
efficient way of solving an individual's problems. Following are
some examples of several major family therapy approaches used to
counter and reverse the deviance process and engage the family's
supjKirl in Iherapy.

Multifile Impact Therapy

This approach is a brief, usually 2-day. -intensive study and
treatment of a family in crisis conducted lay a team of clinicians
(e.g., a psychiatrist, psychologist, and social worker). Treat­
ment is based on the assumptions that crises are times when
families are most receptive to therapy and that greater progress

call be made In the early rather than In later stages i^hhe diffi­
culty (Caplan 196'1; Macgregor 1962; Macgregor et al.^WH; Farad
1965; Ritchie 1960).
The Interviewing procedures arc somewhat unique. Interviews
arc held with the entire family unit and also with individual family
members, both privately and in an overlapping Interview. Team
members focus on obtaining a family history and interventions are
based on this material.
In the overlapping interview, a team
member who has been talking privately with a family member
terminates this interview and joins another conference, either
alone or accompanied by the family member s/he has been seeing.
In this way. differences of opinion or interpretation between
' ■different family members are sometimes aired and resolved. Where
there is an "identified patient," his or her communii alive behavior
may bo shnpod by lining Invulvi'd In >ji adu.illy <<iil.it <(<•<! groups
until s/he Is comfortable speaking in the presence of the entire
family.

A more recent but similar approach based on Milton Erickson's
work has been encouraged by Jay Haley (1973,. 1976). Sometimes
termed "strategic therapy," the approach rests on a communica­
tions systems orientation. Intervention during crisis is considered
desirable, therapy is brief (though longer than 2 days), and the
entire family is seen (though perhaps in different groupings).
The focus of therapy, however, is on presenting symptoms (rather
than family history), and specific intervention strategies are
based on identified symptoms.
Structural Family Therapy
This approach, like strategic therapy, is based on a systems oriented family therapy (Guerin 1976) and is one of the most
widely used techniques. It is the focus of this report because it
has recently been used, apparently with some success, with
families of heroin addicts (Stanton 197tla; Stanton ct al. 1978;
Stanton and Todd 1978).

Minuchin (197
t),
*
who has been most instrumental in developing
structural family therapy, describes it as
. .a body of theory
and techniques that approaches the individual in his or her social
context." It is based on three assumptions: (1) that the context
of an individual's behavior affects inner processes; (2) that
changes in context produce changes in the individual; .and (3) that
the therapist's behavior is significant in any movement toward
change in the family structure. Minuchin considers the third
assumption especially important, and stresses the therapist's
intimate role in changing or "restructuring" the family's trans­
actional patterns, alliances, subsystems, sensitivity to the Indi­
vidual member's actions, sources of support, and so on.

Minuchin and his colleagues have found these techniques especially
effective when working with families they term "disorganized"
(Minuchin and Montalvo 1967; Minuchin et al. 1967). Children or

young adulMn these families arc often the "victims" in the
family's shifting alliances, and structural family therapy tech­
niques reportedly help identify and change such subgroupings for
the benefit of all. Including the person the family has chosen to
be the “victim."

Other Systcms-Oricntcd Approaches
In one view, any therapist who ventures into the family area
becomes, by implication, a "systems-oriented" therapist. Some
approaches, however, are more grounded in systems theory than
others.
Particularly notable in this regard are those techniques
and theories which involve the analysis of <■ family's communication
piolileiir, .ind Imhilviol's.

Although it is difficult to differentiate clearly the several
approaches employing communic.itions analysis in family therapy,
•.ever.ll individuals h.ivi; emerged .is advocates of this set of
techniques.
A brief description of the ideas of each of these
individuals follows.
(>r.’gory_ B.iteson. Although Bateson is clearly a leader in this
field, several researchers/practitioners who have either worked
with Bateson or relied on his concepts could lay claim to being on
an equal plane in the application of systems and communications
principles to family therapy (e.g., Don Jackson, Jay Haley, Paul
Watzlawick, and John Weakland). Their clinical research with
families led to two concepts which remain important in the theory
and practice of family therapy today, namely, the concepts of
double bind (Bateson ct al. 1 956; Weakland 1960) and family
homeostasis (Jackson 1957).
The importance of these concepts for family therapy, more than
'he specific therapeutic techniques derived from them, lies in the
way they require the therapist to view the family. The double
bind concept emphasizes the disturbed communication patterns
present in a family and calls for the therapist to be aware of
these patterns and, especially, to make the family aware of them.
The concept of family homeostasis requires that the family be
viewed as a system which, when its balance is threatened, will
take the necessary steps to recover or maintain that balance.
Viewing the family from this perspective causes the therapist to
radically reorient his/her approach to family therapy, to be aware
of changes in the family system as well as the causes of those
changes, and, most importantly, to make the family think of itself
as a system.

Virginia Satir. In the late 1950s and early 1960s, Satlr was
associated, at the Mental Research Institute (MRI) in California,
with a number of individuals from the Bateson group, notably Jay
Haley and Don Jackson. She believes, quite simply, ", . . that
by observing and learning to understand communication in a
family we can discover the rules that govern each individual's
behavior" (1971). Her technique involves viewing the family as

an open system which has developed its own rulc^^bout how
changes may occur:
(1) within individual family "'members;
(2) between family members; and (3) between family members and
the demands of the social environment (Satir 1967). She believes
that the therapist helps the family to uncover these rules, make
them explicit, and analyze how they affect the operation of their
family system.
The goals of Satir's therapeutic approach are related to this
analysis of family communication. Three changes in the family
system are sought in the following ways:
First, each member of the family should be able to
report congruently, completely, and obviously on what
he sees and hears, feels and titinks, about himself and
others, in the presence of others. Second, each person
should be addressed and related to in terms of his
uniqueness, so that decisions arc made in terms of
exploration and negotiation rather than in terms of
power. Third, differentness must be acknowledged and
used for growth.
(1971 )

Satir believes that when these changes are able to be achieved,
communication within the family will lead to appropriate outcomes.
These "appropriate outcomes" are defined by Satir (1971) as:

. .
decisions and behavior which fit the age, ability,
.aid role of the individuals, which fit the role contrac ts
and the context involved, and which further the common
goals of the family.
Murray Bowen. Bowen has utilized systems theory and communica­
tions analysis in a somewhat different manner than have Bateson
and Satir. First, Bowen believes that an "undifferentiated family
ego mass" exists in varying levels of intensity in all families
This "conglomerate emotional oneness" (Bowen 1961 , 1966, 1976)
is, in its more intense forms, debilitating for a family. Its effects
may be relieved by encouraging differentiation of self among the
family members, that is, helping each member of the family to see
themselves as individuals who are a part of many systems, includ­
ing but not limited to, the family system.
Second, Bowen asserts that family problems are the result of a
mult igenerationai transmission process.
Intervention in tiiis
process may be accomplished by an analysis of current family
interaction, as well as through historical analysis.
Finally, Bowen cautions that the identified patient in any troubled
family may be involved in a very complex communications pattern.
This individual may be "triangled," that is, forced to play the
role of the mediator of communication between the parents. S/he
may become- the scapegoat and receive only negative communication
or may remove himself or herself from family communication in
order to survive as an individual.

Guerin ^j>76), In summarizing Bowen's approach, notes that:
The Bowenian model is cautiously idealistic and optimistic
about the human potential for growth and change. It is
strongly based on a philosophy of freewill. Education
at its best is seen as a combination of the Implicit
knowledge of experiences, solidified and reproduceoby
cognitive appreciation of its form.

' ■:
IN

Existential Approaches to Family Therapy

Laing (1969) and Laing and Esterson (1964) suggest a helpful and
unique way of considering families in which one or more individuals
report emotional difficulties, although they offer no specific
techniques.
The approach was derived from studies of families with a schizo­
phrenic child. Il involves reformulating the behavioral bases of
such families. Ordinarily, the behavior of these families Is con­
sidered bizarre or senseless because family interactions are seldom
considered.
However, Laing points out that the behavior may
make sense if it is viewed in the original family context; there
may be a good reason, however unspoken, for the seemingly
bizarre acts of the family members.
Like Bowen, Laing considers the study of several generations of
the same family an important diagnostic tool, especially where
there is an "identified patient." Considering the identified
patient's behavior in the context of other family members' behavior
is believed to be especially useful. The patient's behavior that
seems so inappropriate in most social contexts may come to be
vicwi.i as a necessary means of coping when considered in the
family context.

SUMMARY

Each of the broad classes of techniques may be used in resolving
difficulties faced by family units.
The family structure, the
problem at hand, and the particular skill and training of the
therapist make up the variables that are considered when choos­
ing a particular therapeutic modality or technique.
Haley (1971a) makes the further point that a family therapist,
once he or she gains experience, will .begin to view these tech­
niques of family therapy ". . . not ... as a method of treatment--one more procedure in a therapist's armentarium . . . but
as a new orientation to the arena of human problems."
There is'evidence that this new orientation is taking hold, that
family therapy is being adapted to other than specific mental
health problems. It is now being used in several other areas,
including drug abuse, corrections, and alcohol abuse.

family therapy services in the drug treatment field^^llowcver,
they suggest that several family therapy approaches wr.g. . struc­
tural and multifamily therapy) are effective in treating drug
abuse clients.

Family Therapy with
Alcohol Abusers
The literature contains many positive claims about the effectiveness
of family therapy with alcoholics. As in other fields, such claims
are based mostly on clinical impressions which have been supported
by a few recent empirical studies. These studies will be discussed
after a brief presentation of major theoretical orientations related
to the use of family therapy In the alcoholism field. It can be
noted that the theoretical considerations and studies are limited to
alcoholism; there appear to be no attempts yet to focus on concur­
rent use of alcohol and other drugs.

THEORETICAL ORIENTATIONS

The use of family therapy with alcoholics is a relatively recent
development. During the 1950s, the prevailing theories on alco­
holism were not compatible with the psychosocial concepts underly­
ing the emerging field of family therapy. Alcoholism was then
viewed as a disease which absolved the patient of any respon­
sibility for his or her behavior. Treatment reflected such theories
of causation as biochemical sensitivity and oral dependency (Davis
et al. 1974).
In the late 1960s many investigators began to believe that environ­
mental factors were important contributors to alcoholism. The
behavioral model gained in prominence and family therapy was
introduced into the Held. Alcoholism began to be viewed as a
symptom of larger family problems (Steinglass 1976; Steinglass et
al. 1971).
Since that time, no standard definition of family therapy has been
adopted in the field. Many definitions appear in the alcoholism
literature, and they reflect diverse opinions about who should be
included in family therapy and/or which method of intervention
should be used and in which setting.
There are also various different theoretical concepts related to
the drinking process; these generally incorporate a systems
theory approach, and alcoholism and finally treatment are viewed
in the context of that system. Among the most influential theorists
and/or practitioners on this subject are Bowen, Ewing, Fox,
Steinglass, Davis, and their associates.

Ill Ibtwti»i's I !9?M) framework; ''estl-Bsslve diliil-.liit) utf-uis when
family anxiety Is high." This excessive drlnkinuflkelghtens the
anxiety of family members who are dependent up^^thc drinker;
they, in turn, "react by anxiously doing more of whal they are
already doing," Bowen stales that this "|>i'<>< nnn of dilnlilnq to
relieve anxiety" and "increased family anxiety In resjxinse to
drinking, can spiral"; the result may be "functional collapse" or
the development of a "chronic pattern." In his view the goal of
family therapy is to reduce the level of spiraling anxiety so that
family functioning patterns can be examined and Improved.
Bowen believes that any "significant" family member who can
"'cool' the anxious resjxinse," or their own anxiety, "can make a
step towards deescalation"; thus, family Ihmapy sessions may Im
limited to one or two family membei s without the drinking momhei
necessarily being present.
Ewing and Pox ( 1968) view alcoholism as an established part of
rigid family interactional patterns which maintain family homeo­
stasis. All family members strongly resist changes in drinking
patterns—including abstinence—because the changes threaten the
family "status quo." Steinglass ( 1976) also notes that al< oholisin
may serve as a stabilizing factor in the family, one which prodine
"extremely patterned, predictable, and rigid ■.<■!■, ol interactions."
In his view, these interactions reduce uncertainties not only
about family life but also about the family's relationship to society.
Thus, the goal of family therapy is to increase understanding
about the role of drinking in the family so that interpersonal
relationships may be improved. Treatment is focused on nurtur­
ing family growth, rather than on a reduction in drinking, and
the entire family is viewed as "the patient."

Davis and associates (1974) include aspects of behaviorism in
their theoretical approach. They view alcoholism as having certain
adaptive consequences which al! family members reinforce in ways
that maintain the drinking hit.it. In this framework, the pools of
family therapy are to discover the adaptive functions and r ■■nforce
*
rnents of drinking, to help the family members use this adaptive
behavior during periods of sobriety, and to assist members in
learning adaptive alternative behaviors.

UTCOME

STUDIES

. acre is very little published research on the effectiveness ol

family therapy with alcoholics. Most of this research has been
conducted by specialists in alcohol rather than by family therapists.
Most of the research based on family therapy outcomes with
alcoholics appears in two reviews by Steinglass ( 1976, 1977).
The 1977 Steinglass review includes only 10 studies. All of these
support the use of family therapy with alcoholics. However,
these studies are so limited in number, comparability, and metho­
dological rigor that one cannot draw any firm conclusions about
the effectiveness of family therapy with alcoholics. For example.

18

)
*
'''It'.mil
Juhastll es ranged triim highly subjective measures such as
social a^k marital satisfaction to measures of abstinence from
J!
alcohol ,
he use of abstinence as an outcome measure Is especially
controversial because of existing research which Indicates that
n|
some alcoholics are able to drink socially after receiving treatment
n
(Ewing 1974; Pattison 1968; Pattison ot al. 1968).
.
T he studies included in the Steinglass reviews are further limited
by the nearly universal failure of the researchers to use compari­
son groups or to include many female alcoholics In their samples.
I he failure to include female alcoholics In outcome studies may
introduce a bias that has serious Implications for treatment.
Meel-. and Kelly | 19/01, fur ox.-implo, have argued (hdl"
. . . wives of alcoholics seemed better able to shift the
locus to the family unit and to view their own behavior
within the framework; husbands, with their masculinity
and competence at stake, may have a greater need to
keep the alcoholic wife in the sick role.
When the
husband is the alcoholic he may have less difficulty
relinquishing the role of identifier! patient.

A l.uge-sc ale and as yet unpublished study of family therapy
outcomes supports the claims ol sex differences in treatment for
ahohohr s.
I hese differences were found by Williams ( 1972 ) In
hrs evaluation of the Hospital Improvement Project at the Center
for Alcoholics in Avon Park, Florida.
In that study, 44 percent of 647 patients offered family therapy
chose to participate in that treatment. Only 17 percent of the
total 647 completed the 4 sessions (initially in the office and later
at the client's home) that were intended. Intact families were far
more ns ipfive to the treatment than other families; about threefourth-. ,>! pre jialienls living with a sjxruse and children received
the th, r.ipy. Also more likely to jiarticipate in the family therapy
were patients of "middle class and above" social status. While
nonwhite patients were- as likely as white patients to accept the
therapy initially, nonwhites were less likely to complete all three
■'.u 11< g ..i I inn in III,' lainily Ihei.ijiy appears to contribute to fulltime cinjiloyment and ini reuses in attendance at Alcoholics Anony­
mous among patients at killowuji (i.e., 6 to 12 months after
discharge); these findings were more characteristic of male than
of leui.ilv patients. The family therapy also seemed to influence
the likelihood of abstinence al followup; this finding was more
characteristic of jiatienls who c'omjiletcd all four therapy sessions.
At followuji, a majority of the males showed significant changes In
"gains in self-awareness"; these changes were not found In the
majority of females, even though females were judged to have a
"less severe" degree of impairment on psychiatric formulation
measures at the time of intake.

Data from two small-scale studies raise the question of whether
many alcoholics hold as jiositive a view of family therapy as
|>rofessional jirojicinenls ot the method.

19

' * |
I
I

Pl-Ice anti Curlee-Sallsbury ( 1975) obtained attflbllnal data from
51 male alcoholics after their discharge from alCTnolism treatment
at the Veterans Administration Hospital In Indianapolis. These
men rated eight treatments they received on eight "helpfulness"
dimensions; treatment included such interventions as group ther­
apy, individual counseling, lectures, and family counseling. Of
the Imminents, family <:oiiilt><illng rei rived .imoiig the least favorable
ratings on "worth," "therapeutic benefit," and "pleasantness" mid
was not ranked highly on the remaining live dimensions.
Similar results have been reported by Hoffman et al. ( 1975-76).
They compared attitudes toward treatment among two groups of
male alcoholics who had previously completed a 6-wcek AlsoholicsAnonymous-orlented program where they received the six types of
treatment (detoxification, lectures, group therapy, individual
counseling, work therapy, and family therapy). In rating treat­
ments, a significantly higher percentage (p=0.03) of the "success­
ful" group rated family therapy as "most Helpful"; * however, the
percentages of "most helpful" responses were quite low in both
groups (22 versus 7 percent in the "successful"—N-37--and
"unsuccessful" groups—N=46).
In forms of the •"total" group,
family therapy was as likely to receive a "least helpful" (1'1
percent) as a "most helpful" (If percent) rat'ig. Treatments
that received the highest percentages of "most helpful" ratings
from the total group were group therapy (54 percent) and indi­
vidual counseling (26 percent).
While one obviously cannot generalize the findings from the two
studies on attitudes toward family therapy to the large universe
of alcoholics, these studies do suggest significant optimism in this
area.

SUMMARY
Reports based on clinical impressions suggest that various types
of family therapy are effective in the treatment of alcohol abuse.
Positive claims have been made by professionals for a systems
approach using concurrent therapy, conjoint therapy, and maritalcouples therapy. Two small-scale studies on client attitudes raise
the question of whether alcoholics view family therapy as positively
as do clinicians.
Empirical studies provide limited support for the clinical impres­
sions. These studies generally are based on small samples, lack

’These differences In group ratings may be related to statistically
significant group differences in marital status and educational
backgrounds. Compared to the "successful" group, the "unsuc­
cessful" group was less likely to be married at the time of the
study (41 versus 73 percent) and had fewer mean years of
education (9.5 versus 11.8 years).

alcoholics, and use a variety of
The research findings cannot
ilmcnt programs and all alcoholic client
*

Hepatology
with and without cirrhosis, there is a strong positive
correlation between hepatocyte size and portal pressure
(10). However, as a group, cirrhotics have a higher mean
portal pressure associated with a larger mean hepatocyte
size than noncirrhotics (10, 11). Elevated portal pres­
sures were found in 49.4% of alcoholic patients without
cirrhosis, and 23.6% of patients with cirrhosis have pres­
sures below 10 mm Hg (10).
It should be noted that while the hypothesis of hepa­
tocyte expansion followed by sinusoidal compression ap­
pears attractive as a mechanism to increase hepatic
resistance and thus portal' pressure, this postulate does
not exclude the contribution of a number of other factors,
such as fibrosis, compression by nodules or portal blood
flow, in determining portal pressure. In fact, the corre­
lations observed suggest that in some cases the mecha­
nism of portal hypertension is not related to sinusoidal
compression; this certainly appears ^o be the case in our
sample of patients with nonalcoholic liver disease.
Our data do not allow us to conclude on these other
mechanisms.
The mechanism postulated here to play an important
role in portal hypertension, based on hepatocyte expan­
sion, could provide a possible explanation for the obser­
vation that in some patients portal pressures are reduced
within a short period of hospitalization (26, 27). Al­
though, obviously there is no information derived from
human studies on the time it takes for enlarged hepato­
cytes to return to normal after Kvld^rawal from ethanol,
data in rats have shown that ttggtftomegaly subsides with
a half-life of approximately 4days- after discontinuing
alcohol administration (28). These results support a
causal relationship between hepatocyte enlargement,
compression of the sinusoids and portal hypertension.
These data also suggest that further investigation of
the mechanisms leading to.hepatocellular expansion in­
duced by ethanol might result in new approaches to
treatment of portal hypertension, one of the leading
causes of mortality in alcoholic liver disease.

0270-9139/85/0503-0408$
Hepatology
Copyright & 1985 by the I

1977, 87:228-264.
liver injury in the alcoholic. Medicine 1967; 46:119-129.
7. Nakano M, Womer TM, Lieber CS. Perivenular fibrosis in alco­
holic liver injury: ultrastructure and histologic progression. Gastro­
enterology 1982; 83:777-785.
8. Goodman ZD, Ishak KG. Occlusive venous lesions in alcoholic liver
disease. A study of 200 cases. Gastroenterology 1982; 83:786-196.

patic pressure with collagen in the Disse space and hepatomegaly
in humans and in the rat. Gastroenterology 1981; 80:546-556.

aly: pathogenesis and role in the production of portal hypertension.
Fed Proc 1982; 41:2472-2477.
12. Dotter CT. Catheter biopsy; experimental technique for transven­
ous liver biopsy Radiology 1964;82:312-314.
ver and kidney
and bronchial
biopsy. Radiology 1972; 105:445-447.
14. Rosch J, Lakin PC, Antonovic R, et al. Transjugular approach to
liver biopsy and transhepatic cholangiography. N Engl J Med 1973;
289:227-231.
15. Boyer TD, Triger DR, Horisawa M, et al. Direct transhepatic
measurement of portal vein pressure using a thin needle. Compar72:584-589.

cal correlations and comparison of radiographic techniques. Gas­
troenterology 1980; 78:197-205.
17. Reynolds TB, Ito S, Iwauuki S. Measurement of portal pressure
and its clinical application. Am J Med 1970; 49:649-657.
18. Orrego H, Amenabar E, Lara G, et al. Measurement of intrahepatic
pressure as index of portal pressure. Am J Med Sci 1964; 247:27819.

20. Kalager T, Brubakk O, Lehmann V. Intrahepatic pressures meas­
ured during laparoscopy. Scand J Gastroenterol 1979; 14:301-303.
21. Vennes JA. Transhepatic pressure measurements. Ann NY Acad
Sci 1970; 170:193-201.
22. Khanna JM, Kalant H, Bustos G. Effects of chronic intake of
ethanol on the rate of ethanol metabolism. II. Influence of sex and
of schedule of ethanol administration. Can J Physiol Pharmacol
1967; 45:777-785.
Acknowledgment: The invaluable assistance of Dr. R. 23. Dahlberg E. Estimation of the blood contamination of tissue ex­
Colapinto in performing the transjugular liver biopsies
tracts. Anal Biochem 1983; 130:108-113.
24. Park R, Leach WJ, Arieff Al. Measurement of the liver extracel­
is gratefully acknowledged.
lular space in vivo in dogs. Horm Metab Res 1980; 12:680-684.
25. Colman JC, Britton RS, Orrego H, et al. Relation between osmot­
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ically induced hepatocyte enlargement and portal hypertension.
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aion. In. Arias IM, Popper H, Schacter D et al., eds. The Liver. 26. Leevy CM, Zinke M, Baber J, et al.'Observations on the influence
biology and pathobiology. New York: Raven Press, 1982: 821-848.
of medical therapy on portal hypertension in hepatic cirrhosis.
2. Sherlock S. Diseases of the liver and biliary system, 6th ed. Oxford:
Ann Intern Med 1958; 49:837-851.
Blackwell Scientific Publications, 1981: 134-176.
27. Reynolds TB, Geller HM, Kuzma OT, et al. Spontaneous decrease
3. Reynolds TB. Portal hypertension. In: Schiff L, ed. Diseases of the
in portal pressure with clinical improvement in cirrhosis. N Engl
liver, 4th ed. Toronto: J. B. Lippincott Co., 1975: 330-367.
J Med 1960; 263:734-739.
4. Kelly RH, Baggenstoss AH, Butt HR. The relation of the regen­ 28. Israel Y, Orrego H. Liver oxygen demand and hepatocyte enlarge­
erated hepatic nodule to the vascular bed in cirrhosis. Proc Mayo
ment; their possible role m the pathogenesis of alcoholic liver
Clin 1950,25:17-26.
disease. In: Lautt WW, ed. Hepatic circulation in health and
disease. New York; Raven Press. 1981: 351-375.

Sinusoidal Caliber in Alcoholic and
Nonalcoholic Liver Disease: Diagnostic and
Pathogenic Implications
Eva I. Vidins, Robert S. Britton, Alan Medline, Laurence M. Blendis,
Yedy Israel and Hector Orrego
Addiction, Research Foundation and Departments of Medicine, Pathology and Pharmacology,
University of Toronto, Toronto, Ontario, Canada. M5S 2S1
Portal hypertension in alcoholic liver disease has been attributed to an increased resistance to
blood flow either of sinusoidal or of postsinusoidal origin. The former should be accompanied by
sinusoidal compression while the latter is expected to result in an increased or a normal sinusoidal
diameter. Patients with alcoholic liver disease showed a marked reduction (p < 0.001) in relative
sinusoidal area (995 ±135 mid3; n = 19) when compared to nonalcoholic patients with normal liver
histology (5,100 ± 389 gmJ; n = 6), or to patients with nonalcoholic liver disease (6,242 ± 467
pm3; n = 19). Hepatocyte surface area was significantly increased in patients with alcoholic liver
disease when compared to hepatocytes from normal biopsies (563 ± 32 pm3 vs. 301 ±26 pm3; p <
0.001). Patients with nonalcoholic liver disease had hepatocyte surface areas within the normal
range (327 ±14 pm3). There was a significant inverse correlation between hepatocyte size and
sinusoidal area (r = -0.63; p < 10"
*;
n = 44), indicating that larger hepatocytes were associated
with sinusoidal compression. In the alcoholic patients, portal pressure correlated inversely (r =

below 20% of normal. Such a threshold was not reached in patients with nonalcoholic liver disease,
in whom no correlation between sinusoidal area and portal pressure was observed. Rats fed
chronically with a diet containing 35% of calories as ethanol, in which liver enlargements of 36 to
42% were observed relative to controls fed an isocaloric carbohydrate diet, had a significant
reduction in both extracellular space and blood space per unit liver weight. Data presented support
the hypothesis that hepatocyte expansion and compression of the sinusoidal space appear to be
important determinants in the development of portal hypertension in alcoholic liver disease. In
addition, the striking difference in the observable sinusoids in alcoholic and nonalcoholic Liver
disease should provide an added criterion in the histological differentiation of the two conditions.

The increased hepatic resistance to portal blood flow in the genesis of portal hypertension (9-11). According
that occurs in intrahepatic portal hypertension has been to this hypothesis, sinusoids should be compressed, whil«
classified as: (a) presinusoidal; (b) sinusoidal, and (c) in the case of a postsinusoidal block, such as the onpostsinusoidal in origin (1). In alcoholic liver disease, produced by occlusion of the venous outflow, this should
portal hypertension has been frequently attributed to not occur. Although recently the concept of portal hy
compression of the venous outflow by expanding, “regen­ pertension in alcoholic cirrhosis resulting exclusively
erative” nodules (2-5) or by sclerosis or occlusive lesions from a postsinusoidal resistance has been questioned (1
of the terminal hepatic vein (central vein sclerosis) (6- 2), to our knowledge no studies have been conducted tc
8, Miyakawa, H. et al., Gastroenterology 1983; 84:1385, determine sinusoidal caliber in alcoholic liver diseas
*
Abstract). Recent studies have suggested that in alco­ and to compare it to the sinusoidal caliber in nonalco
holic liver disease hepatocyte expansion and a reduction holic liver disease or histologically normal liver.
in hepatic extracellular space may play important roles
We report studies in which we show that in alcoholic
liver disease there is a dramatic reduction in sinusoids
area, which is not seen in biopsies of patients with
Received Juno 8, 1984; accepted December 18,1984.
Address reprint requests to: Hector Orrego, M.D., Gastroenterology nonalcoholic liver disease or in nonalcoholics with nor
Program, Department of Medicine, Addiction Research Foundation, 33 mal liver histology, in line with a sinusoidal mechanism
Russell Street, Toronto, Ontario, Canada M5S 2S1.
for portal hypertension in alcoholic liver disease.
408

Vol. 5. No. 3,1985

SINUSOIDAL CALIBER IN LIVER DISEASE

409

Vario Orthomat camera (Leitz, Wetzler, West Germany).
Four or five prints (10.5 X 16.5 cm) from different areas
Human Studies
of each biopsy were taken, and the area of the biopsy
A total of 44 patients with liver biopsies were entered included in each print (45,900 pm2) was calculated with
into the study; 38 of these had portal pressures measured. the use of a Leitz stage-calibration micrometer, 2 mm in
Nineteen of these patients were consecutive admissions length, with 10 gm divisions. All prints were made keep­
for alcoholic liver disease (14 men, 5 women; mean age ing a constant negative-to-positive magnification factor.
53 ± 2.8 years) in whom alcohol as an etiological factor Areas in the micrographs were determined by adjusting
(more than 80 gm per day) was assessed on the basis of the total print area measured by the digital computer to
personal interviews. In this group, according to histolog­ the 45,900 gm2, and sinusoidal area was measured within
ical diagnosis, 12 patients had cirrhosis with or without this total area. Final sinusoidal area, expressed in pm2
hepatitis, 2 had alcoholic hepatitis and 5 had fatty livers. per 45,900 pm2 total area, corresponds to the average
Another 19 patients were consecutive admissions for sinusoidal area in the complete set of prints from each
nonalcoholic liver disease (6 men, 13 women; mean age specimen in which all the sinusoidal areas were meas­
46 ± 3.8 years). Alcohol abuse in the patients classified ured. The areas photographed were selected so as not to
as having nonalcoholic liver disease was excluded on the include portal areas, terminal hepatic veins or areas of
basis of personal interviews. In addition, the majority of fibrosis.
these patients had histological characteristics which
clearly distinguished them from the usual abnormalities Determination of Hepatocyte Size
found in alcoholic liver disease. According to history,
In our earlier studies, we estimated hepatocyte surface
laboratory tests and biopsy data, 9 patients had chronic area by counting the number of nuclei in hepatocytes per
hepatitis of different etiologies, 1 had primary biliary field and dividing this number into the total area of the
cirrhosis, 2 had idiopathic portal hypertension and 7 had field (9, 10). In this study, we determined if the use of
cirrhosis with positive viral or immunologic markers. For computerized surface analysis would yield a better sys­
comparison, we included 6 nonalcoholic patients (3 men, tem for this measurement. This was not borne out, since,
3 women; mean age 51 ± 6.2 years) in whom biopsies even in the liver biopsies reported as normal, the com­
had been performed to rule out the following conditions: puter method required the selection of specific cells with
metastatic tumors, 2 patients; Gilbert’s disease, 1 patient; clearly defined boundaries and nuclei. We found that
ulcerative colitis, 1 patient; unexplaired moderate in­ surface areas determined by the computer method, as
crease in transaminase, 1 patient, and unexplained pru­ seen in normal biopsies or in biopsies of patients with
ritus, 1 patient. All of the biopsies in these cases were nonalcoholic liver disease, presenting small hepatocytes
reported as normal. These normal biopsies were retro­ with often well-defined boundaries and nuclei, correlated
spectively collected from the pathology records of the weakly (r = 0.55) with the method of counting the nuclei.
Toronto Western Hospital, in a consecutive manner, In individuals with alcoholic liver disease in whom hep­
until six patients were identified. Data for portal pressure atocytes were frequently irregular, with imprecise bor­
were not available in these subjects.
ders, the tracing of the cell contours was virtually im­
All percutaneous biopsies in this study were obtained possible for the majority of cells. Therefore, this method
with a Menghini needle, while the transjugular biopsies did not appear adequate. Thus, the method of counting
(12-14) were obtained as previously described (10). In nuclei provided a better estimation of relative cell en­
the 19 patients with alcoholic liver disease, only one largement. While this method could be improved by
biopsy was performed by the transjugular route. In the measuring cell surface areas by nuclear counts while
nonalcoholic patients, 9 had transjugular biopsies, and correcting total areas by subtracting the computer-de­
10 had percutaneous biopsies. All biopsies were fixed rived sinusoidal area, we found that correction for sinu­
immediately with 10% formalin and processed for light soidal area altered the results of cell size by only 3% in
microscopy. A variety of staining techniques thought to alcoholics and by 17% in nonalcoholics or in normals.
be of value in the diagnosis of alcoholic liver disease were Since we found that involving such an elaborate method
used. Morphometric data presented in this paper were was not warranted, as the interpretation of the results
obtained from hematoxylin-eosin stained slides. All biop­ was not influenced by this correction, we have presented
sies were examined and reported by one of us (A. M.). our data without correction for sinusoidal area.
Written, informed consents for the biopsy and the pres­
As in any study in which tissues have to be processed
sure measurements were obtained. The study was ap­ for histological observation, there is the possibility of
proved by the Joint University of Toronto-Addiction introducing artifacts. However, it is usually assumed that
Research Foundation Committee on Ethics in Human the relative difference in size of cells seen histologically
Experimentation.
reflects the difference in size in vivo. Since this study
was a comparative one, the actual size of hepatocytes
Determination of Sinusoidal Caliber
and sinusoids in vivo is not critical for the interpretation
Sinusoidal area, as a function of sinusoidal caliber, of the results.
was measured by quantitative digital-image analysis us­
ing a MOP-3 modular system (Carl Zeiss, Inc., Eching, Pressure Determinations
Portal pressures were determined in 19 patients (9
West Germany). Micrographs were taken at 400x mag­
nification with an Orthoplan microscope fitted with a alcoholics and 10 nonalcoholics) by direct measurement

MATERIALS AND METHODS

VIDINS ET AL.
of portal vein pressure, using the Chiba needle (23-15.0
DCN, Cook-Bloomington Inc., Markham, Ontario, Can­
ada) under fluoroscopic guidance (15,16). In all of them,
intrahepatic (interstitial) pressure was also determined
during the same procedure. In 10 patients (9 nonalcoholic
and 1 alcoholic), pressures were determined by measuring
wedged hepatic vein pressure via the transjugular route
(17). In nine alcoholic patients, only intrahepatic pres­
sures were determined as previously described (9,10,18).
Zero pressure was adjusted by placing the transducer at
the midaxillary line at the same level as the Chiba needle,
with the patient in the supine position. The same refer­
ence point was used for wedged hepatic vein pressures.
Pressures were recorded using a pressure transducer
(Gould Statham SP1405, Gould, Oxnard, Calif.) and a
recorder (Statham SP2009, Gould).
It is accepted that wedged hepatic pressure and portal
vein pressure correlate very well (17, 19). We have fur­
ther examined the correlation between intrahepatic pres­
sure and portal vein pressure in the 19 patients in whom
we measured both pressures. In these patients, following
anesthesia of the skin and the intercostal muscles with
2% xylocaine, the needle position was verified radiologically to ascertain the optimal position of entry. A small
skin incision was made at this point with a scalpel. With
the patient apneic at end expiration, the Chiba needle
was inserted parallel to the X-ray table. The needle
obturator was then removed, and the needle was con­
nected to the pressure transducer and the whole system
was filled with saline. Intrahepatic (interstitial) pressure
was then measured and recorded. The needle was then
advanced further into the parenchyma, and a small
amount of Hypaque-M, 60%, (Winthrop, Aurora, On­
tario, Canada) was injected through a three-way stopcock
attachment until a branch of the portal vein could be
identified fluoroscopically. The injection was then
stopped, and intraportal pressure was measured after
fluoroscopic disappearance of the contrast medium. This
procedure was performed twice in each patient by slightly
modifying the angle of needle insertion. As shown in
.Figure 1, intrahepatic (interstitial) pressures correlate

Hepatology

very strongly (r = 0.92) with portal vein pressure in the
same patient. This confirms previous reports showing
similar correlations between intrahepatic pressures and
either wedged hepatic vein pressure (r = 0.93 and r =
0.85) (18,20) or portal vein pressure measured at surgery
(r = 0.93) (21).

Animal Experiments
Four-week old female Sprague-Dawley rats (Charles
River, St. Constant, Quebec, Canada) were fed a liquid
diet containing 35% of calories as ethanol for 30 days.
Control animals were pair-fed a diet in which ethanol
was replaced isocalorically with carbohydrate (22). The
day before sacrifice all animals received control diet ad
libitum.
The vascular space of the liver was determined by
measuring the amount of blood in the liver, using the
spectrophotometric method described by Dahlberg (23).
The animals were sacrificed by decapitation, and the
blood was collected in heparinized tubes. This procedure
assumes an equal degree of exsanguination from the liver
in both the ethanol and control groups. The hematocrits
were not significantly different in the two groups of rats.
The liver was removed, weighed and a portion was ho­
mogenized in 24 volumes of 50 mA/ Tris buffer (pH 7.4)
containing 1 mAf EDTA and 10% v/v glycerol. The
homogenates were centrifuged at 105,000 X g for 1 hr,
and after removing the fatty layer, the clear supernatant
was collected. A sample of blood from each animal was
homogenized in 61 volumes of the same buffer, and
centrifuged at 43,500 X g for 40 min to obtain a clear
supernatant, which was diluted a further 11 times with
buffer. The liver and blood supernatants obtained were
scanned in a Kontrondual-beam recording spectropho­
tometer between 280 and 700 nm, using buffer in the
reference cuvette. Dahlberg (23) reported that superna­
tants of blood and tissues containing blood had absorb­
ance peaks at 540 and 580 nm, and that the heights of
these peaks were proportional to the amount of blood
present. The current experiment confirmed these results
for the liver. Different amounts of blood were added to
homogenates of perfused livers, which contained no
blood, and after centrifugation, the absorbances of the
supernatants at 540 and 576 nm were determined. Linear
plots were obtained, indicating a direct proportionality
between the amount of blood present and the absorbance
at either of these wavelengths. The recovery of blood
added to liver homogenates was measured and found to
be 107 ± 5%; there was no significant difference in
recovery in liver homogenates from ethanol-treated and
control rats. The blood space of the liver was calculated
by dividing the absorbance (at 540 nm) of the superna­
tant from a known amount of liver by the absorbance of
the supernatant from a known amount of blood from the
same animal.
Hepatic extracellular space was determined using [3H]
methoxy-inulin (New England Nuclear Canada, Lachine,
Quebec, Canada; specific activity 238 mCi per gm). Each
rat was lightly anesthetized with ether, and a dose of 2
^Ci per 100 gm body weight (in 0.2 ml of a solution
Fig. 1. Relationship between intrahepatic pressure and portal pres­ containing 5% w/v cold inulin in 0.154 M NaCl, pH 7.4)
sure. See “Materials and Methods’ for details on procedures.
was injected into the femoral vein. After 5 min, the

SINUSOIDAL CALIBER IN LIVER DISEASE
animal was sacrificed by exsanguination from the ab­
dominal aorta. The blood was collected and centrifuged
to yield serum. The liver was removed, weighed, and a
portion was homogenized in 9 volumes of 0.55% w/v
inulin in distilled water. The liver homogenate was cen­
trifuged at 43,500 X g for 60 min. It was found that this
procedure released all of the [3H]inulin from the tissue,
since the same results were obtained after complete
tissue digestion. Aliquots of the liver supernatant and of
serum were counted for 3H. The inulin space (milliliters
per gram of liver) was calculated by dividing the amount
of 3H in the liver (disintegrations per millisecond per
gram) by the concentration of 3H in serum (disintegra­
tions per millisecond per milliliter) per 0.94, where 0.94
is the correction for serum water (24).

Figure 2 shows the striking difference in the appear
ance of sinusoids in biopsies from patients with alcoholii
and nonalcoholic liver disease. A marked reduction i:i
sinusoidal space is seen in the former, where sinusoid
are hardly visible. Also seen in Figure 2 is the larger siz<
of hepatocytes in the liver of patients with alcoholic live
disease.
We have previously reported a good correlation (r =•
0.74 to 0.79) (11) between hepatocyte surface area an-

Statistics
Results are expressed as means ± S.E. Statistical
significance (p < 0.05) was determined using Student’s t
test. Regression analyses were performed using a prepro­
grammed Radio Shack (Division of Tandy Corp., Barrie,
Ontario, Canada) TRS80 microcomputer.

RESULTS
Table 1, in which sinusoidal areas are presented, shows
that sinusoids are markedly compressed by 80 to 84% in
the livers of patients with alcoholic liver disease, when
compared to either patients with nonalcoholic liver dis­
ease or to patients with normal liver biopsies. In only 1
of 19 patiepts with nonalcoholic liver disease was the
sinusoidal ■‘area compressed to values within the range
found in alcoholic liver disease. Since there were 13
women and 6 men in the nonalcoholic liver disease group,
the sinusoidal area between these two subgroups was
compared and found to be not significantly different
(women 6,680 ± 561; men 5,464 ± 632; not statistically
significant). Data also showed that hepatocyte surface
areas were markedly increased by 72 to 87% in alcoholic
liver disease, when compared to those in nonalcoholic
liver disease or in biopsies reported as normal. In non­
alcoholic liver disease, hepatocyte surface areas were not
significantly different from those of patients with normal
liver histology. Average portal pressures in the patients
with alcoholic liver disease were elevated (17.7 ± 2.3 mm
Hg) and were not different from those in patients with
nonalcoholic liver disease (21.0 ± 2.7 mm Hg).
Table 1. Portal Pressure, Cell Size and Sinusoidal Area in Patients with Normal Biopsies, Nonalcoholic Liver
______________________ Disease (NALD) and Alcoholic Liver Disease (ALP)
Normals
NALD
ALD
(6)
(19)
(19)
Sinusoidal area (pm’/45,900 gma total
5,100 ± 389
6,242 ± 467
995 ± 135
*
(4,189-6,826)
(2,137-9,908)
(301-2,422)
Cell surface area (jun’)
301 ± 26
327 ± 14
563 ± 32
Portal pressure (mm Hg)
21.0 ±2.7
17.7 ±2.3
Differences
Sinusoidal area

Portal pressure

k NS, not statistically significant.

Normals vs. NALD
*
NS
NS
-

Normals vs. ALD
p < 0.001
p < 0.001
-

NALD vs. ALD
p < 0.0001
p < 0.0001
NS

VIDINS ET AL

Hepatology

portal pressure in alcoholic liver disease, irrespective of
the presence or absence of cirrhosis. We have recon­
firmed this observation (r = 0.66; p < 0.01, data not
shown). In nonalcoholics, however, no such correla­
tion was found (r = 0.32; not statistically significant)
(Figure 3).
We have analyzed the interrelation between sinusoidal
area and cell surface area in the complete patient sample.
As shown in Figure 4, a good inverse relationship was
observed between these two parameters (r = -0.63; p <
10“6; n = 44), indicating that smaller sinusoidal areas
were associated with larger hepatocytes. Further analysis
of the data (curve in Figure 4) shows that, within the
normal biological variation in cell size, sinusoidal areas
can vary markedly, while a strong inverse correlation (r
= -0.79, p < 0.001) between cell size and sinusoidal area
is found in the pathological range of sinusoidal areas
below 900 /xm2.
For the alcoholic patients, the relationship between
FlG. 4. Relationship between cell surface area and sinusoidal area m
portal pressure and sinusoidal area was found to be
with or without alcoholic liver disease. The straight line corre­
conspicuously exponential in nature, and by computer patients
sponds to the regression line for the complete population. The corre­
iteration it could be best described by two linear func­ lation coefficient between cell surface area and sinusoidal area for
tions in relation to sinusoidal areas either greater or sinusoids smaller than 900 pm’ is -0.79; (y = 988.8 -0.692X; n ■= 9).
smaller than 900 /xm2. Figure 5 shows the strong negative Sinusoidal area is expressed as pm’ per 45,900 pm' total area (see
correlation (r = -0.77; p < 0.01) between sinusoidal area “Materials and Methods”).
and portal pressure for livers in which sinusoidal areas
were smaller than 900 pm2. No correlation between si­
nusoidal area and portal pressure was found for livers
presenting larger sinusoids (r = -0.17; not statistically
significant).
In nonalcoholic liver disease in which all sinusoidal
areas exceeded 2,000 pm2, no correlation was observed
between sinusoidal area and portal pressure (r = -0.15,
not statistically significant; n = 19) (data not shown).
In the group of nonalcoholic liver disease patients, 10
of 19 patients had transjugular biopsies, while the rest
had percutaneous biopsies. Since the methods of obtain­
ing the biopsy specimen could conceivably have different
effects on liver morphology, we compared sinusoidal
areas and cell surface areas in these two subgroups. No
statistically significant differences were observed (sinu-

900

1220

1540

1860

2180

2500

Fig. 5. Relationship between sinusoidal area and portal pressure in
patients with alcoholic liver disease at sinusoidal areas below (A) and
above 900
(B). Sinusoidal area is expressed as pm’ per 45,900 pm’
total area (see “Materials and Methods").

Vol. 6, No. 3.1985

SINUSOIDAL CALIBER IN LIVER DISEASE

Table 2. Extracellular (Inulin) Space and Vascular (Blood) Space in Livers of Rats Fed Chronically with
Ethanol and in Controls
Ethanol
CW)”'
change
(7)
Body weight (gm)
Liver weight (gm)
Liver/body weight (gm/100 gm)
Total hepatic extracellular water (ml/
100 gm body weight)
Hepatic extracellular water (ml/gm

Body weight (gm)
Liver weight (gm)
Liver body weight (gm/100 gm)
Total hepatic vascular space (ml/100 gm
body weight)
Hepatic vascular space (ml/gm liver)

Extracellular Space
117 ±3
5.23 ± 0.17
4.47 ± 0.12
0.43 ± 0.02

99±4
6.29 ± 0JO
6.33 ± 0.08
0.47 ± 0.02

-15
+20
+42
—

<0.01
<0.01
<10“’
*
NS

0.097 ± 0.01

0.075 ± 0.01

-22

<0.01

Vascular Space
144 ±5
6.28 ±0.25
4.35 ± 0.11
0.16 ±0.01

131 ±6
7.73 ±0.45
5.91 ± 0.23
0.15 ± 0.01

+23
+36
—

NS
<0.02
*<10NS

0.036 ± 0.002

0.026 ± 0.002

-27

<0.01

• NS, not statistically significant.

soidal areas: 5,786 ± 647 and 6,675 ± 671 pm2; cell surface
area: 373 ± 26 and 391 ± 18 pm2, for the transjugular
and percutaneous biopsies, respectively). Portal pres­
sures in these two subgroups were not significantly dif­
ferent (24 i? 3.8 and 19.8 ± 3.4 mm Hg, respectively).
Chronic alcohol administration to rats which led to a
marked hepatomegaly (36 to 42%) resulted in a signifi­
cant reduction in the volume of the hepatic vascular
compartment (-27%; p < 0.01), measured as blood space
and also in a reduction of the extracellular space per unit
liver weight (-22%; p < 0.01). The total hepatic blood
and extracellular spaces were not increased despite the
increase in total liver weight that was observed in the
alcohol-treated animals (Table 2).

DISCUSSION
Data presented indicate that a marked compression of
the sinusoidal area exists in the liver of patients with
alcoholic disease, when compared to that in patients with
normal biopsies or in patients with nonalcoholic liver
disease. The difference in sinusoidal areas is so striking
that this observation might be used as an additional
criterion in the histological differentiation of alcoholic
liver disease from that of other etiologies, especially
chronic hepatitis.
We have previously shown that hepatocellular enlarge­
ment induced by chronic alcohol consumption leads to a
compression of the extracellular space in the liver, and
we have hypothesized that this compression could in­
crease the resistance to blood flow, thus contributing to
portal hypertension (11). However, our previous studies
have not included the measurement of hepatic blood
space in animals or a determination of the actual sinu­
soidal areas in humans. The present data were in line
with our earlier postulate, in that chronic alcohol con­
sumption was observed to result in a reduction in the

hepatic vascular compartment in animals and in a strik
ing decrease in the observable sinusoidal area in patienU
with alcoholic liver disease. These observations strongly
suggest that in alcoholic liver disease portal hypertension
is unlikely to be of postsinusoidal origin, but agree witl
the postulate that the increase in liver resistance t*
portal blood flow may have a sinusoidal origin (1, 2).
We observed a strong inverse relationship between
sinusoidal area and portal pressure for relative sinusoidal
areas smaller than 900 pm2. Such a correlation, however
was not observed in livers presenting larger sinusoids
thus suggesting that the sinusoids must be compressed
by about 80% before they become important contributor
to increases in portal pressure. Previously, we have alsx
reported that hepatocytes must also exceed a threshok
volume before affecting portal pressure (10, 11). It is
recognized that a correlation between two factors doe
*
not necessarily indicate causality between them. Never
theless, it is of interest that in rats where chronic alcohol
treatment results in hepatocyte enlargement withoui
hepatitis or cirrhosis, those animals with very large hep
atocytes have a reduction in the hepatic extracellula?
space and elevated intrahepatic pressures (9). We hava
also shown that hepatocyte enlargement produced os
motically in perfused rat livers results in a decrease ir
hepatic extracellular space and in an increase in both
portal pressure and hepatic resistance (25). These result
*
support a causal relationship between hepatocyte
enlargement, compression of the sinusoids and porta
hypertension.
Classically, alcoholic liver disease has been categorized
as fatty liver, alcoholic hepatitis and cirrhosis. The smal
number of patients without cirrhosis in the present study
did not permit the comparison of cell sizes and sinusoida
area within these categories. However, in previous stud
ies, we have observed that in alcoholic patients, boti

HH ' 9-«-32_
The International Journal of the Addictions, 16(4), 749-758, 1981

Clinical Note

Phencyclidine Ingestion: Drug Abuse

and Psychosis
Moire S. Jacob,
*
MD, FRCP(C)
Peter L. Carlen, MD, FRCP(C)
Clinical Institute
Addiction Research Foundation;

Department of Medicine
University of Toronto
Toronto, Ontario, Canada M5S 2S1

Joan A. Marshman, PhD
Addiction Research Foundation;
Faculty of Pharmacy
University of Toronto
Toronto, Ontario, Canada M5S 2S1

Edward M. Sellers, MD, PhD, FRCP(C)
Clinical Institute
Addiction Research Foundation;

Departments of Medicine and Pharmacology
University of Toronto
Toronto, Ontario, Canada M5S 2S1

♦To whom requests for reprints should be addressed at Addiction Research Foundation,
33 Russell Sb, Toronto, Ontario, Canada M5S 2S1.

749
Copyright © 1981 by Marcel Dekker, Inc.

750

JACOB ET AL.

Abstract

Phencyclidine (PCP) is a popular illicit drug often misrepresented as
some other hallucinogenic substance and distributed in widely varying
dosage forms and strengths. Users of hallucinogenic drugs may present
with unintentional PCP overdoses. Toxicological laboratory analyses
are essential to establish the diagnosis. In nine admitted overdose
patients, the consciousness level ranged from alert to comatose on
presentation, and all showed a prolonged recovery phase with agitation
and toxic psychosis. Severe behavior disorder, paranoid ideation, and
amnesia for the entire period of in-hospital stay are characteristic.
In very high dose patients, shallow respiratory excursions and periods
of apnoea and cyanosis coincided with generalized extensor spasm and
spasm of neck muscles. Excessive bronchial secretions, gross ataxia,
opisthotonic posturing, and grimacing occur. PCP toxic psychosis
should be considered in drug-abusing patients presenting with schizo­
phrenic-like symptoms, psychosis, or other bizarre behavior, whether
or not they admit to taking PCP.
INTRODUCTION

Phencyclidine is a drug better known as PCP, a designation which is derived
from its chemical name l-(l-phenylcyclohexyl)piperidine. It is structurally
related to the clinically useful anaesthetic agent ketamine and was introduced
into clinical trials in the late 1950s as an intravenous anaesthetic with potent
analgesic activity (Greifenstein and DeVault, 1958; Luby et al., 1959; Meyer
et al., 1959). Despite the findings that it was an effective anaesthetic agent for
superficial surgery (Greifenstein and DeVault, 1958), clinical testing was dis­
continued in 1965 because of a high incidence of adverse effects including a
complex spectrum of sensory and cognitive effects characterized by alteration
in body image with feelings of depersonalization, delusional and illusional
experiences, a sense of isolation sometimes associated with intensification of
dependency feelings, disorganization of thought, drowsiness, apathy, and
euphoria. Repetitive motor behavior, anxiety, and depression were encountered
occasionally. The duration of these effects after PCP anaesthesia ranged from
a few hours to 4 d, and patients generally experienced amnesia for events which
occurred after they regained consciousness (Greifenstein and DeVault, 1958).
The effects of an acute dose of PCP have been likened to a sensory deprivation
syndrome (Luby et al., 1959;Meyer et al., 1959).
In 1967 a PCP-containing tablet known as the “PeaCe Pill” appeared in
San Francisco and within a year this drug was widely available in the eastern
United States under the name “hog” (Londgren et al., 1969). Since that time

PHENCYCLIDINE INGESTION

751

it has become a common drug on the illicit market throughout North America,
being found frequently in material alleged to contain some other drug(s) (Baselt
et al., 1972; Brown and Malone, 1973; Marshman and Gibbins, 1970; Schnoll
and Vogel, 1971). The drug is therefore often ingested unintentionally.
During the past 4 years our Emergency Department has seen numerous mild
PCP intoxications. Patients presenting with mild impairment were observed in a
quiet room in the Emergency Department and the “talking down approach” was
very effective in controlling the manifestations of toxic psychosis. Diazepam
(10 mg orally) was used to sedate some patients. The majority of patients were
discharged. The minority of patients who did not respond over a period of 8 h
to the above management were admitted. The nine admitted patients comprising
this report can present (to the unsuspecting physician) a bewildering clinical
picture easily misdiagnosed as a primary psychosis. The clinical characteristics
and course of nine patients admitted for PCP overdose are presented in Tables 1,
2, and 3. PCP was detected qualitatively by gas chromatographic analysis in the
urine and/or blood of all nine patients (Marshman et al., 1976), although only
three patients reported use of this drug.

CASE REPORTS
Patient 2
A 33-year-old male allegedly took tetrahydrocannabinol (THC), 1 g, 2 d
prior to presenting in a catatonic, mute state at another hospital’s Emergency
Department. On examination at the time of transfer to the Clinical Institute, he
was found to be alert with roving eye movements but showed no nystagmus,
normal pupils, decreased response to pain sensation, catatonic rigidity, increased
deep tendon reflexes, and flexor plantar responses. His heart rate was 88/min,
blood pressure was 140/90 mmHg, respiratory rate and temperature were
normal, and he showed excessive salivation. The catatonic mute state lasted 4 h
and was followed by a period characterized by staring into space, making click­
ing noises with his tongue, echolalia, inappropriate monosyllabic answers, and
euphoria. He was confused, disorientated, agitated, and hallucinating; he fre­
quently assumed bizarre postures and showed a short attention span and
profound sleep disturbance. Urine and blood samples on admission were positive
only for PCP. He was given diazepam (10 mg) intravenously, q6h.
By the sixth day he was orientated in time and place and his mental state
had improved significantly. At the end of 9 d in hospital he had completely
recovered and showed no evidence of toxic psychosis. He was amnesic for the
entire period of in-hospital stay. Urine and blood remained positive for PCP
for nine consecutive days.

752

JACOB ET AL.

Table 1

Patient
Age/sex
Drug use
history

Drug alleged­
ly taken
prior to
admission
Drug ingestion
time prior
to admission
Duration of
toxic psy­
chosis
before
complete
recovery

2
3
26/M
33/M
16/M
Hallucinogens,
Heroin, THC,
M DA, THC,
antidepres­
mescaline,
cocaine,
sants, multi­
amphetamine,
hashish,
ple street
heroin, PCP
LSD, PCP,
drugs
diazepam
LSD, mescaline, THC(lg)
PCP, heroin
imipramine,
amphetamine,
LSD
2d
2d
2d

3d

9d

2d

4

18/F
LSD, PCP,
amphetamine

PCP

3d

5d

Patient 8
A 20-year-old male allegedly took 31 tablets of THC as a suicidal attempt.
Soon after this he became violent and then fell unconscious. He was immediately
brought to the Emergency Department and on examination he was unconscious,
responded to painful stimuli, and showed normal pupils, generalized rigidity,
and normal plantar response. His blood pressure was 150/100 mmHg, heart
rate was 120/min, temperature was normal, respirations were shallow with
intermittent laryngeal spasms, apnoea, and cyanosis. Investigations on admission
included: blood gases (room air), pH 7.32, PCO2 50 mmHg, PO2 88 mmHg,
actual bicarbonate 25.5 mEq/L. Blood taken on admission was positive for
phencyclidine. During the period of coma, he received oxygen and intravenous
fluids. Approximately 5 h after his initial presentation he was drowsy and just
able to repeat words said to him. Tone and rigidity increased intermittently.
After 14 h he was awake with slurred speech, echolalia, copralalia, and decreased
response to pain sensation. He manifested quiet periods alternating with periods
of uninhibited, inappropriate behavior consisting of agitation, kicking, and
thrashing around in bed, screaming and singing, confusion, disorientation,
hallucinations, and paranoia. He would stuff his mouth with food until he
vomited. General supportive care included maintenance of minimal stimuli so as
to lessen agitation, hyperactivity, and violence. Hypersalivation and increased

753

PHENCYCLIDINE INGESTION

Clinical Histories of Nine Cases of Phencyclidine Toxic Psychosis

5
17/M
Amphetamine,
heroin, LSD,
PCP

PCP (6 tablets)

18/F
LSD, THC,
marijuana,
hashish,
mescaline

8
18/M
20/M
LSD, ampheta­
LSD, ampheta­
mine, heroin,
mine, heroin,
marijuana,
opium,
marijuana
PCP

Mescaline
(5-7 g)

Cocaine,
THC (31 tablets) THC
amphetamine

9
18/M
Marijuana, LSD,
mescaline,
THC

bronchial secretions required frequent suctioning. Chlorpromazine (100 mg)
orally, q6h, was given to control his psychotic behavior.
On the fifth day he was depressed and suicidal and over the next 2 to 3 d
he continued to be destructive and irrational. Thereafter, gradual improvement
was noted. By the tenth day his speech was slow and deliberate and although
he was unable to initiate conversation, he was polite and cooperative. On the
twelfth day he had completely recovered, showing no evident psychotic signs
and chlorpromazine was discontinued. He remains amnesic to the entire period
of toxic psychosis.

DISCUSSION
The wide discrepancy between the patients’ description of drugs abused
and his/her actual street drug use is consistent with the findings of various
street drug analysis programs. For example, during the period 1971-1976 PCP
was the drug most commonly encountered in the street drug analysis program
of the Addiction Research Foundation of Ontario. The samples had been volun­
tarily submitted to the Ontario Addiction Research Foundation for qualitative
analysis by people not associated with law enforcement. Approximately 22%
of all drug-containing samples (N = 294) examined by the laboratory contained
PCP; of these, 26% were combinations of PCP with some other drugs, commonly

754

JACOB ET AL.

Table 2
Clinical Manifestations of Nine Cases of Phencyclidine Toxic Psychosis

Patient
Agitation
Confusion and disorientation
Hallucinations
Delusions
Staring into space
Short attention span
Alterations in communicative ability:
Difficulty in verbalizing
Slurred speech
Echolalia
Catatonic mute state
Behavior disorder
Paranoid ideation
Depression
Amnesia for period of psychosis

LSD. Only 11% of the PCP-containing samples were alleged by the submitting
physician (or patient) to contain PCP; the remainder were described as THC,
mescaline (or peyote), MDA (i.e., methylene-dioxyamphetamine), LSD, psilo­
cybin, cocaine, and less frequently as some other drug or drug combination.
Tablets, powders, and capsules in a wide range of colors were the most fre­
quently encountered dosage forms, and in some cases it was evident that
capsules intended for legitimate pharmaceutical preparations had been diverted
or emptied of their original contents and PCP had been introduced for street
sale. Some of the street drug preparations had the form of yellow brown gummy
materials or crystalline chunks, forms which suggest “illicit” synthesis. Occasion­
ally the drug was encountered in solutions or in admixture with mushroom
material (either decaying or dried) or green leaf material, sometimes marijuana.
Quantiative assays of a random sample of these products revealed PCP contents
ranging from 2.2 to 9.9 mg for tablets and 0.4 to 81.0 mg for capsules.
With widespread availability and the variation in dose level of PCP, it is not
surprising that the recent literature contains several clinical reports of acute
states of intoxication associated with nonmedical ingestion of the drug, involving
not only teenagers and adults (Burns et al., 1975; Eastman and Cohen, 1975;
Kessler et al., 1974; Liden et al., 1975a, 1975b; Lin et al., 1975; Marshman et
al., 1976; Reed et al., 1972; Reynolds, 1971; Stein, 1973; Tong et al., 1975)
but also young children whose ingestion of the drug was accidental (Burns et al.,
1975; Liden et al., 1975a, 1975b; Lin et al., 1975). Despite the “street” impres­
sion that PCP is a benign recreational chemical, several recent reports of PCPassociated deaths confirm its status as a drug of substantial risk (Burns et al.,

Table 3

Abnormal Physical Signs in Nine Cases of Phencyclidine Overdose
Patient
Level of consciousness on admission
Intermittent apnoea and cyanosis
Excessive bronchial secretions
Blood pressure on admission
Nystagmus
Visual disturbance
Ataxia
Catatonic signs
Neck rigidity
Generalized rigidity and opisthotonic
posturing
Grimacing and trismus
Athetotic movements
Decreased response to pain
Autonomic changes:
Hypersalivation
Lacrimation

Drowsy
+

Alert

3
Alert
+

Alert

5
Alert

Coma

140/100
+

140/90

140/90

. 130/90

130/90

190/100

+

+
+

7

+
+

130/90
+

8
Coma
+
+
150/100

+

9
Coma
+
+
140/90
+
+
+

*

+

+

+
+

+
+

+
+

+
+

+

+
+

+

+

+

+
+

+

756

JACOB ET AL.

1975; Eastman and Cohen, 1975; Kessler et al., 1974; Lin et al., 1975; Reed
et al., 1972; Reynolds, 1971). The clinical manifestations ofPCP toxic psychosis
seen in our patients (Table 2) are consistent with previous reports (Burns et al.,
1975; Liden et al., 1975b; Stein, 1973; Tong et al., 1975). The abnormal physi­
cal findings (Table 3) in all nine cases are typical of intoxication with moderate­
ly high (Patients 1 -5) to very high (Patients 6-9) doses of PCP.
When present, coma lasted 4-6 h, and two of these patients had shallow
respirations during the period of coma. Periods of apnoea and cyanosis occurred
which coincided with neck muscle spasms (including laryngeal spasms) and
generalized extensor spasms. Pooling of excessive bronchial secretions inter­
fered with normal ventilation in unconscious patients, but in alert patients
these secretions were easily expectorated and constant spitting was a charac­
teristic feature.
Even in the presence of a normal respiratory rate, PCP overdose patients
must be closely watched in the first 12-18 h for apnoea and cyanosis which
may be associated with localized or generalized muscle spasm. Unless the history
suggests very recent ingestion of a large number of tablets or capsules, gastric
lavage is contraindicated in the alert patient as it may induce laryngeal spasm
and aspiration of emesis. Respiratory acidosis, which occurred in two of the
nine cases, was treated by adequate ventilation and by frequent suction of
excessive secretions. Intubation and ventilatory assistance were not indicated
in any of our cases.
Nystagmus, transient photopsia and blurred vision, gross ataxia, and other
motor system abnormalities (Table 3) observed in these patients were consistent
with previous reports (Burns et al., 1975; Eastman and Cohen, 1975; Liden et
al., 1975a, 1975b; Stein, 1973; Tong et al., 1975). Opisthotonic posturing and
generalized rigidity were present in three patients who were comatose, but
seizures did not occur (cf. Burns et al., 1975; Liden et al., 1975a). Although
opisthotonus has been previously noted in an adult patient (Liden et al., 1975a),
it has been more commonly reported in children (Burns et al., 1975; Liden et
al., 1975a, 1975b). Decreased response to pain was observed in most patients
during the alert state.
Our treatment approach in all patients support the observations that inter­
action with staff causes exacerbation of the drug-induced problems (Stein,
1973; Tong et al., 1975) and that avoiding even minimal stimuli to the patient
lessens severity of the toxic psychosis. Patients uncontrolled by symptomatic
treatment should receive medication. Oral or intravenous diazepam was useful
in reducing agitation and muscle spasm in Patients 2, 4, 6, and 7. Chlorproma­
zine was used in the management of more severely psychotic cases (Patients 5,
8, and 9).
Phencyclidine is a commonly available street drug frequently mislabeled as
some other substance and marketed in a wide range of doses. The staff in

Table 3

Abnormal Physical Signs in Nine Cases of Phencyclidine Overdose

Patient
Level of consciousness on admission
Intermittent apnoea and cyanosis
Excessive bronchial secretions
Blood pressure on admission
Nystagmus
Visual disturbance
Ataxia
Catatonic signs
Neck rigidity
Generalized rigidity and opisthotonic
posturing
Grimacing and trismus
Athetotic movements
Decreased response to pain
Autonomic changes:
Hypersalivation
Lacrimation

1
Drowsy
+

2
Alert

3
Alert

4
Alert

5
Alert

6
Coma
+

7
Coma

8
Coma
+

9
Coma
+

140/100
+

140/90

140/90

. 130/90

130/90

130/90

150/100

140/90

+

+
+

190/100
+
+
+

+

+

+

+

+

+
+

+

+

+

+

+

+

+

+
+

+

757

PHENCYCLIDINE INGESTION

Emergency Departments should be trained to consider PCP toxicity in patients
presenting with schizophrenic-like symptoms, delirium, psychosis, or in fact in
a young drug user with any form of bizarre behavior. The slow recovery is
largely the result of slow elimination of PCP (half-life approximately 15 h)
(Marshamn et al., 1976). Toxicological laboratory findings were particularly
valuable in facilitating diagnosis when the patient presented with psychosis
and/or abnormal neurological and systemic manifestations.
ACKNOWLEDGMENTS

We are indebted to Miss Naomi Hunchuck and Miss Cathy Van Der Giessen
for their help in the preparation of this article.
REFERENCES
BASELT, R.C., CASARETT, L.J., and WINN, N.E. Illicit drugs: Chemical identity versus
alleged identity. Drug Forum 1: 263-267,1972.
BROWN, J.K., and MALONE, M.H. Qualitative analytical results of a street drug monitoring
program-A new aspect of toxicology. Proc. West. Pharmacol. Soc. 16: 134-137,1973.
BURNS, R.S., et al. Phencyclidine-States of acute intoxication and fatalities. West. J.
Med. 123: 345-349, 1975.
EASTMAN, J.W., and COHEN, S.N. Hypertensive crisis and death associated with phency­
clidine poisoning. J. Am.Med. Assoc. 231: 1270-1271, 1975.
GREIFENSTEIN, F.E., and De VAULT, M. A study of 1-aryl-cycio-hexyl-amine for
anesthesia. Anesth. Analg. 37: 283-294, 1958.
KESSLER, G.F., et al. Phencyclidine and fatal status epilepticus. N. Engl. J. Med. 291:
979, 1974.
L1DEN, C.B., LOVEJOY, F.H., and COSTELLO, C.E. Phencyclidine-Nine cases of poison­
ing. J. Am. Med. Assoc. 234: 513-516, 1975a.
L1DEN, C.B., LOVEJOY, F.H., and COSTELLO, C.E. Phencyclidine (Sernylan) poisoning.
Ped. Pharmacol. Therap. 83: 844-845, 1975b.
LIN, D.C.K., et al. Quantification of phencyclidine in body fluids by gas chromatography
chemical ionization mass spectrometry and identification of two metabolites. Biomed.
Mass Spectrom. 2: 206-214, 1975.
LINDGREN, J.E., et al. The chemical identity of “hog”-A new hallucinogen. Am. J.
Pharm. 141: 86-90,1969.
LUBY, E.D., et al. Study of a new schizophrenomimetic drug-Sernyl. AjW_4. Arch. Neur.
Psychol. 81: 363-369, 1959.
MARSHMAN, J.A., and GIBBINS, R.J. A note on the composition of illicit drugs. Ont.
Med. Rev. 37: 429-430,441,1970.
MARSHMAN, J.A., RAMSAY, M.P., and SELLERS, E.M. Quantitation of phencyclidine
in biological fluids and application to human overdose. Toxicol Appl. Pharmacol. 35:
129-136, 1976.
MEYER, J.S., GREIFENSTEIN, F.E., and De VAULT, M. A new drug causing symptoms
of sensory deprivation. Neurological, electroencephalographic and pharmacological
effects of Semyl. J. Nerv. Ment. Dis. 129: 54-61,1959.
REED, D„ CRAVEY, R.H., and SEDGEWICK, P.R. A fatal case involving phencyclidine.
Bull. Int. Assoc. Forensic Tox. 8: 7, 1972.

758

JACOB ET AL.

REYNOLDS, P.C. Phencyclidine poison. Bull. Int. Assoc. Forensic Tox. 7: 12-13,1971.
SCHNOLL, S.H., and VOGEL, W.J. Analysis of “street drugs.” N. Engl. J. Med. 284: 791,
1971.
STEIN, J.I. Phencyclidine induced psychosis. The need to avoid unnecessary sensory influx.
Mil. Med. 138: 590-591,1973.
TONG,T.G., et al. Phencyclidine poisoning. J. Am. Med. Assoc. 234: 512-513,1975.

i
4

’

SCIENTIFIC SECTION
REVIEW Al’,TICl.H

Use of drugs with dependence liability
Moire S. Jacob,

md, frcp[cJ;

Edward M. Sellers, md, ph d, frcp[c], facp

The term addictive as used by the popular press frequently confuses the more
precise concepts of acute and chronic tolerance, physical dependence and
withdrawal, and psychologic dependence. Serious physical dependence on
psychoactive drugs is rare and is easily managed. In contrast, psychologic
dependence, the most important reason for persistent drug use, is much
more common and is difficult to treat. Some tactics are available — for example,
confrontation and discussion with the patient about how a drug is not going
to be effective over long periods. Treating the symptom of a complex problem
should, of course, not be expected to solve the problem. The most important
tactic is to prescribe dependence-associated drugs only when clearly indicated,
when the problem is responsive to drug therapy and for the shortest period
necessary, without the option for renewing the prescription. Many problems
related to drug use long after the period of expected benefit is past can be
avoided by far more restrictive drug prescribing. Barbiturates and nonbarbiturate
sedative hypnotics (e.g., ethchlorvynol, glutethimide, meprobamate,
methaqualone and methyprylon) should not be prescribed for insomnia, acute
reactive anxiety, chronic anxiety neurosis or depressive illnesses, since the
safer and equally effective benzodiazepines, which are less associated with
dependence, are available.
Dans la presse profane 1'expression toxicomanogene confond souvent les
notions plus precises de tolerance aiguii ou chronique, d'assuetude et de
sevrage, et dependance psychique. Une assuetude serieuse aux medicaments
psychoactifs est rare et se traite facilement. Par opposition, la dependance
psychique, la cause la plus importante d'utilisation persistante des drogues,
est beaucoup plus frequente et difficile a trailer. Ouclques tactiques sont
disponibles — comme. par exemple, de susciter une confrontation et une
discussion avec le patient pour lui expliquer comment un medicament ne pourra
etre utile pendant de longues periodes. On ne devrait pas s'attendre a cc
que le traitement des symptomes d'un probleme complexe puisse resoudre
le probleme. La tactique la plus importante consiste a ne prescrire les ‘
medicaments capables de produire de la dependance que quand ils sont
parfaitement indiques, quand le probleme repond au medicament et pour la
plus courts pcriode necessaire, sans possibilitc de renouveler la prescription.
Plusieurs problemes relies a ('utilisation des medicaments pour des periodes
outrepassant la duree prevue d'clfet benefique pourraient etre evites par
une prescription plus restrictive des drogues. Les barbituriques et les sedalifs
non barbituriques (e.g., ethchlorvynol, glutethimide, meprobamate, methaqualone
et methyprylone) ne devralent pas etre presents pour I'insomnie, I'anxiete aigue
reactionnelle, la nevrose d'angoisse chronique ou la depression, alors que les
benzodiazepines, des medicaments plus surs. tout aussi efficaces et moins
associes a un etat de dependance, sont disponibles.
medicine, University of 'lotonto

From the division of clinical phar­
macology. Toronto Western Hospital
and the clinical institute. Addiction
Research Foundation, and the
departments of pharmacology and

Rept ini requests to: Dr. I dvvard M
Selleis, Addiction Research Foundation.
33 Russell St., Toronto, Ont. M5S 2SI

Knowledge in two areas is impor­
tant for the proper use of drugs
with dependence liability: first, an
exact appreciation of the meanings
of terms often applied to “addictive”
drugs (acute and chronic tolerance,
physical dependence and withdraw­
al, and psychologic dependence);
and second, the clinical pharmacol­
ogy of psychotropic and analgesic
drugs, including their proven indi­
cations, proven duration of optimal
efficacy, dosages, toxicity and true
physical liability.' In each of these
areas there is often . considerable
misinformation. For example, oxy­
codone (as in Pcrcodan1") is com­
monly prescribed as a drug with a
lesser risk of producing dependence
than other opiates, yet the risk of
physical dependence with this drug
is no different from that of mor­
phine or meperidine.

Terms applied Io addictive drugs
/latte tolerance

Acute tolerance is the adaptation
to a thug’s effect after a single ad­
ministration of the drug. For ex­
ample. after alcohol or diazepam
ingestion a greater effect may be
observed during the ascending
phase of the drug’s concentration­
time curve than at the peak con­
centration or during the descending
phase.’ Such acute receptor site
tolerance or adaptation to the drug
may be viewed as a therapeutic ad­
vantage or as an unwanted side ef­
fect. The drowsiness and sedation
produced by benzodiazepines used

CM/3 JOURNAL./SFI’IF.MHl-R 22, 1979/VOL. I2l

• for ni/'srrihinn InbwmMIhn

777

717

for prcopcrzitive sedulion, endo­
scopic procedures' or treatment of
seizures aie beneficial therapeutic
effects, but when benzodiazepines
are used as anxiolytic agents the
acute drowsiness is an unwanted
side effect.’

both, that have occurred during pendence (Table J). Other terms
long-term ding administration. The used for psychologic dependence
withdrawal reaction presents as a arc behavioural, psychic or emo­
hypcradrenergic state, with anxiety, tional dependence and habituation.
agitation, tachycardia. mild hyper­ In the management of patients the
tension, hyperacuity of all the predominant role of psychologic
senses, hyperreflexia and decreased dependence must always be con­
seizure threshold? The withdrawal sidered. Evidence for this comes
reaction is most prominent for from two principal sources. First,
Chronic tolerance
drugs that can be taken frequently, many patients who have taken “ad­
Long-term administration of bar­ are associated with extensive adap­ dictive" drugs for long periods do
biturates, benzodiazepines, ethanol, tation (tolerance), are taken by a
nonbarbituratc sedative hypnotics route whereby absorption is rapid
Table I—Drugs with physical or psycholo­
gic dependence liability or both
and opiates is associated with de­ and produce a response that is
creased effects of the same dose or closely associated with the drug
Central nervous system stimulants
a need to administer larger and taking. In addition, the drug must
Amphetamines
larger amounts of the drug to ob­ remain in the body long enough to
Dextroamphetamine sulfate (e.g.,
Dexedrine")
tain the same pharmacologic ef­ permit the adaptation associated
Methamphetamine hydrochloride
fects. Early in therapy repeated in­ with chronic tolerance to develop
(e.g., Methedrine"')
Amphetamine
congeners
gestion of diazepam may lead to ex­ (as with alcohol). On the other
Chtorphentermine hydrochloride (e.g.,
cessive sedation. If treatment is hand, the drug must be eliminated
Pre-sate"')
Diethylpropion
hydrochloride (e.g.,
continued at the same dose the from the body at a rale greater than
Tenuate ")
sedation abates even though the that of the corrective biochemical
Mazindol (Sanorex®)
blood concentrations of diazepam and neurophysiologic processes that
Methylphenidate hydrochloride (e.g.,
Ritalin")
and its active metabolite, desme- reverse the drug-induced changes
Phentermine (e.g., lonamint?)
thyldiazepam, greatly exceed those associated with chronic tolerance.
Central nervous system depressants
measured during the early part of All these criteria will determine the
Barbiturates
therapy, when drowsiness was most severity and likelihood of physical
Amobarbital (e.g., Amytal sodium)
evident? Similar results have been withdrawal in relation to the devel­
Barbital sodium
Pentobarbital sodium (e.g.,
observed with single- and multiple­ opment of chronic tolerance.
Nembutal» sodium)
dose flurazepam therapy? Another
The physical dependence syn­
■ Phenobarbital sodium (e.g..
Luminal")
practical consequence of the devel­ drome can be treated by readminiti­
Secobarbital sodium (e.g., Seconal?)
opment of chronic tolerance has re­ tration of the same drug or a drug
sodium)
cently been illustrated during the with similar pharmacologic prop­
Nonbarbilurate sedative hypnotics
Chloral hydrate (e.g., Noctec®)
use of diazepam for gastroscopy. erties (c.g., barbiturates and alco­
Ethchlorvynol (e.g., PlacidylS)
The intravenously administered hol). What contribution the need to
Glutethimide (e.g., DoridenS)
Meprobamate (e.g., Miltown'S)
dose of diazepam necessary to pro­ prevent the withdrawal reaction
Methaqualone hydrochloride (e.g.,
duce sufficient relaxation for pas­ plays in persistent drug taking is
Mequelon" )
sage of a gastroscope varied 22-fold not known and has certainly been
Methyprylon (Noludar®)
Benzodiazepines
among patients, and those who had overemphasized. The requirement
Chlordiazepoxide hydrochloride (e.g.,
been using benzodiazepines re­ to take a drug to prevent the symp­
Librium " )
Clonazepam (e.g., Rivotril ®)
quired larger doses for relaxation toms of withdrawal appears late,
Clorazepate dipotassium (Tranxene®)
than those who had not? Chronic only after physical and psychologic
Diazepam (e.g., Valium S)
tolerance or adaptation al the drug’s dependence are well established?
Flurazepam hydrochloride
(Da!mane»)
receptor site exceeds the relatively The classic characterization of the
Lorazepam (e.g., Ativan®)
small changes in drug half-life or alcohol, barbiturate or opiate ad­
Oxazepam (e.g., SeraxS)
Triazolam
*;)
(Halcion
clearance caused by enzyme induc­ dict is often generalized to all
tion during long-term administra­ abusers of these and other agents
Analgesics
tion.1
without any firm basis. There is
Non-narcotic
Acetylsalicylic acid
considerable evidence that persist­
Narcotic
ent drug taking is the result of
Alphaprodine hydrochloride
Physical dependence
(Nisentil "•)
many more subtle factors than the
anil withdrawal
Anileridine (e.g., Leritine5')
need to prevent withdrawal symp­
Codeine
Physical dependence is a physio­ toms?
Hydrocodone bitartrate (e.g.,
Hycodan"')
logic state of adaptation to a drug
Hydromorphone (Dilaudid ®)
following the development of Psychologic dependence
Levorphanol tartrate (LevoDromoran"')
chronic tolerance that results in a
Psychologic dependence can be
Meperidine hydrochloride (e.g.,
characteristic set of withdrawal associated with repeated consump­
Demerol»')
symptoms ("abstinence syndrome") tion of virtually any drug, and is
Methadone
Morphine
when administration of the drug is characterized by little or no tend­
Oxycodone (c.g., Percodan®)
stopped.
ency to increase the dose of the
Pentazocine (c.g., Talwin®)
Propoxyphene napsylate (e.g.,
Physical withdrawal is the un­ drug and by satisfaction of a
Darvon-N "■)
masking of the adaptive neurophy­ psychic drive without necessarily
siologic or biochemical changes, or the development of physical de­
71K

CMA JOLIRNAI./SEPTHMIIIR 22. 1979/VOI.. 121

not manifest any withdrawal signs
or symptoms. Second, rehabilita­
tion programs for individuals truly
physically dependent that have re­
lied on pharmacologic agents (e.g..
methadone) as the only treatment
modality have consistently failed.
Psychologic dependence is die most
important reason for persistent drug
use by patients. The etiology of
such dependence is complex, often
being rooted in a matrix of familial,
social and economic problems. Pre­
sumably the stimuli to take drugs
arc subtle, acquired, conditioned
internal and external cues.

modify central nervous system func­
Barbiturate and nonbarbiturale
tion is uin known. Drug use may sedative hypnotics: Sccobarbitalsubstitute for the learning of per­ or amobarbital-dependent individ­
sonally effective and flexible ways uals can have a severe, life-threat­
of solving problems and adapting to ening withdrawal reaction, in part
new stressful situations.
because the plasma half-lives of the
The most important lactic avail­ drugs are about 25 hours and phy­
able to the physician is to prescribe sical dependence is unmasked when
dependence-associated drugs only drug use is abruptly stopped. Phe­
when clearly indicated, when the nobarbital is eliminated more slow­
problem is responsive to drug ther­ ly (half-life 87 hours) and is seldom
apy and for the shortest period associated with an important with­
necessary, without the option for re­ drawal reaction.” Other barbitu­
newing the prescription. Of course, rates and nonbarbiluratc sedative
these tactics apply to all drug pre­ hypnotics can produce physical de­
scribing, but they may be less con­ pendence and have a narrow mar­
sistently applied when the problem gin of safely. Barbiturates amt non­
is not readily responsive to the barbiturate sedative hypnotics (e.g.,
Prevention of physical
ethchlorvynol, glutethimide, mepro­
drug and the drug is “.safe"’.
and psychologic dependence
Patients with acute reactive an­ bamate, methaqualone and melhyxiety. occasional insomnia, reactive prylon) should not be prescribed
General principles
depression or minor pain often do for insomnia, acute reactive anxi­
not require prescribed drugs since ety, chronic anxiety neurosis or de­
The reasons drugs are prescribed these common experiences arc tran­ pressive illnesses, since the safer
and individuals persist in taking sient and not particularly serious. ami equally effective benzodiaze­
them in situations in which thera­ Persistent problems require full in­ pines, which are less associated with
peutic advantage is unclear are vestigation and treatment directed dependence, are available. Individ­
complex. Overall social traditions' at the cause rather than the symp­ uals currently taking these drugs
and attitudes do not discourage the tom. In this respect the use of should have their management re­
use of drugs for coping with the marital counsellors, psychologists viewed to establish the need for
stress and strain of normal life. ami other community-based individ­ continued therapy.1
Medical and popular advertisers of uals, facilities and programs related
Benzodiazepines: Numerous ben­
substances as diverse as alcohol, to problem solving needs to be in­ zodiazepine derivatives are available
cigarettes and prescription and non­ corporated more commonly into in Canada.- These drugs arc all si­
prescription drugs frequently pro­ the treatment choices of physicians. milar structurally and in their phar­
mote the notion that the use of
macologic actions. In -general, a
these agents is associated with life­ Specific drugs (Table J)
generic preparation of chlordiaze­
styles that arc variously portrayed
poxide or diazepam will suffice for
as glamourous, seductive or neces­
Amphetamines and their anal­ most patients with insomnia, acute
sary. or all three. In a far more ogues: Under the Canadian Food reactive anxiety, chronic anxiety
subtle way newspapers, by simply and Drugs Act, amphetamines and neurosis or alcohol withdrawal.
reporting patterns of drug use and their analogues are "designated-’ Many such patients do not require
abuse, may promote experimenta­ drugs and may only be prescribed even a short course of drug ther­
tion and more widespread drug use. for narcolepsy, hyperkinetic dis­ apy. Other’ conditions for which
Should the widespread use of orders in children, mental retarda­ benzodiazepines are indicated in­
psychoactive agents cause concern? tion (minimal brain dysfunction), clude continuous seizures (e.g., dia­
Excessive prescribing or use of any epilepsy, parkinsonism and hypo­ zepam); petit mal “absence attacks”
drug when it is not needed must tensive states associated with anes­ (e.g., clonazepam); neuromuscular
be associated with increased health thesia. These restrictions have fair­ disorders, including backache and
care costs and an increased fre­ ly effectively decreased the previous muscle trauma, cerebral palsy, teta­
quency of adverse effects. For ex­ widespread abuse.1” The effective­ nus anil stiff man syndrome; and
ample, despite the safety and low ness of the legislation presents a a variety of psychiatric problems in
physical dependence liability of strohg argument that physicians which their efficacy is unclear —
benzodiazepines, these drugs share played a major role as the cause for example, toxic psychosis, anxi­
disadvantages with barbiturates.
*
of the widespread misuse. These ety-depression and phobic dis­
They produce drowsiness and agents and their congeners (e.g., orders.
*
For the physician prescribing ben­
"mental clouding-’, interact with methylphenidate) should not be pre­
other psychotropic drugs, including scribed to patients unknown to the zodiazepines the following guide­
alcohol, and can produce in some physician. Drugs such as methyl­ lines are useful:
0 Determine the cause of or
individuals psychologic dependence phenidate and dicthylpropion have
even after short-term use. The recently been placed on Schedule precipitating factors in insomnia
long-term behavioural and so­ Ci of the Food and Drugs Act. and anxiety, and treat the primary
cietal consequences of persistent ad­ Their use will decrease as a result problem (Table II). Decide if the
drug is necessary.
ministration of drugs that subtly of this change.
CMA JODUNAl./Sl PI IlMItlUl 22. 1979/701.. 121

719

• Prescribe chlonliuzcpoxidc or caffeine and small amounts of
ili.Tzepuin rulher tlunt other prod­ codeine (less than 30 mg). These
ucts. Agents marketed specifically agents arc no more effective than
for insomnia (e.g., flurazepam | Dal­ acetylsalicylic acid or acetamino­
matic'11']) are not proven to have phen alone.” Propoxyphene alone
clinically important advantages.
and in combination is not included
• Older patients should start because of its questionable effi­
with half the usual dose. When cacy,” relatively high cost” and ap­
morning drowsiness is a problem an parent risk of lethal overdose."
agent with a short half-life, such as
Indomethacin, naproxen, phenyl­
oxazepam (half-life 6 hours), should butazone, oxyphcnbutazonc. other
be considered. Similarly, a newly nonsteroidal
anti-inflammatory
marketed benzodiazepine, triazolam drugs and combination products
(Halcion1^), could be considered containing small amounts of acetyl­
when a short duration of action is salicylic acid must be avoided in
desired. The relative role for this individuals allergic to acetylsalicylic
new drug is not clear at present. acid since these drugs all cause
Both oxazepam and triazolam are cross-reactions.” Acetaminophen is
much more expensive than nonpro­ n reasonable alternative. Individuals
prietary diazepam and chlordiazc- who claim intolerance to a wide
poxide.
range of drugs may be sensitive to
• Exercise special caution in tartrazine, a frequently used colour­
prescribing standard doses for pa­ ing agent ubiquitous in medica­
tients who arc small or over 60 tions.”
years of age or have liver disease.
Narcotic analgesics: There are a
• Warn the patient of the un­ large number of analgesic-contain­
predictable and potentially serious ing narcotics (or opiates) available.
interactions of benzodiazepines with Unfortunately the names are suf­
alcohol, cold tablets, antihistamines, ficiently confusing that few practi­
other tranquillizers, hypnotics and tioners are likely to be able to keep
analgesics. Emphasize that such in­ them straight. Drugs such as hydro­
teractions arc more predictable -at codone (Dilaudid1®), levorphanol
the time drug therapy is started. tartrate (Lcvo-Dromoran1^). Panto­
• Do not provide more than 2 pon'11 (a mixture of morphine and
weeks’ supply of the drug initially, all the opiate alkaloids) and oxyco­
and do not allow for automatic pre­ done (Percodan'15’) can produce phy­
scription renewals. Reassess for sical dependence and differ from
continuation of medication, im­ meperidine and morphine only in
provement of symptoms and main­ potency." Opiates administered
tenance of other supportive meas­ orally arc often not as effective as
those administered parenterally be­
ures.
Non-narcotic analgesics: Table cause a large proportion of the in­
HI summarizes recommendations gested opiate is metabolized on the
that arise from reviewing analgesics drug’s “first pass" through the
with respect to effectiveness, toxi­ liver." The dose of morphine re­
city and relative cost. Of particular quired parenterally is approximately
note is the exclusion of combina­ one seventh of the oral dose.
Narcotic analgesics arc indicated
tions of acetylsalicylic acid with

for the control of moderate to se­
vere acute pain, such as postopera­
tive pain and chronic pain of ter­
minal illness. Non-narcotic anal­
gesics may be combined with nar­
cotic analgesics to produce an addi­
tive effect. Chronic pain of terminal
illness is best controlled by parent­
eral administration of medication at
regular intervals that arc sufficient­
ly short (3 to 4 hours) to prevent
the recurrence of pain. The usual
dose range of morphine required
for adequate pain relief is 5 to 10
mg every 4 hours; in small or eld­
erly patients as little as 2.5 mg may
be adequate. The initial drowsiness
associated with the introduction of
high-dose narcotic therapy is tem­
porary, lasting for 48 to 72 hours.
After this period the dose must be
titrated for the individual patient;
this is facilitated by the fact that
the pain relief threshold is lower
than the sedation threshold. In the
terminally ill patient, tolerance and
dependence on narcotics is not im­
portant. Excessive and unrealistic
concern about the danger of addic­
tion in patients with pain typically
biases toward undertreatment with
narcotics. Often an increase in the
dosage requirements heralds a
change in the disease status rather
than tolerance."

Management of physical
dependence

Any drug, if perceived by a pa­
tient to be essential, can be asso­
ciated with “dependence”. How­
ever. such dependence is not syn­
onymous with physical dependence.
The management of physical de­
pendence is relatively simple."-”

Table Ill-Guidelines for symptomatic
relielof pain
Table II—Tactics lor selection of a benzodiazepine
Indication

Insomnia with day-time anxiety
Acute anxiety

Chronic anxiety

Simple insomnia

Typical dose’

Drug

Chlordiazepoxide
or diazepam
Chlordiazepoxide
or diazepam
Chlordiazepoxide
or diazepam
Oxazepam

25 mg at bedtime
5 mg at bedtime
25 - 50 mg
5 - 10 mg
25 - 100 mg daily
5 -40 mg dailyf
15 mg, increasing to 30 mg and
then 45 mg, at bedtime

•Elderly or debilitated patients should receive lower initial doses — for example, 15 mg of
oxazepam, 2 to 5 mg ol diazepam or 10 mg of chlordiazepoxide.
tInitiate treatment with the lowest dose and increase the dose gradually according to ef­
fectiveness and side effects. The daily dose may be administered in two divided doses or even
ono dose, usually at night.

720

CMA JOURNAI./SEI’IT-MHI-R 22. 1979/VOI.. 121

Drug

Proven effective
dose when given
every 4 to 6 hours

Initial choice
AcetyIsalicyclic acid 650 mg orally
or acetaminophen 650 mg orally
If above ineflective
’
add codeine
32 mg, increasing
to 65 mg orally
If above ineffective
Codeine
120 mg orally
II above ineffective
Parenteral
narcotics
(e.g., meperidine
or morphine)

1 he cessation of drug consumption
120 mg generally indicates that the
in the physically dependent individ­ patient is not physically tiependent
ual results in a drug withdrawal re­ and is unlikely to have a physical
action, which is usually a self-limit­ withdrawal reaction. Occasionally
ing disturbance, seldom lasting supplemental doses of phenobarb­
longer than 2 weeks.’ Various ital given orally may be required in
studies have been done to determine a patient with rapid metabolism of
levels of drug consumption that arc the drug, resulting in rapid decline
associated with sufficient physical of the scrum phenobarbital concen­
dependence to result in a sympto­ tration and development of signs of
matic withdrawal reaction. How­ withdrawal." Oral administration
ever, the general applicability of of the loading dose may be more
such studies is confounded by inter­ convenient in some patients; 120
patient variations, the special pop­ mg of phenobarbital can be given
ulations studied and a failure to by mouth every hour until the de­
take the kinetics of the various sired clinical end point has been
drugs into consideration. As a con­ reached. Through titration of the
sequence, only a general guideline drug’s dose the physician can re­
can be given — namely, any pa­ duce his or her uncertainty con­
tient who is taking on a long-term cerning the adequacy of treatment
basis three times the maximum rec­ and effectively manage drug seek­
ommended dose <>l a barbiturate ing by the patient; clinical fluctua­
(except phenobarbital), nonbarbi­ tions during physical withdrawal
turate sedative hypnotic or narcotic arc minimized, so that drug-taking
analgesic should be considered at behaviour is not reinforced. The
risk for clinically important signs total loading dose and the peak
or symptoms of withdrawal. The serum concentration may be ob­
spectrum of withdrawal potentially jective indicators of the central
ranges from mild to life-threatening, nervous system’s tolerance to the
and the severity cannot be predicted drug abused.
for a particular patient beforehand.
Opiate withdrawal is usually not' Benzodiazepines
life-threatening, contrary to the per­
Occasionally patients who have
ceptions of “addicts” and the pop­
ular press. On the other hand, al­ been taking benzodiazepines for a
long
time or who have been taking
cohol.” barbiturate and nonbarbituratc withdrawal" can be life- extraordinarily high doses manifest,
threatening and may need to be when they stop taking the drug,
symptoms and signs including in­
managed in hospital.
somnia, agitation, diaphoresis, de­
creased appetite, seizures, twitch­
Barbiturate and nonbarbiturate
ing, recurrence of depression and
sedative hypnotics
exacerbation of psychosis.’ Case re­
Physical withdrawal is managed ports, unfortunately, have not dis­
by giving phenobarbital (10 mg/ml) tinguished psychologic dependence
intravenously in a dose of 0.03 to from physical dependence or the
0.04 mg/kg per minute until with­ reappearance of the symptoms of
drawal signs arc controlled." Vital anxiety, depression or insomnia for
signs, level of consciousness, short­ which the drug was prescribed. In
term memory, nystagmus, dysar­ addition, many of the allegedly de­
thria, coordination, ataxia and pendent individuals were using a
tremor arc assessed hourly during variety of other drugs with a far
the infusion. The infusion is ter­ greater likelihood of causing physi­
minated when the patient is able cal dependence. Furthermore, dia­
to sleep but is easily arousablc. zepam and chlordiazepoxidc arc so
This loading with phenobarbital is slowly eliminated that it is difficult
a safe and efficacious treatment of to accept that the physical depend­
barbiturate and mixed sedative ence could be unmasked. Unfor­
withdrawal; no further treatment is tunately, to simply stop taking the
required in most cases since pheno­ drug is not sufficient since it docs
barbital has a long half-life, which not provide an alternative problem­
ensures a slow decline in scrum solving behaviour.
concentration. A loading dose of
Most indications for benzodiaze­
phenobarbital equal to or less than pines — those for which the effi­

cacy of these agents is proven —
necessitate only 2 to 4 weeks of
therapy, and such short-term ther­
apy is not associated with clinically
important dependence. Al the com­
mencement of a trial of benzodiaze­
pine therapy the desired therapeutic
goal and the duration of therapy
should be identified.
Narcotics

The estimated number of users of
narcotics in Canada increased over
the period 1965 to 1974 from 4655
to 12 194 according to the bureau
of dangerous drugs of the Depart­
ment of National Health and Wel­
fare." Physicians must be extremely
wary of patients not well known
to them who seek analgesics by
name (c.g., Dijaudid® and Percodan1®). Such patients frequently
have an “opiate-seeker's disease"
such as' Crohn’s disease, kidney
stone, back injury, migraine or “ad­
diction”. The physician must insist
on objective evidence for the prob­
lem such as a previous medical
report documenting the presence
of the problem. Needle tracks
should be looked for while the
blood pressure is taken. The' pa­
tient should be asked if he or she
has received a prescription for a
narcotic from another-.practitioner
within the last 30 days (see sections
3|3| and 40 of the Narcotic Con­
trol Regulations).
Do not give even a small pre­
scription. These patients usually go
to many doctors. The physician can
most effectively manage patients
professing addiction by offering to
refer the patient to a methadone
clinic or to a hospital for manage­
ment of withdrawal. A firm, con­
sistent and sympathetic approach is
essential since the ability of multi­
drug users to manipulate physicians
will challenge the most astute, res­
olute and capable clinician.
Methadone is a long-acting
opioid used as a substitute for
abused opioids of shorter action.
Methadone maintenance therapy is
recommended when repeated at­
tempts at withdrawal from opioid
abuse are unsuccessful in persons
with long-term narcotic dependence
and entrenchment in the addict life­
style.” No study has proven the
efficacy of long-term methadone
maintenance therapy without ex­

CMA JOURNAl./SI-ITHMItER 22. 1979/VOl.. 121

721

tensive counselling and other com­ dures. Only authorized individuals
ponents of a rehabilitation program. may prescribe methadone.
Methadone withdrawal is generally
recommended for persons with Management of psychologic
short-term opioid dependence and
dependence
those under IS years of age; mo­
tivation to become free of opioids
For most patients, including
is essential. To establish that a pa­ those with an clement of physical
tient is physically dependent on a dependence, the main therapeutic
narcotic the physician should ad­ Challenge is to reduce the psycho­
minister intravenously naloxone, logic dependence upon drugs, ident­
0.2 mg initially, then 0.4 mg in ify the causes and consequences of
5 minutes. The signs of narcotic the dependence and design a treat­
withdrawal start in I to 2 minutes, ment plan that deals with each of
the peak effect lasts 7 to 10 min­ these areas. Since the causes and
utes and the duration of effects is consequences of drug dependence
30 minutes. Morphine, 5 to 15 mg, arc multiple and arc complex, the
can be given if the reaction is se­ therapeutic strategies are according­
vere.” If no signs develop, the pa­ ly multiple and. ideally, should be
tient is not physically dependent. In adapted to the individual patient.
addition to the naloxone test, an Nevertheless, it is usually difficult
assessment of psychologic depend­ to provide the psychologically de­
ence and motivation to stop taking pendent individual with an alterna­
the drug(s) is required. If the pa­ tive pattern of behaviour for prob­
tient is physically dependent 10 to lem-solving or support because the
20 mg of methadone is given ini­ existing behaviour pattern has
tially and then in 12 hours, to a evolved over many years.
maximum of 30 to 40 mg/d. Simi­
It is usually essential to have the
lar doses are recommended for the individual stop taking the medica­
management of narcotic addicts tion. This can be done in a variety
before and after surgical procci of ways — for example, by taper­

ing the supply. Such an approach
often ends up sis a time-consuming
and usually pointless scries of nego­
tiations between patient and physi­
cian. One of the most successful
tactics is to confront the problem
directly. “Mrs. Smith. I am con­
cerned that the sleeping pills you
are taking aren't working anymore,
and I think we should talk about
having you stop taking them." Pa­
tients frequently acknowledge that
the medication is taken out of habit
rather than for its therapeutic ef­
fect. Many have thought about the
problem and are relieved when the
topic is approached. There is no
scientifically valid evidence that pa­
tients will stop going to a doctor
when prescriptions for such drugs
arc no longer given.
The next step is to stop giving
the patient the prescription and to
.maintain a sympathetic but firm
hand on the situation. In the dis­
cussion of the problem with the
patient a full review of the level
of alcohol consumption is impor­
tant. Frequently alcohol is the most
important substance of abuse. As
few as four and six drinks per day

Combined Meeting of

Sydney Australia

Royal Australasian College of Surgeons

February 24-29, 1980

The Royal Australasian College of Physicians
and by invitation

The Royal College of Physicians and Surgeons of Canada
This unique meeting comprises symposia each morning; breakfast and
luncheon sessions, and afternoon meetings of the special sections of the Royal
Australasian College of Surgeons and certain special societies of The
Royal Australasian College of Physicians.

The meeting will be held at the Sydney Hilton and Wentworth Hotels and
accommodation has been reserved at both hotels for Canadian delegates.
There will be a varied social programme for delegates and associates.
For further information please contact:

Mr. Robert A. Davis
Associate Director
Division of Fellowship Affairs
The Royal College of Physicians and Surgeons of Canada
74 Stanley Avenue
OTTAWA, Ontario K1M 1P4, Canada
CM A lOURNAl./SiriliMlirR 22. 1979/VOL. 121

(one drink = one beer or 40 nil patient. The most important thing
in Social Aspects of the Medical Use
<>l Psychotropic Draps. CoorERof spirits or 116 nil of wine) in that can be done by physicians is
stock R (cd), Alcoholism and Drug
women and men respectively can to be far more circumspect in the
Addiction Research Foundation of
increase the risk of liver disease.
initiation and maintenance of ther­
Ontario, Toronto. 1974, p 9
In the long course of increasing apy with psychotherapeutic drugs.
dependence on drugs there can be
II. Martin PR, Karuk BM, Whiteside
disintegration of many aspects of We are indebted to Cathy Van Dcr
F.A, ct al: Intravenous phenobarbital
treatment of barbiturate withdrawal.
physical, mental and social func­ Giessen for her help in the prepara­
tion of this article and to Ms. M.
Clin Pharmacol Ther (in press)
tion. The degree to which each type .Holloway, pharmacy department,
of function is affected must be Toronto Western Hospital for her
12. Moertel CG: Relief of pain with
assessed completely, and specific revisions of the tabular material.
oral medications. Aust NZ J Med
steps must be taken on the basis
6 (suppl 1): 1, 1976
of the problems identified. Fre­
quently personal encouragement, References
13. Moeriei. CG, Ammann DL, TaYt oil WF, cl al: A comparative evalu­
direct intervention or counselling,
1. Si.i.li-.rs EM: Addictive drugs: dis­
ation of marketed analgesic drugs.
or a combination, is necessary be­
position, tolerance, and dependence
N Enpl J Med 286: 813, 1972
interrelationships. Drux Metab Rev
cause the patient's capacity to cope
8: 5, 1978
with the conventional demands of
14. Siurner WQ, Garriott JC: Deaths
society is impaired. Psychotherapy
involving propoxyphene.-A study of
2. MacI.i.od SM, Gins 1IG. Patz.au k
sliouid aim at replacing drug con­
41 cases over a two-year period.
G. ct al: Diazepam actions and plas­
JAMA 223: 1 125, 1973
sumption by more effective prob­
ma concentrations following ethanol
lem-solving methods. Many com­
ingestion. Ear J Clin Pharmacol 11:
15. Parker WA, Shearer CA, Kirkmunities have mental health, social
345, 1977
Pai kick SI.: Canadian drug prod­
service or self-help groups or as­
ucts containing ASA. Can Fain Phy­
sertiveness training programs that
3. Gll.its HG, MacI.i.od SM. Wright
sician 23: 848, 1977
can be very helpful. In particular,
JR. ct al: Influence of age and
previous use on diazepam dosage
groups that have focused on the
16.
Barter WR: Tartrazine-containing
required for endoscopy. Can Med
special problems and requirements
drugs. Can Med Assoc J 115: 332,
Assoc J 118: 513, 1978
1976
of women have become interested
in this area. Since women much
GKl.iiNnt.ATT
DJ.
Shader
Rl:
17.
Jaffi; JH: Narcotic analgesics, in
more commonly receive psycho­
Dependence, tolerance, and addic­
Pharmacoloxical Hasis oj Thera­
therapeutic drugs, such a develop­
tion Io benzodiazepines: clinical
peutics, 4th cd. Goodman L-S, Gil­
ment is important.1* Information
and pharmacokinetic considerations.
man zk (eds), Macmillan, Toronto,
Drug Merab Rev 8: 13, 1978
about existing community groups
1970, p 237
for women can be obtained from
local community information cen­
5. Gki inhi.att DJ. Shwik RI. Kor n
18.
Berkowitz BA: The relationship of
Wr.si
a
J:
Flurazepam
hydrochlo
­
tres, provincial governments or the
pharmacokinetics to pharmacological
ride. Clin Phaimacol Ther 17: 1.
women’s program directorate of the
activity: morphine, methadone and
1975
naloxone. Clin Pharmacokinet 1:
Secretary of State (15 Eddy St.,
219. 1976
Hull, PQ J8X 4B3). The federal
6. Si units EM, Kai ANT II: Drug
government has published the “Di­
therapy: alcohol intoxication and
19.
Mouni BM: Palliative care of the
rectory of Canadian Women’s
withdrawal. N Enyl J Med 294:
terminally ill. Ann R Coll Physi­
Groups 1977", which is not gen­
757, 1976
cians Surg Can 11: 201, 1978
erally available but can be obtained
through the Secretary of State.
7. Kai ant H, I.eBianc Alt. Giiiiuns
20.
Jacoii MS. Si.i.t.t.RS EM: Emergency
RJ: Tolerance to. and dependence
In general, few family practition­
management of alcohol withdrawal.
on. some non-opiaic psychotropic
ers are able to personally conduct
Drop Ther (Hosp) 2: 28, 1977
drugs, Pharmacol Rev 23: 135. 197 1
the full range of support or coun­
selling services (hat may be re­
21.
Smart RG: Drug abuse and its
8. St 111.RS EM. Cai-1‘1 it HD, Marsh­
quired. Psychiatric management
treatment in Canada. Addict Dis J
man J A: Promoting anil measuring
3: 5. 1977
may be necessary. However, co­
compliance in the control and treat­
ordination of the various treatment
ment of-alcohol abuse, in Compli­
22.
Goidsiihn zk: Heroin addiction and'
modalities may be carried out by
ance with Tlwrapcatic and Proventhe role of methadone in its treat­
live Reximens. H \s i s RB. Taviok
the family physician or by another
ment. Arch Gen Psychiatry 26: 291.
DW. Sacki it DI. (eds). Johns Hop­
responsible person with interest and
1972
kins. Baltimore (in press)
experience, such as a social work­
er, a psychiatrist or a public health
23.
Zu M DH. St t t.i rs EM: The quan­
9. SitiirsFM: Clinical pharmacology
nurse. The essential role of the co­
titative assessment of physical de­
and therapeutics of benzodiazepines.
ordinator is to be familiar with how
pendence on opiates. Drax Alcohol
Can Med Assoc J 118: 1533. 1978
to use the' resources available in
Depend 3: 419, 1978
the community, be able to design
10. Mokiusos AB: Regulatory control
and coordinate an overall treatment
24.
Cooi't RsiiK K R: A review of wom­
of the Canadian government over
en's psychotropic ding use. Can J
plan and be prepared to provide
the manufacturing, distribution ami
Psychiatry 24: 29. 1979
prescribing of psyeholiopic drugs.
ongoing, long-term support to the
724

CMA JOURNAl./SEPTEMBl'R 22, I979/VO1-. 121

..Icobolisri is & .'icjor prabia-i In the country - urbm c.% rar®l,
Uifbrtwietely, ;r>t
feiportcnco be,3 b vn paid to this ; eobloc,
..v nr© a;:-7Q oS too iaUivldanl, f roily x..: soMsl c.'-isG^onoos, olootollsn
Is u ;.cobl® ■ -x j&n fatly, it sosaltr to ’jtwhm up fruillss, &>
ttoabty, one out of ton dlvams wo is>x«to •■/: ■" ’ >-Aol <a Jwsb^e’s. . ’a
•k> ...Oi ix-va
i,io-!,at (into ebtot Wo otfet of Wo ■jWb.io't, especially
In f.-t wsosn-ni^ja r?«I rurl - >• t-x-» Xt is ostib tai Wet there
®t
3 t-Jllton ■ -iCsMI®
*
it toe ow.atsy (put pf f .-x?t &) "T:.:iw I.yJ,i.-u8
©jus&se p.coaol)
*
’*3»o toSlta Corneil af
I iiasm'oa study fo
lor-,-9 ' .-ibi,
; -.C :><iord
f‘-t
of usrbta corssu:-rs
of ^taotol bai b6&«® totally depctriwrt eg it, Za the vilX;gee» th©
'1 -'■■ X .X..
?» .//?:.■ tVitO
<■ ,". j, ,; £b-;fe.stjrws
*
XX:..X:.
4riafcto0 » drinkii.. ;on£« to &nrtrcd «w& p^r;x/.xi® cot? deeseas
*
la
prjuucti-tty»

2,
18 chr.rrtorlaed by ftojasslw use of rdeofeoX which
■;.,'njl.. rosalt ia
tional iuacti;ning» Bie eosaoaie
casts ob’ sXcK&oi dago n-c sofestmicl. vilh tosu ■>£ jc-b, aaa&iMSt
e::i'O d
GCWid. ffc3bi<KiS. 'b i.a
X .'cv..;’, : ■
bx
laic’s to . '..-:i:y cisu;-ios» iaols^iug outa^sXs ©C .live;
tJi8ut'S..s "■£
W© nctvouB sysusuj it is r ils
*c
£»tor ii tbo crusj-tlta of © SKri>a?
of dir.-a‘S . AlQfl&uXi® c’v.sos QKtmsiw ■ :■ G-^vai’s dyafractloa <J
th© t!0aj,tb» with aa &O£err$cd da-.K?-'.d £.;? ..-/ ita O;«o
viaos. '<<z;
risfc \
bi. ./ b:;;.e •■'■- :b ..; ■ r ...b r i.:;.br..: .
is bi'3 Ca
foar ti ss t?.
*'t
f-w the -jawr 1
b: ;iord©BG drln9ci&g KCKrstod
for o lob. loss of paUutial yews of xW
*
3» aMMMMKapst uoeK driulilntf ’is fnirly coixoa. If ifciltai, Wore
...:C bo ' ^iobbaT, -i'.:. :-■ bi.:? C'J-xs ■-■ r i b ;.. ;.x'.x. '.cc.: :cc jVdicWd
to Ofxi
m slcefjol
*
It Is ax^rotostiKd by to© Ctovolor cat o£
taler..- .;oat hgIog Snora; slag r «mts to sshicv© tho desired rc-salts ■ ::J
witadrsBsi
*
occu
v/uea tu© pergsw rodw&a or stops tbe iatrhe
Of isoliol •

ii^sij.s-i-as j.?■•/ v'adarst dOiX! people mi' ai-a psaao to i&&os® proUoa
drintears. It boa 5eai said tbst thuro is *n plO'tioilo persondtty * '
i..pulsL'lty, poor eelf-otuen, lor; ago str;;-.:;jtb dur’ ;< dsttdtered aid
ed lesccnen. CxiJuct diampdfirs '•■■■■<-ay predispose
to rloobaUgss, es Mso uintoal brnisj dys^aotioa, "icouolto nqy bo
87©q rxM» «cu..3»ly In ccrt-ia fssllias, prt^rbiy tooro
go««tic
factors pI so fcHMlvod,
ftMMrfpi|<>lap faetaftM .'*K®g too ^oipitu-ias c’ticss wo loss of job,
dor-tb of r Bpotiso ami sitantloadl ehong&s, feprcyoma.1 in fac-jc® oca
tmjtlxs tool to ojswssiw drtatetoa.

r-looboitsa iw **
> waparl-voa0** iJQ » pWMsdsttoy psyobirtrio
rboMBaallty liferduprusslon or sahiaophsreri;:
*
In sum's ©ss©s» etoJauJisa
asy bo iMMrleuic Sa ftrture rad responds wall iv W-> yaeat of We prfcarey

*
uiswracr

cute 1st ralcsttoo is usurlly duo to uxc.'sslve -.urn titles
or oleohol Sra.to; .- -<KJC^ -,^y a short
(usonlly to blow’, levels are
■jre t -n l..' ? uj par (JI). Too «V-g& of to teak. ti-jo ary i.-r.t mw upto
12 hones ■to:.? r.:0;< Sag dylaLin... Tto? jxsrsjn -y bchraro in ’istoliibited
or vio&eet nr.-.:®r ra-1 :aiy h-ve loss ef ?«wry for thu period of
l-s; •.raiontton (cl-obuiIo Ueckout). to s«.» people
prthologloeft
tot«sie-■<!<«, ito cggvessive tad otter boh w Soar dl c • ages n;y occur
to ter indulging to rarahol to •-.« riititios ouch roller thm t!.:. usual.
-> toXiaoiar.i . toppogo of rlcotel rfter . rei<»f;od drltoing .'.-j
result hi ..tottersial syrgpt-w. These wsy fro olid * tscaon of the heads.
rauscr ?ra v.v.Uto '« rato.oty or irr£t
bility
*
-.;to insoraln. to severs
fvsne. It v-.ny leal to so.:;'!,iiioaB («kj fits or ?:ito.tora:i seizures). The
Mocoat fora results to wliriu : traaors. oocurtog within one week of the
rotfuotlOS or coBsetion of .'...; -vy drinking. to.?.. sywptOQS consist of
*
tosoanis
illusions, linlieotoctions (oepooieliy vlsu.'l). rostlossaoso rad
trooors of the ..rad, tots parson nay b-vs foverj tiohyjrntlou -y bo
pr .'- ’t.

?:

. 1,:? <X.: 01O \

\

'X

■ h .h?>

disortoutotlixi. coufusicc '.-id ajrossivc Lch viour • ••y t.- soo. i%t>drinkin;t
-oiore In pv-xipit. ting dollriui trooors w> :.”ou':o’ji-. faeod injury n:-<J
f.
liv.'i' uise ao.
-'leotelifea in. .la'iustrgi .'. o rdvorso of&cts of /rcblcn ilrto-jto,
produotivlty. to vo >ui kuII rooognlO’od. Tao ■-.-as ;s« xatj l-w iieca®
'.•■■.■.laotous ojT the robl-ss »»•: '■ ■:>: f.-aai-l 'r.<: /catwilc c aisc^ajcoe. .ray
prsgrsi ns to tel-.: to -• eaployeoa clve ap OKCCssive :rtoJiin:j h' -.n teen
tostitotod. ?o.\; of
sooc.ravlul .••».' tto; tpr!; .?! «•?,
J .......
•.: ■;'• .£ rcu to t . V..-"hto.to tin
rgoygitloni fta aciph.-sis will bo ^.1 ranveatto n»«jos»ive (JrtoL’to before
ONI ,n'
oriscs. ...I, ■. to. :...:
Luj
C:.;.nnto : z; ■■; ?■:.. ;. to .
lito'lyhood of too ; roblo.:. Courson \4U ■.•■ cratojeted for to.-.; steff (ntcag
v.lth their frail.ice
supervisory persouael If possible), ’too staff
will else be trrtoed to dot• ot 0-.toy signs rato CiQptoa® of ratolara orinblo.
nostlonniros will be developed niu eitafcii sterad to ixj strff.

i'T0bia3 drinltite Is rftoa mraifest
by laprisod work • e.toomaica -ud rbscntoesfci. Bto^so .fori tests rad soH-tsti')
•’postionriro# ci» sovcrl the problou ■•ad load to t-raly dotvotioo of t”.o
problea drtofciag. .'loohoUrolrjial dis.r.bli.Stlos arc :. mjor esaao £ r
aodioel e-aouitotiono fcritb varied present: tions of iajury» stoopleswssa,
asBseo rad voaitiaot ot©j. in sueii ofsos» ehijft dogroo c£ aisplcioo oust
bo kept to '.jfcdt so tort clMbol»r§lr.tod dluefrUlties xy be datactod orrly
iatervutting rt e stege aboo tte drinking boh:-vfctw is K»rc orxieblo to
trerfcionl. v^-nk liver disontors, lilta aur.-tesio of th© liver md serves
•Jisurdazs are Ide scaifestniiiMSf i;hsa it twui.i h-a <ao difficult to worn
toe person w-y fr 1 drinking.

■ niEibor of lastrincutg --tg qiasci .•ariros lr vo tom
to help
i9 t’.;'.i dingtwai
*
of Moo tai ■.'•■-':■» (UM ..tea Ixilng t& I G:,' C.V.: kti 0'1
owieil oi‘ ' 1 octal Iso
*
.» tta
"iGobollan r-srooninc -'--’st
■’d the "tasinb Mcotalias Xeot. ihoy uca tta ^-isysU .»» nooSd
*
fcitrrperscQnl
;; yotalogio tta ; foor-t '-aj critorln
*
»horo r--.-.- ■clialzr 1 fodie tl>,w
of rlcoaol :’•»!»•

Cne of V- crxlieBt to<Hc cicao of dcctal abase is 0 growing
c^joorn or worry ?tant ©I’BMnl driaidn,; Irbit: «

U3»morv..a- r^rsi .'Jacyno stylos ora ivro: 1 flcmtal rf»ee: cortri
jrvoa • yiutc. .yl tr~ib>,...‘Uf-'fc rcost® -Bprrt'to t.: dnotr ir’oirso cco
incra.'uud 1. sloutaliu-. Xta norn &or..O3csla
*
v<floe ef fd-.s Is rlsad
/.:■ - O.u of pdcohollcs. eras iKg’. x.^lty Uproprotoln -talesterol level
13 srisx 2-; 10 - '■ .'. .
.itaCWXl WJCCfitn 1100 of 3CJUQ bile ccitls ,.-y :o
g ocnoitiW lad-Senior
rlestalio liver i;icor?c.

1
.yU; ’XOo t£v;-C
i-;.
J'X'
t'rij’xr
i
be r.»tlvnt<xi to seel; help ao fustOex- oiivaied to
ti.c b-bit of
OrSn’dnj. Jiir.a-joos■•■ to tKJdo&’oo tejrx ■■:.:& is i porimt for tl;' susoqss
of
••.-..%» It is r.x; t ffiiceeuyxui in
cionis u;o h';<- not re clcG
'-ev. .’cod s c jc of nloctal nbuse.

;:.■

•■

w. tfc-at c:--;- cteristies urte n jro--'.tcr a.,7aot « tta onto .•.:» then
. .. ■ ...... s
..! : .diy
'. : - tr;
*
it

Ilia tyrfiost will ■■■-. ctrried out by tto aueaftlttog psycuiatrio
sort'lco. the teia »ttl aoasist of
(1) Consultrct psychiatrist
(li) CXtHcnl psycMltfUt
(liD social tfOfcior

in Xnuustries
*
the ^ersoosoX icifwa Gffleov xe ottar siuliir pers .'aa
will bo nsfiooioteil with the pregrfmo
*
ftypgjfomm op^-arraSi ■ yood history (iaeivldual, f?«l.y, oe:u;)eti-»ni
md social) is n requisite
*
Sbo oarreot at-tus with rospoot t- aisobUitles
related to dlcohal abuse nuat be determined
*
Iho psyctasoolrl pr<?blefls
sol- tod to dytofetoo ‘fld dq'jX'Cnce oa cioobol anct be stodlcd
*

Cottoy&llinc .eaaploct On© or :©re counsoiifec scoiass cry bo bcrtoffcldL
*
«i0 stMMVMiat is ravicttol with the pattani nsd the fcrjorrto frt-lly
*
CHphissising lb© rwpjwsibllit/ Q~ t^® P’titBt rtKl the trolly to
eitfe the
*
jjk-oblcK
Tbo persoot to-jetbor with the frtiliy
*
shailu be talped to sot
goals with rosyoot to nit.j ©i use iatataiatag £r>a aic.holt etc)
*
pers-sit
*
health
t.'orb ■ad hitesperBonti reV'tjaashlps. Ita p-ttot md .;c^ors of
the f-«lly BUould be givea odnonti-jo enteric! on nleotal
*

- 4 -

2&orc will t» need for tre.--tiwnt -,^t
withdrawal synptxis idiiob g.md ba cheated to occur in «a dccholic.
itsc geocr-i nutrition will have to bo iaprovotf, frcmsdllMrs »y help
?t t.iio st&je
*
detoxification wag be nocessasry. ^syehotkerrpy
(Individual md group) any be required for the underlying eaotioasS,
probless. 5irjgr psychiatric <lGserders, If pws».itg will hare to ba
d~aXt with :p;.rci>riirtoly» IjOlirvlonr rad electrical wjralosi therapy
asy 1» useful.
.'t irter st
diculflrra (Antabuse) may have to rse given,
after infotnlng the person of the ccnceqitsr.ces of tddng alcohol.
*'cr.wly
<dst
uapleaSant systemic rerotions cm arise after the ingestion of
even snail onounts of alcohol. feisulfirns is gives la s dose of 30Q - Sbo ag
doily (Initial dose c.;?y be hl$i, reducing to about loo - 200 eg dolly
letcsr as). Olsulfirso lords to the mcwidutic® of fcetclddiydo (the
product of the first step of addition of r-iooboi}» m it blocks tiio
activity .of the ensync, aeotBlciehyde dahyclsogem sc. deactims
*
include
flushing of the facet healnete, pal citation, uausoa red voraitiug. '.’itli
larger cnounis of alcohol. csrdi«e errhytirnias
*
hypotension rgd colxjpso
a^y occur.

Fol low-lip 3 Frequent rnd sustained £oll<Jt>fip is uecossfary for the success
of obstincnoo, fiic.-?. who drop out .just be identified without loss of
tfe aid the fmllfes oixitroted. delopa.:& ers cox^on within the first
ye?3r tad so the f'c'ilft.wdp tanst bo carried out vigorously at ieost during
this period. 3&o socirl worker s’/oulo 11 alto constrflUy with the pernoo,
tint fraliy. the .'.tac^uaort rad pc-rewel deprsuoeat to detect droupoats
and bring than for ctnsultr-tiou, c:4mselllfl; rad other thor.-py ns
necess' ry.

Ute preogreews of preventing j^roUca d^lnkinG, detection ;.-f.
eleuboliaa and troauxxst is© highly cast-fiffcxstlrc i& reducing loss of
productivity, boosting raorriu sad proven tiny or docro. sing ejtpoadlturo wi
i30dlG»l ttoniiaeal of oon.iitims arising out of excessive c^sisaption
of nlcohol. Trcs-tacat of the problea drinkers os® here beneficial effect
an other staff in the industry.

FAMILY PROCESS

22.

23.

24.
25.

26.

27.

28.
29.

30.

31.

32.

33.

34.
35.

36.
37.

38.

/

123

Smith, C. J., “Alcoholics: Their Treatment and Their Wives,” Brit. J.
Gliedman, L. H.. Nash, H. T.. and Webb, W. L., “Group Psychotherapy 39.
■
Psychiat.. 115: 1039-1042, 1969.
of Male Alcoholics and Their Wives,” Dis. Nerv. Sys., 17: 90-931
40.
Steinglass, P.. Weiner, S., and Mendelson, J. H., “A Systems
1956a.
Gliedman, L. H.. Rosenthal, D., Frank, J. D., and Nash, H. T., “Groujj
Approach to Alcoholism: A Model and Its Clinical Application,”
Arch. Gen. Psychiat., 24: 401-408, 1971.
Therapy of Alcoholics With Concurrent Group Meetings WithThei
Wives, Quart. J. Stud. Ale., 17: 655-670,1956b.
-11. Steinglass, P„ Weiner, S., and Mendelson. J. H„ “Interactional
Jackson. J. K.. “The Adjustment of the Family to the Crisis of Alcr. j
Issues as Determinants of Alcoholism,” Amer. J. Psychiat., 128:
275-280, 1971.
holism," Quart. J. Stud. Ale., 15: 562-586, 1954.
Jackson. J. K., “Alcoholism and the Family," Ann. Am. Acad. Pol::'42.
Steinglass. P.. Davis, D. I., and Berenson, D.. “In-Hospital Treat­
ment of Alcoholic Couples.” Presented at the American Psychiatric
Soc. Sei., 315: 90-98. 1958.
Association Annual Meeting, May 1975.
Jackson. J. K., "Alcoholism and the Family," in D. J. Pittman and(R. Snyder (Eds.), Society, Culture and Drinking Patterns, Ne,| 43.
Weiner. S.. Tamarin. J. S., Steinglass, P., and Mendelson, J. H..
“Familial Patterns in Chronic Alcoholism: A Study of a Father and
York, Wiley, pp. 472-492, 1962.
Keller, M. (Ed.), “Trends in Treatment of Alcoholism," in Seconci
Son During Experimental Intoxication,” Amer. J. Psychiat.. 127:
Special Report to the U.S. Congress on Alcohol and Healtt.l
1646-1651, 1971.
Department of Health, Education and Welfare, Washington, D.C.,1 44.
Westfield, D. R., “Two Years’ Experience of Group Methods in the
Treatment of Male Alcoholics in a Scottish Mental Hospital," Brit.
1974, pp. 145-167.
I
Kelly, D.. “Alcoholism and the Family,” Md. State Med. J., 22: 25-X|
J. Addict., 67: 267-276, 1972.
1973.
I 45.
Whalen. T., "Wives of Alcoholics: Four Types Observed in a Family
Kogan, K. and Jackson, J., “Stress, Personality and Emotiomj
Service Agency,” Quart. J. Stud. Ale., 14: 632-641. 1953.
Disturbance in Wives of Alcoholics,” Quart. J. Stud. Ale.,
46.
Wolin, S., Steinglass, P., Sendroff. P., Davis, D. I., and Berenson,
D.. "Marital Interaction During Experimental Intoxication and the
486-495, 1965.
|
Macdonald, D. E., “Group Psychotherapy With Wives of AlcoholitxJ
Relationship to Family History," in M. Gross (Ed.), Alcohol Intoxi­
cation and Withdrawal, New York. Plenum Press, 1975. pp. 645-653.
Quart. J. Stud. Ale., 19: 125-132, 1958.
Meeks, D. E. and Kelly, C., “Family Therapy With the Families
!*
Reprint requests should be addressed to Peter Steinglass, M.D.. Depart­
Recovering Alcoholics, Quart. J. Stud. Ale., 31: 399-413, 1970. | ment of Psychiatry and Behavioral Sciences, George Washington Univer­
Paolino, T. T. J. and McCrady, B., “Joint Admission as a TreatiMsjsity Medical Center, 2300 Eye Street. N.W., Washington, D.C. 20037.
Modality for Problem Drinkers: A Case Report,” Amer. J. Psychl
*-$
133: 222-224. 1976.
j
Pattison, E. M., “Treatment of Alcoholic Families with Nurse Host
Visits,” Fam. Proc., 4: 75-94, 1965.
Pattison, E. M., “A Critique of Abstinence Criteria in the Treatment®
Alcoholism,” /nt. J. Soc. Psychiat., 14: 268-276, 1968.
K
Pattison, E. M., Courless, P., Patti, R., Mann, B., and Mullen, 5|
“Diagnostic Therapeutic Intake Groups for Wives of Alcoholics.
Quart J. Stud. Ale., 26: 605-616, 1965.
Pittman, D. J. and Tate, R. L., “A Comparison of Two Treatasf
Programs for Alcoholics, Quart. J. Stud. Ale., 30: 888-899, 196?- .
Pixley, J. M. and Stiefel, J. R., “Group Therapy Designed to Mee!f|

Needs of the Alcoholic Wife,” Quart. J. Study. Ale., 24:
1963.
-‘f
Sands, P. M. and Hanson. P. G„ “Psychotherapeutic Groups®
Alcoholics and Relative^ii an Outpatient Setting, Int. J.
Psychother., 21: 23-33, i0i.
•»

Ub

/

AMII.Y PROCESS

Washington, D.C., Social Rehabilitation Service. Department of *
Health, Education and Welfare, 1969.
6. Mindel, E. D. and Vernon, M., They Grow in Silence—The Deaf Child !
and His Family, Maryland, National Association for the Deaf, 1971. ,
7.
Moores. D. F.. “Psycholinguistics and Deafness,” Am. Ann. Deaf. H5; '
37-48. 1970.
8.
Rainer, J. D. and Altshuler, K. Z., Comprehensive Mental Health i
Services for the Deaf. New York. Columbia University. 1966.
9.
Rainer, J. D. and Altshuler. K. Z. (Eds.). Psychiatry and the Deaf i
Washington. D.C., Department of Health, Education and Welfare, j
1967.
10.
Rainer, J. D. and Altshuler, K. Z„ Expanded Mental Health Care far I
the Deaf: Rehabilitation and Prevention, New York. New York State I
Psychiatric Institute, 1970.
PETER STEINGLASS, M.D.+
11.
Rainer, J. D., Altshuler, K. Z.. and Kallman, F. J., "Psychotherapy |
for the Deaf,” Advances in Psychosomatic Medicine, 3: 167-179.1
1963.
12.
Robinson, L. D., "Group Psychotherapy Using Manual Communica-j
tion,” Mental Hospitals, American Psychiatric Association, 1965. I
13.
Robinson, L, D. and Weathers, O. D., “Family Therapy of Deal
Patients and Hearing Children: A New Dimension in Psycho-!
The attention given family therapy approaches to alcoholism has
therapeutic Intervention,” Am. Ann. Deaf, 119: 325-330, 1974.
I
been disproportionately low in relation to the magnitude of alcohol
14.
Sarlin, M. B. and Altshuler, K. Z., “Group Psychotherapy with Dee;?
Adolescents in a School Setting,” Int. J. Group Psychother., 18:1 abuse as a clinical problem and its acknowledged impact on family
life. Although the literature to date is limited and most studies
337-344, 1968.
15.
Schlesinger, H. S. and Meadows, K. P.. Sound and Sign: ChildhootSshould be characterized as pilot in nature, preliminary results have
Deafness and Mental Health, Berkeley, University of Californiij enthusiastically endorsed family therapy approaches to alcoholism.
This critical review assesses the existing experimental and clinical
1972.
16.
Vernon, M., “The Final Report” in Grinker, R. R. (Ed.), Psychia^l literature of the past 25 years. It also offers potential explanations for
Diagnosis, Therapy, and Research on the Psychotic Deaf, Washing-I the reluctance of family therapists to engage this problem more
ton, D.C., Social Rehabilitation Service, Department of Healt^j actively.
Education and Welfare, 1969.
£
onservative estimates indicate that at least 9 million adults in
Requests for reprints should be sent to Rodney J. Shapiro, Departmental

Experimenting with Family
Treatment Approaches to
Alcoholism, 1950-1975:
A Review ’

Psychiatry, University of Rochester School of Medicine, 300 Crittend#
Blvd., Rochester, New York 14642.

•

C the United""States abuse or are addicted to alcohol. Less

conservative estimates range up to 15 million people. A stream of
reports from both scientific and government sources have called
attention to the fact that alcohol is once again the drug of choice of
lhe American teenager. Financial estimates indicate that alcohol
( The preparation of this paper was supported by Grant No. R01 AA 01441 from the National
nsutute on Alcohol Abuse and Alcoholism. The author wishes to thank Ms. Lydia Tislenko for
-rr assistance in the preparation of this paper.
, + Assistant Professor, Department of Psychiatry and Behavioral Sciences; the Center for
•mily Research, George Washington University School of Medicine, Washington. D.C. 20037

98

/

FAMILY PROCESS |

/

99

abuse exacts a staggering toll on American industry via absenteeism, s clinical interest focused on disturbed communications! patterns and._j
interference with performance, and interference with sound judg. | Structural dissonance within the family. Although these phenomena /
ment./lhese dramatic “tips of the iceberg" indicate that alcohol | are hardly absent in the family with an alcoholic member, the /
abuse in our culture carries with it staggering social and psychologi- I. abusive consumption of alcohol and its attendent behavioral and j
physical consequences appeared at first glance to be so overwhelm-\
cal consequences.
The pervasiveness of alcohol use and abuse in the United States is | jng that it was hard to imagine successful treatment being achieved '
of such proportions as to guarantee that any mental health profes- | in any way other than intensive work with the individual who was i
>
sional practicing in this country will be working with a significant ' doing the drinking.\
number of patients whose use of alcohol has reached abusive |
Despite these obstacles, family therapy techniques have been used
proportions./For family therapists, who traditionally work with ;; with increasing enthusiasm in alcoholism treatment. In recognition ,
groups of tvVcror more adults in conflict either with each other or | of this trend, the Second Special Report to the U.S. Congress on
with their adolescent children, the likelihood that one member of | .Alcohol and Health (27) called .family therapy “the most notable
this group abuses alcohol becomes even greater. It seems._clear, I current advance in the area of psychotherapy (of alcoholism)." We
therefore, that treatment techniques for alcoholism should- be..of | will review this development historically, paying attention both to
theoretical trends and to those innovative experimental studies that
primary concern to the family therapist^
Whereas previously alcoholics were conceptualized as homeless, g have advanced the field. Although somewhat artificial, we can
jobless, physically ravaged individuals with meager psychological | divide the existing literature into a four-step sequence that roughly
resources, it is now clear that this “end stage" alcoholic is most I builds one on another. Initial interest (1) in the "alcholic marriage." ,,
unrepresentative of the patient population that abuses alcohol.(A I led to (II) experimentation with concurrent group therapy tech­
significant, if not major, proportion of the alcoholic^ population | niques. Later interest (III) in application of new family theory
continues to function within nominally intact and stable family I concepts to alcoholism, led to tentative use (IV) of more traditional
systems, a natural clientele for the family therapist. Therefore, I family therapy techniques for alcoholism.
whether or not the family therapist feels alcoholism per se is a |
condition appropriately treated by family therapy techniques, the I
I.
THE ALCOHOLIC MARRIAGE
symptom itself is so pervasive as to be virtually unavoidable. As we s
shall see in our review of the literature, however, alcoholism 1
Scattered reports concerning family factors in alcoholism had
therapists have come relatively late to the family field, and family'£ appeared in the literature prior to 1950, but the first concerted effort
therapists have only recently begun to view alcoholism as an area of | in this direction was a series of clinical reports about marriages
interest. This mutual disregard is frankly not at all surprising.
ff between male alcoholics and their wives (2). The primary concern
\From the perspective of the traditional establishment in the
centered on the role of the wife in initiating and perpetuating her
husband’s drinking. A debate arose between a faction represented
alcoholism field, the priority issue has been the transformation of
primarily by psychiatrists and psychiatric social workers who viewed
! alcoholism from a moral problem into a medical problem. This
the wife of the alcoholic as a person with severe, longstanding
conversion has been seen as a necessary prerequisite for the transfa
of responsibility for alcoholism treatment from the judicial system | psychopathology antedating marriage, which led her to choose an
:
alcoholic
husband as a wdy of satisfying and stabilizing intrapsychic
into the medical establishment?) With this goal in mind, the
need^ (4, 19), and a faction represented primarily by sociologists who
emphasis has been on the medical model. Alcoholism is viewed as J
disease process with an etiology, a set of symptoms, a typical course, i explained the behavior of these wives as directly resulting from
and a predictable prognosis( However, the medical model is.designrf i having to deal with the repetitive pressures and stresses placed upon
primarily to describe disease processes as they affect an individual ; ’he marriage by the husband's drinking (24, 25, 23, 29). In retrospect.
I ’his debate was probably artificial. The most recent review of this
Hence family therapy feels strange and foreign.
("From the perspective of the family therapist, on the other hand. i “terature (13) concludes that no convincing evidence has emerged

/

•
suggesting a single personality “type characteristic to wives of |
alcoholics, or a theoretical explanation of their behavior.
In any event, although interactional models were being proposed I
to explain behavior in an alcoholic marriage, most of the clinical I
data stimulating these ideas came from individually oriented *
therapy or research. For example, a clinician would be impressed i
with repetitive stories of inconsistent behavior on the part of his |
alcoholic patient's wife in which the wife is described as keeping the f
liquor cabinet well-stocked, pouring drinks for her husband, and I
making excuses for him in his w’ork situation, at the same time that t
she is complaining bitterly about his excessive drinking and threat-1
ening to leave if he doesn't stop. Only rarely was this clinical data I
verified via a clinical interview with the wife as well (30, 45).■
Sociologists, on the other hand, obtained much of their data directly 8
from wives, and had little opportunity to substantiate these reports a
via direct observation or collateral interviewing (24, 29). >
However, these studies were important in providing a changing®
focus for therapy. Whereas earlier studies focused on family issues 1
only from an historical perspective, the focus on the alcoholic
*
marriage was a focus on the here-and-now/As long as the alcoholkfe
individual was viewed in isolation and expIanationOorJtis or hal

abusive drinking weferetated only to individual psychodynamics~org
pathophysiology, the only logical treatment approaches would bel

individually oriented. If,{however, questions were raised about the £
extent to which an interactional relationship between a husband and!
wife might either cause or perpetuate abusive drinking, then logics
would dictate that a place had to be found for the spouse in tht?
treatment plan;- As Joan Jackson (25) has noted: “Once attention#
had been focused on the families of alcoholics, it became obvious!
that the relationship between the alcoholic and his family is notig
one-way relationship. The family also affects the alcoholic and his£

illness. The family can either help or interfere with the treatment®
process’’ (p. 91). Jackson therefore concludes that significant family®
members must be taken account of, if not actively involved, itg
treatment in order to achieve success/^

II.

CONCURRENT GROUP THERAPY

FOR ALCOHOLICS ANDj

SPOUSES
In 1954, a project was instituted in the outpatient department o!s
the Henrv Phipps Psvchiatric Clinic at the Johns Hopkins Hospital

|.!

101

involving concurrent group meetings of male alcoholics and their
wives (21, 22, 23). This project represented the first attempt to adapt
the most successful psychological therapy approach to alcoholism,
<rroup therapy, to a family orientation. Nine male alcoholics and
their wives were recruited and placed in two separate groups, one for
the alcoholics, one for the wives. Thus, once they had volunteered for
the study, husband and wife went their separate ways and entered
into a group that developed its own schedule, therapy format, rules.
and group process issues:
Despite the very small patient sample, this study was a pivotal one
in the development of family techniques for the treatment of
alcoholism. Although the specific results of the study were equivocal
i marginal, but not convincing, improvement in most of the patients
treated), ground was broken in a number of important areas that have
subsequently become characteristic of family approaches. Perhaps
the most important of these areas is the issue of outcome variables.
Most alcoholism treatment programs have focused almost entirely
on a diminution of drinking as the sole outcome variable of merit.
Although the wisdom of this approach has been questioned on
occasion (34). the majority of treatment programs continue to be
judged against a standard of percentage of patient population
abstinent within a specified time frame\Gliedman, by including
wives as potential clientele for the treatment program, significantly
expanded the scope of appropriate outcome variables against which
sutcessful treatment was to be judged. Symptom reduction, for
example, applied to the wife equally as well as it applied to her
alcoholic husband. If symptoms such as depression are applicable for
the spouse, then they must also be applicable for the identified
alcoholic. Thus reduction in depression is added to reduction in
drinking as an acceptable criterion for successful treatment. Sec­
ondly, the concurrent treatment of both members of a marriage
naturally leads to an examination of marital satisfaction and marital
interactional behavior as target criteria for therapeutic change.
Patients were therefore evaluated before and after treatement by
means of four measures: (a) a drinking checklist to measure the
severity of drinking; (b) a symptom checklist to indicate the amount
of distress from psychological symptoms; (c) the mutual satisfaction
°r dissatisfaction experienced by the alcoholic husbands and their
wives with each other during sobriety as contrasted with intoxicabon; and (d) a social ineffectiveness scale.

102

/

£

FAMILY PROCESS J

Within this widened perspective. Gliedman and his associates j
found that although there was some reduction in drinking behavior, |
the greatest changes in behavior resulting from the concurrent group t
therapy technique were in the areas of "marital milieu” (defined as®
satisfaction of alcoholic husband and his wife with each other) and I
“personal morale” (the alcoholic individual’s satisfaction with |
himself). A significant change also was felt to occur in reduction ini
psychological symptomatology, especially irritability and depres-1

sion, on the part of both alcoholic husband and non-alcoholic wife. I
The least change seemed to occur in the area of social effectiveness.®
which was judged to be poor at the start of therapy and showed little <
improvement as a result of the group experience. Gliedman'si
conclusion was that his concurrent group therapy technique was!
most effective in its ability to improve or elevate self-esteem in aS
patient group that tended to be demoralized prior to therapy.
Following the Johns Hopkins study, several clinical papers ap-1
peared in the literature describing group techniques for working witil
spouses of alcoholics (7, 30, 35, 37, 44). These papers indicated el
growing interest in the development of techniques for changing the g
treatment focus from the alcoholic individual alone to the alcoholism
individual in a marital context. It also reflected the conviction thatg
the inclusion of the non-alcoholic spouse in the treatment of those|
alcoholic individuals who retained a stable marriage was a necessary
prerequisite for successful therapy. Pixley and Stiefel *
(37), fefe
example, state: “There is no question at this point that if psycht-T
therapy is to be effective for a larger proportion of the alcohols®

population the wife must also be treated” (p. 312).
The most ambitious study of concurrent group psychotherapy wa g
carried out by Ewing and his colleagues (18) at the University
North Carolina School of Medicine. For a period of four yea
*fc
starting in 1955, a program was established offering an optionig
concurrent group therapy program for spouses of alcoholic individei
als already in treatment. Although the program was offered to built
male and female alcoholics alike, only wives of male alcoholiSS

/

103

group and wives' group. Both groups met weekly in different rooms
in the same.building: the basic therapy technique was described as
• dynamically oriented group psychotherapy.”
Long-term, follow-up data provided by Ewing’s group is impres­
sive on two scores. First is the finding of a significantly greater
persistence in therapy for those male alcoholics whose wives were
attending a concurrent group psychotherapy session. Second, long­
term follow-up (a minimum of three years after the inception of
group therapy) indicated significantly improved control of drinking
and considerable improvement in marital harmony for those men
engaged in concurrent group therapy with their wives, as opposed to
men coming alone to the therapy program. The question of whether
this improvement was due to the specific working through of marital
issues in the therapy sessions or merely due to the increased
longevity of treatment (because the engagment of the wives assisted
in keeping their alcoholic husbands in treatment for a longer period
of time) is raised but left unanswered by this study. However, since
engagement of alcoholics in long-term therapy, has in and of itself
been a major obstacle to successful treatment, the results of the
Ewing study have to be viewed as impressive.
Ewing’s findings were strongly supported in a study carried out by
Smith (39) at the University of Edinburgh. Despite the fact that the
treatment program was radically different, (alcoholics were hospital­
ized for up to a siS-week stay as opposed to being treated on an
outpatient basis in the Ewing study), the institution of a separate
therapeutic group for wives of alcoholic men led to a significantly
greater rate of improvement as contrasted with men whose wives did
not attend.
These clinical papers have therefore been by and large enthusias­
tic about the concurrent group psychotherapy technique. Although
the emphasis remains on the effectiveness of the technique as an
adjunct to the treatment of the alcoholic husband, wives are reported
to be engaged in treatment for their own needs, having demonstrated
independent issues of concern that could benefit from therapeutic
examination.

volunteered for the program.
During the first 18 months of the program’s inception, •£
*
still-married alcoholic men were accepted into the group there)??
program offered by the Department of Psychiatry for alcoholics

"I- THE ADAPTATION OF FAMILY THEORY TO ALCOHOLISM

treatment. Of these 32 men, 16 wives volunteered to participate®
concurrent group psychotherapy sessions. In contrast to the Johs'|
Hopkins group, similar schedules were adopted for the husbanijr

THERAPY
The studies discussed up to this point, although taking cognizance
family factors in alcoholism, were by and large adaptations of

FAMILY PROCESS ft

existing individual and group therapy techniques. During this same 1

time frame, however, a body of clinical theory dealing with family I
pathology, family concepts of symptoms formation, and family. |
oriented therapeutic interventions was being developed. Since most. 8
of these clinical thinkers were psychiatrists (Ackerman. Bowen. &
Jackson, Minuchin), their attention was naturally drawn toward new fc
explanations for traditional psychiatric conditions such as schizo- *
phrenia, psychosomatics, and adolescent dysfunction. Although >
somewhat puzzling in retrospect, alcoholism and drug abuse were k
almost totally ignored both theoretically and clinically.
In the late 60s and early 70s, some cracks began to appear in this I
wall of indifference. ^The first marriage of family theory and $
alcoholism therapy appeared in Ewing and Fox's article "Family 1
Therapy of Alcoholism” (17). Ewing and Fox adapted theoretical j

concepts associated with Bateson and Jackson’s work with families, g
especially Jackson's notion of homeostasis in family systems.(The J

alcoholic marriage is viewed as a “homeostatic mechanism” that is
“established... to resist change over long periods of time. The J?
behavior of each spouse is rigidly controlled by the other. As a result, ft
an effort by one person to alter his typical role behavior threatens the 1
family equilibrium and provokes renewed efforts by the spouse toB
maintain the status quo'yp. 87).
Specifically addressing marriages between male alcoholics and S
their wives.Cthey suggest a process in which these two people strikeB
an elicit anct"implicit.. .interpersonal bargain." a marital "quidprog
quo,” to use Jackson’s terminolog-w-in-whrch~the male alcoholic'
®
*
passive dependency needs implicitily encourage his wife’s protective g
nurturing needs. A sexual bargain is also struck engaging aiift
undemanding alcoholic husband in a behavioral-pattern-that comoffi
plements the behavior of his sexually unresponsive wife. Both
these interactional pacts are played out within the context of a ft
cyclical system in which the alcoholic marriage alternates between g
periods of sobriety and periods of intoxication. “By alternating■
between suppression of impulses and direct expression of them, ht £
can maintain the conflict surrounding impulse gratification for aft
lifetime” (17, p. 91).
Ewing and Fox recommended family therapy for such families fog
two reasons: it increases the likelihood that a drinking problem
be acknowledged by a patient population (middle-class, gamma
*®
type, male alcoholics) who are usually resistive to such self-labeling

<TEi^ss

/

105

procedures, and it stimulates motivation toward change within the
jlcoholic himself.
.
Based on their extensive clinical experience\Ewing and Fox
conclude that “alcoholism can no longer be seen purely in terms of
intrapsychic dynamics... It is the family emotional homeostasis
which seems to perpetuate the drinking, and it is this behavior which
must be changed if the drinking is to be controlled” (17, p. 91). Their
therapeutic approach, concurrent^ group therapy, emphasized the
need for reciprocal^Work with husband and wife in order to
coordinate change in both halves of the homeostatic dyad) The
corollary prediction was that working within an individual frame­
work might increase the drive to change in the individual but would
..]><> increase the pressure toward resistance on the part of the
>pouse. Therapeutic efforts in one direction would therefore be
countermanded by resistances in the other direction, minimizing the
opportunity for a positive therapeutic outcome, y
Steinglass and his co-workers (12, 40, 41, 42, 46) have incorporated
any of the same concepts (homeostasis, marital bargain, complementary role functioning) -in a more comprehensive interactional
model of alcoholism developed in response to clinical observations of
Limilyjr^ractipiL.made-during^states'-of-experimentally induced
intoxication. These observations suggested that interactional behavduring
*
tnr
intoxication is highly patterned and often dramatically
different from the- behavior predicted by the family during sobriety.
one example, a family that claimed drinking by their "identified
.I’.coholic” caused depression, fighting and estrangement was ob­
served to show increased warmth toward each other, increased
■ retaking, and greater animation when the "alcoholic” was permit­
ted to drink.
The interactional model proposed by Steinglass is based on
-’•neral systems concepts of family functioning. These concepts posit
that families are operational systems obeying laws general to all
■'.'■stems, including the importance of organization, drive toward
homeostasis, circularity of causal events, and feedback mechanisms
as factors determining the quality of interaction between the com>N,nent parts of the systems (in this case, members of the family
plus alcohol).
Alcohol ingestion and intoxicated behavior is then viewed from the
perspective of the extent to which, and manner in which, it affects
",e interactional life of the members of the family. Steinglass also

....... •suggested that alcohol, by dint of its profound behavioral, cultural,I
societal, and physical consequences, might assume such a central I

position in the life of some families as to become an organizings
principle for interactional life within these familes. He labeled sucha I
family an “alcoholic system." In such a system the presence or|
absence of alcohol becomes the single most important variable
*
determining the interactional behavior not only between the identil
fied drinker and other members of the family but among non-drink-g
ing members of the family as well.
This model implied that an intricate and delicate balance exists!
between drinking and the day-to-day functioning of the family. It|
fact./it:jyas suggested that in certain instances alcohol might big
unconsciously viewed by the family as a stabilizing rather~tKan st

disruptive influence on their interactional life. Although superficalbE
disruptive, from a different vantage point, the abusive use of alcoholf
seemed to produce extremely patterned, predictable, and rigid seiig
of interactions that dramatically reduced uncertainties about tlxl
family’s internal life and its relationship to the external society, f
The opportunity to directly observe intoxicated interaction's
behavior led not only to unique theoretical proposals but also ttl
quite different conclusions about therapeutic intervention. If,ii

fact, alcohol might be aiding “system maintenance." which k|;
clinical terms means serving some important dynamic function ifc
the interactional life of the family, then the first role of the therapists
dealing with the drinking symptom in a family context is ml
appreciation of the relationship between alcohol and family lil'<^.£.|.

certain situations it seems cle^LthatjUie identified.patient’s drinking
behavior emerges de novo in a family situation at a time of stressed
strain. in_these._sit.uations, the drinking behavior. might well jtl
viewed as a signal or symptom reflecting this stress. or_^train,_ae:S
crisis intervention is called for. On the other hand, if al cobag
consumption is part of an ongoing interactional pattern within tfcg
family system, then the traditional therapeutic intervention aimefB
at abstinence is totally inadequate to the task.
A logical extension of this theoretical model is to view famiMg
therapy not so much from the point of view of involving fan$l
members as a mechanism for improving treatment with the ideffig
fied alcoholic but rather to view the entire family or the marriafS
itself as the patient. Therapeutic intervention becomes interaction®
ally oriented rather than intrapsychically oriented, and goals f'|

' 107

treatment center around an improvement in the functioning, flexi­
bility, and growth potential of the family system as a whole rather
than the more limited focus on reduction in drinking on the part of
the identified alcoholic.
A paper by Davis, et al., (12) expands on this theoretical model in
two significant directions. First, it incorporates behavior theory, and
second, it underscores the importance of focusing on maintenance
factors rather than etiological factors at this very primitive stage of
(>ur understanding of chronic alcoholism. Pointing out that histori­
cally there have been two major premises underlying therapeutic
approaches to alcoholism—the notion that excessive drinking is
maladaptive and the belief in the existence of ultimate causes as
explanations of why alcoholism develops—Davis notes that these
premises have given rise to a wide variety of therapeutic approaches.
These range from moralistic exhortations and aversive behavioristic
approaches deriving from the maladaptive premise to the uniform
psychodynamic or psychobiological approaches based on ultimate
cause theories. Clinical experience, however, suggests that alcoholic
behavior is more profitably thought of as a final common pathway.
Incorporating behavioral concepts into the systems model allows for
clinical diversity while at the same time suggesting new therapeutic
strategies.
Davis .et a/^^postulate-the following: that the abuse of alcohol has
certain adaptive consequences; that these adaptive consequences are
sufficiently Reinforcing to serve as the primary factors maintaining
the habit.of drinking,Xregardless of what underlying causation there
may be; and that the particular adaptive consequences or “primary
factors” for each individual may differ and might be operating at a
number of different levels including intrapsychic, intracouple, or the
level of maintenance of homeostasis in a family or wider social
system but that the final common pathway is the reinforced, chronic
abuse of alcohol.
Two major implications for therapy are suggested. First, it is
necessary for the therapist to determine the specific manner in which
drinking behavior is serving an adaptive function for an individual or
family. The maladaptive consequences are obviously readily appar­
ent. Search for the adaptive consequencs requires more clinical skill.
Second, it^ is suggested that once the adaptive consequences of
drinking have been ascertained, therapy may be structured around
wiping a patient to manifest the adaptive behavior while sober

/

108 /

109

FAMILY PROCESS

instead of only during drinking and to learn effective, alternate E

behaviors.
/ Bowen (6). using similar concepts, also views alcoholism as |
potentially explainable in the language of family systems theory. |

Pointing out that alcoholism is one.of the common.humaD_dysfunc- '
tions, Bowen contends that, as a dysfunction, alcoholism must “exisKg

in the context of an imbalance in functioning in the total family I
system”'(p. 115). In this context, every family member is seen as t
contributing tq_the dysfunctional beh.avior.of the alcoh olic_memlier. ;
In fact, Bowen would contend that the dysfunction of the alcoholic |
can only continue with the support of his or her family. Treatment *
that alters the behavior patferns of these other family members will S
therefore, by definition, eliminate the necessary substratum for the g
existence of alcoholisms Bowen therefore states that “when it is»
possible to modify the-family~~relationship system, the~a1toholic t
dysfunction is alleviated, even though the dysfunctional one may not |

have been part of the therapy^' (p. 117).
IV. FAMILY THERAPY TECHNIQUES

A. Conjoint Family Therapy

H
The previous section has reviewed the growing theoretical literals
ture on family therapy for alcoholism. The literature reporting®
results of the use of conjoint family therapy for alcoholism hastc-E
date been limited to infrequent clinical papers describing case.B
histories offered in support of the use of family therapy techniques.!
By conjoint family therapy, we are now talking about techniques®
involving conjoint interviewing of both members of.a.marital pair. Kg
conjoint interviewing of two or more members of a nuclear.fli|
extended family. Of the limited number of reports on family therapj|
with alcoholics currently available, none has appeared in a journalol
publication primarily addressed to family issues (e.g., Famii’S
Process or Journal of Marriage and the Family).
The state of the literature, however, is in all likelihood unrepresCT-l
tative of the extent to which family therapy techniques are actual!)1
being utilized for the treatment of alcoholism. In many alcoholifil
treatment centers it is routine for therapists to insist on the inclusi®!
of other family members in the initial evaluation, and conjoin1!
interviewing techniques are often included as one option available ;

the treatment team. However, on the other side of the fence, it is not
vet the case that family treatment centers routinely view the
treatment of alcoholism as within the scope of their expertise.
Traditional family agencies will often refuse to work with families
containing an identified alcoholic member, even when the families
present themselves because of problems other than alcoholism. This
js particularly true with agencies working with lower middle-class
and lower-class families where a rapid referral to the “alcohol"
center is the preferred disposition regardless of the nature of the
presenting complaint.
An interesting study by Meeks and Kelly (31) evaluating the
efficacy of family therapy techniques introduced during the recovery
phase of the treatment of the alcoholic member of the family is the
most representative and influential of the clinical studies of conjoint
family therapy. Although only five families were treated and
studied, as a pilot study this report is of considerable interest to us.
Meeks and Kelly adhere firmly to the theoretical orientation of the
family therapist (in this case. Virginia SatirJ. Conjoint family
therapy was begun following an intensive 7-week program of individ­
ual and group psychotherapy in a day treatment program. During
this 7-week program, family members were seen separately from the
"alcoholic patient.” At the beginning of the aftercare phase,
however, family members were seen in conjoint interviews only; the
alcoholic member was never seen separately from his or her family
during the aftercare phase. Families were seen for periods ranging
from 10 to 12 months.
Therapy focused on interaction, communication, role perform­
ance, and redefinition of problems in family7 rather than in individ­
ual terms. Therapeutic goals were derived from Ackerman, and
included achievement of a clearer definition of interactional con­
flicts, improved and more open communication about these condiets. a greater understanding of intrapsychic determinants of
interpersonal conflicts, and an improved level of complementarity in
family role relations. Treatment evaluations included an interest in
the drinking behavior of the identified alcoholic but focused more
intensely on issues of improved family interaction and family
equilibrium. Such issues as problem definition, communication.
patterns of relating, and methods of problem-solving were included
as possible variables indicating improved family functioning. The
study also attempted to assess the extent of the family involvement

/ Hl
in the treatment process, the extent to which the therapists were able
to remove the alcoholic member from the "identified patient” status, !

and issues of therapist involvement.
Although Meeks and Kelly underscored the exploratory nature of 1

their report, they were enthusiastic about their experience. The, J
concluded that techniques geared toward redefining alcoholism |
issues in family terms are quite profitable. The more drinking I
behavior can be seen as merely one aspect of family interaction, the k
greater the likelihood that the "alcoholic" member of the family will |
be able to shed his or her label and establish new patterns of |
interaction within the family. )
Esser (14, 15. 16) reached similar conclusions in reports stemming I
from his experience with conjoint family therapy in the Dutch city of g
Haarlem. Once agajn the emphasis is on the recovery or aftercare 1
phase of treatment(^Family_therapy is seen as potentially;expanding I

the scope of treatment from.hospitalization and clinical care for the *
identified alcoholic to a more sociotherapeutically oriented approach I
to the entire family. The family of an alcoholic is viewed as a “group ®
under stress,” but this stress is related as much to disturbed in-1
teractions as it is to the .behavioral effects of alcohol. Restoration cf 1
communication, concentration on role conflicts, and the removal of <
the alcoholic from the role of the “identified patient” are again seen
as the central issues that the therapist must approach^)
These clinical reports can best be characterized'as promising but I
unsubstantiated, enthusiastic but primarily impressionistic. They fe
seem to reflect the level of optimism attached to family therapy fo? I
alcoholism—e.g., the Alcohol and Health (27) statement and Chafers

et al. (10)—but leave unanswered questions about the verifiable tl- i
ficacy of these techniques.
>.
;•

B. Multiple-Couples and Multiple-Family Group Therapy Approaches |
Multiple-couples group therapy is a particularly popular form d |
family therapy currently being utilized in alcoholism treatment. It? |
increasing popularity as a treatment modality in alcoholism treat- S
ment programs is perhaps related to the assumption that ?-|

represents the "best of all possible worlds.” It retains, in format
least, a group therapy structure and is therefore attractive to man?
*
alcoholism therapists who have viewed group therapy as the treat-1
ment of choice. However, it also acknowledges and takes account

the importance of family factors in the exacerbation of alcoholism
ind is responsive to the growing feeling that alcoholism treatment is
]e<s effective if significant family members are not involved in
therapy.
A growing body of experimental and clinical literature now exists
concerning multiple-couples group therapy approaches to alcohol­
ism. This literature includes traditional treatment outcome studies
,9 11), reports of experimental treatment techniques (42). and
summaries of clinical experiences .15, 20, 38). We will examine three
reports more extensively: an outcome study of multiple-couples
therapy based on group techniques (9); an experimental study based
,,n family therapy principles (42): and a clinical report of the
extensive use of mulitple-couples groups in an operational alcohol•,m treatment program (20).
Cadogan (9) presented the first controlled study in the literature of
multiple-couples group therapy in alcoholism treatment. Forty
alcoholics (both men and women) and their spouses were recruited
while the alcoholics were still inpatients at a traditional alcoholism
mil and asked to volunteer for a "new and effective method of
treatment” in which “an attempt would be made to improve family
problem-solving patterns, to encourage, the expression of feeling in
marital communications and to develop a new awareness of the
effect of their behavior on others" (p. 1188). The study group
represented the first 40 couples volunteering for this new outpatient
multiple-couples group therapy program. Subjects were then ran­
domly assigned to one of two groups: an immediate treatment group
or a waiting list in which they continued with the traditional
treatment program but did not engage in the outpatient, multiple^
couples group. Ultimately 20 couples were assigned to each group.
Groups proved to be comparable in age, socioeconomic status.
•everity of alcoholism, and involvement with other treatment
programs (especially AA).
The treatment group engaged in open-ended, multiple-couples
group therapy sessions (90-minute sessions on a once-weekly sched­
ule). The average group was composed of five, couples, and member■hip was fluid with dropouts being replaced by newly interviewed
recruits. Follow-up evaluation occurred six months after the couple
*as recruited for the study. Follow-up results were striking. At six
Months, nine alcoholic members in the therapy group remained
'•ostinent, four were doing some drinking, and seven had relapsed

completely. Among the control group, however, only two werf;
abstinent, five were drinking moderately, and 13 had demonstratej |
complete relapse.
Gallant, et al., (20) have provided a report of the most extensiwl
application to date of multiple-couples group therapy as an integral
phase or component of an ongoing alcoholism treatment program?
Their program, the New Orleans Alcoholism Clinic, comprises twtf
integrated units, a 36-bed inpatient unit, and an outpatient alcohol ?
ism clinic. Gallant has been routinely assigning every discharge-'
married patient who is returning home to live with his or her spous
*
to a multiple-couples therapy group in the outpatient clinic as theft
major form of ongoing treatment. These therapy groups, cora!
prising four to seven couples meeting every two weeks for a tw»l
hour session have
*
a traditional alcoholism treatment goal of totfj
abstinence for the alcoholic combined with_an. interpersonal goals?
improvement in marital-interaction. Treatment techniques combiaboth family therapy orientations toward analysis of interactional htfc
havior and group therapy techniques of encouraging direct er?
change and feedback between all members of the group.
Gallant has reported the results of 118 couples assigned to tte|
Clinic’s multiple-couples groups. Follow-up data were not systemaii-E
cally gathered, but most couples were contacted following treatment|
and drinking history and quality of family life were explored. (Tbfe
follow-up period varied from two months to 10 months.) Fifty-thru®
of the 118 couples were considered to be definite successes at
time of follow-up (either complete abstinence or no more than tr: j,
brief drinking episodes and “reasonable” marital relationship), ail
41 were considered definite failures (unhappy family life, freques^

drinking episodes, or sobriety felt by the treatment team toBS
temporary and without satisfaction or contentment). Twenty-ram
couples were lost to follow-up. Based on these findings, Gallant,:’®
al., “conclude that marital-couples group therapy is the treatment’- ;:
choice at this time for married alcoholic patients^)The denials?!
"projection mechanisms, exaggerated in the alcohdl-marital problei? |
are more easily approached and treated in group” (20, pp. 43-44|!
Steinglass and his colleagues have carried out work with multip’fl
couples therapy groups as part of their research studies examini":®
interactional behavior in alcoholic families. An experimental treifc
ment program was established at NIAAA’s Laboratory for Alco&l.
Research in which couples with one or two alcoholic members d?|

placed in an intensive, six-week, multiple-couples group. therapy
program. Although the treatment program was conceptualized
primarly as an experimental model that permitted the establish­
ment of a rich clinical field allowing for the examination, of
interactional behavior, the treatment process itself was highly
unusual and proved to be quite fascinating in its own right. In
contrast to Cadogan s work, where the emphasis was on the
desirability of involving the spouse in a group process, the NIAAA
group was firmly based iiufamily therapy.
The experimental treatment program was divided into three
phases: an initial two-week outpatient phase in which groups met for
ihree sessions per week: a ten-day inpatient phase during which time
three couples were simultaneously admitted to an inpatient facility;
and finally, a post-hospitalization, three-week outpatient phase of
two group meetings per week. Following the six-week intensive
treatment program, groups reconvened at six-week intervals’for
follow-up sessions over a six-month. follow-up period.
The core of the program, and clearly its most innovative feature,
was the hospitalization period. The hospital setting itself was a
redesigned inpatient unit in a traditional state hosptial. This unit
was described by the research team as a “simulated apartment
setting that was supposed to provide a homelike atmosphere for the
couples, allowing them to reproduce as accurately as possible their
usual interactional behavior. Of greatest importance, however, was
the fact that alcohol was made freely available during the first seven
days of the hospitalization period, and couples were asked to engage
tn their usual drinking patterns while they were on the ward. This
last feature of the treatment program was an extension of the use of
experimentally induced intoxication as a potential adjunct-to
therapy and was based on theoretical notions about the role alcohol
can play in maintaining fixed interactional patterns within familes
'these notions are discussed in Part III). The specific rational
provided to the couples for this free availability of alcohol was that
the therapist, by being able to directly observe intoxicated behavior,
could gain a better understanding of the role that alcohol consump­
tion was playing in the couples’ lives.
The treatment program utilized a variety of techniques to examine
*’;lLerns °f interaction exhibited by each couple and to contrast the
. I fererice between interaction during sobriety and interaction dur,ng intoxication. These techniques included vic 'otape recording and

FAMILY PROCEj; »

feedback, role-playing techniques, use of one-way mirroi observs. | despite its strenuous demands and reported a profound emotional
tion, and feedback from observers, analysis of speech and communi. * ,-nlpact deriving from the in-hospital experience particularly. The
cation patterns, emphasis on non-verbal behavior and postural,anal-I enthusiasm of patients for the therapeutic work was particularly
ysis, and use of three-generational family genograms. All of thest I nnpressive to the therapists in light of the fact that all couples had
techniques have been used extensively by family therapists in mor; J jailed repeatedly in previous therapeutic efforts. The therapists were
also most enthusiastic about the in-hospital experience as a mechatraditional settings.
The multiple-couples groups were conceptualized by the researchc| ,;ism facilitating the rapid clinical understanding of the relation
between drinking behavior and interactional life for each of the
ers as a societal system composed of three dist inct elements or level;;
individuals, couples, and whole''group. This type of group was? couples involved. —
Reports of six-month. follow-up data have not yet been completed,
therefore viewed as an excellent vehicle for observing the relation and it is therefore unclear at this time to what extent the intensity of
between individual dynamics and intra-couple dynamics while at
the same time having an opportunity to observe the couple'jj •nis therapeutic experience was meaningfully integrated and had a
behavior in negotiating its position in a group of strangers (perhaps y :..-ting effect in changing the interactional patterns of the couples
analagous to the relation between family and the outside society).® involved. In all likelihood this experimental study will be more
However, the therapeutic target was always the couple, and individ- g .,doable in suggesting directions for therapy rather than establishing
ual dynamics or whole group behavior was viewed from the vantap 1 .1 definitive therapeutive approach.
Two additional studies, although not focusing specifically on
point of its relation to each of the three couples.
Although this NIAAA program obviously represented a radica I multiple-couples therapy, will be mentioned here because they also
departure from traditional alcoholism treatment, it also is the purest j. evolved simultaneous work with spouses in a traditional hospital
example in the literature of an approach to alcoholism treatmeot| -citing. Corder, el al., (11) carried out a pilot project at a residential
based on family principles. Let us therefore summarize the mahi alcoholism treatment center. Wives of male alcoholics were included
■ n a four-day, intensive workshop that followed a traditional,
features that made this program unique: First, the program tE
*
cruited middle-class, intact couples who displayed a substantia® three-week inpatient program. The workshop program included
degree of economic and interactional stability despite the chroniff croup therapy and A'ideotape and analysis of the sessions, didactic
abuse of alcohol by one of its members. Second, the program not only | •vctures. group discussions of “gamerplaying" and role-playing,
did not insist on the usual abstinence model of treatment, it actuals# recreational activities, and AA and Al-Anon meetings. A six-month
suggested that intoxicated behavior can be utilized by the therapist j * >llow-up performed on the pilot group of 20 alcoholics indicated a
as an adjunct to treatment. Third, instead of viewing the individual •ijmificant reduction in drinking for the experimental group com­
pared with a control group that had gone through the traditional
alcohol abuser as the “problem,” therapy was directed at the coujfc*:
Fourth, both drinker and spouse enjoyed similar status as inpatiet|a treatment program alone.
Paolino and McCrady (32) have been experimenting with the
in a psychiatric hospital, and treatment goals and techniques wetfe
based on examining the relation between alcohol use, intoxicates joint admission” of a non-alcoholic spouse as a “guest" of the
hospital. The couple lives on a psychiatric ward that includes
behavior, and interaction. And last, the therapists insisted
improved family functioning rather than a reduction of drinki^l patients of all diagnoses and ages over 12. The non-alcoholic spouse
P-irticipated in ward activities as much as possible while retaining
behavior as the primary target.
or her job. The patient and spouse also participated in three
Although Steinglass and his colleagues have advised cauti#® ■
recording outcome results from this experimental study, emphases ■>pes of weekly therapy groups: a group for problem drinkers only, a
ing the highly experimental, pilot nature of the program, it was foifiwS rroup for spouses only of problem drinkers, a group for couples in
that couples responded quite positively to the treatment approa®® *nich one member is a problem drinker and the other member does
have a problem with alcohol. These groups all continued after
Although only ten couples were treated, they all completed the stuwl

116

/

A

FAMILY PROCEp,?

/ 117

the couples left the hospital and were considered an essential pajl viewed as pilot or exploratory ventures rather than definitive
.nempts to validate a treatment method. The traditional difficulof the treat ment program.
Paolino and McCrady conceptualized the goals of such a joig-v 7 #. inadequate sample size, absence of an appropriate control
^admission as follows:! (a) to give the staff the opportunity to obsen.f ■r,>up. lack of consistency in definition of subject population,
(he couple’s interactions: (b) to provide comprehensive feedbackfr.•
iriability in outcome measurements are all amply represented in
the couple about their patterns of interacting; (c) to integrate tj,; these studies. However, it must also be recognized that these studies
spouse into the milieu so that the spouse has the same opportunity^? ,vere often difficult to carry out, involving major manipulations of
the problem drinker to experience the closeness and caring of rfe f •■■■e environment, or the introduction of alien therapeutic techniques
unit: (d) to integrate the spouse into the milieu so that the spomj -to a hostile treatment environment.
may incorporate the approach to handling problems that is taughttj
In addition to the traditional difficulties, however, there are at
the milieu. They plan extensive experimental studies based ontfej . jst two specific difficulties with the existing studies that deserve
treatment approach.
oecial mention. The first is the singular absence of trained family
• "erapists carrying out these studies. The Steinglass study is the
■ ■nly report that specifically identifies its therapists as family rather
DISCUSSION
than alcohol specialists. Meeks and Kelly followed family therapy
When compared to the magnitude of the problem, our review H#
principles outlined by Satir. All other studies were apparently'
revealed a remarkable paucity of studies dealing with family therags
carried out by alcohol specialists, firmly grounded in group therapy
for alcoholism. Although the literature is probably not representaaS
chniques, who were extending their approaches to include addiof actual therapeutic practices, it is nevertheless striking tL;. :,.>nal family members. As a’ consequence, very little technical
alcoholism, in comparison to such conditions as schizophrenia,^
information is available in the existing literature for the family
linquency, or psychosomatics, has engendered remarkably
therapist interested in specialized techniques applicable to alcoholic
interest among family therapists. (Parenthetically, a similar avers®
*
families.
seems to exist in the area of drug abuse.) Let us therefore dis:_.i
The second aspect that deserves special mention is the issue of
two issues raised by this review: first, the demonstrated efficaqgw ■itcome measures. The criterion of abstinence has been the tradifamily therapy techniques for the treatment of alcoholism «s.i '..'■nal outcome measure for alcoholism treatment programs (34).
second, potential explanations for the disinterest of family therapas One of the contributions of the studies described in this review
toward alcoholism.
has been to expand notions of treatment outcome to include not only
•■’her aspects of individual functioning but also aspects of interactinnal and social functioning. On the one hand, we should view this
Evaluation of existing research
•' a positive contribution. On the other hand, it introduces a whole
The existing literature leaves us with a sense of guarded opt intig panoply of outcome measures that are highly subjective in nature,
about the application of family therapy techniques in the treat!®# xiry from study to study, and are not necessarily appropriate to the
of alcoholism. Although every' study we have mentioned conc'tO Patient population being treated. The current trend in family
with an enthusiastic statement encouraging greater use of fasts ’herapy research has been toward more objective outcome measures,
therapy, it is also apparent that very little hard evidence exist® *need for rehospitalization, number of flare-ups of a psythis point demonstrating either the efficacy of family therapy?# '"osomatic illness, adolescent arrest records in delinquent families,
,tc- Alcohol consumption would be such an objective measure but
itself or the comparative value of family therapy versus
traditional forms of therapy in the treatment of alcoholism. -”88 -:early a distasteful one. Until this dilemma in outcome measures is
Even taking into account the inherent difficulties in psychot^g f*
solved, it will be impossible to ascertain the particular effectiveapy research, most of the studies reported in this review shou'-'S
of family therapy for alcoholic families.

i

118

/

£

FAMILY PROCEjf

Given these rather extensive reservations, what does the existing
literat ure suggest about the efficacy of family therapy for alcoholisjl

that gives us grounds for optimism. The most obvious finding is thg-y
every study reported positive results. Although their reasons f<>i
doing so differed, all investigators wound up enthusiastically sup
porting the involvement of families in the treatment process. Thtgi
studies in particular. Ewing’s and Smith's studies of concurren t
group therapy and Cadogan’s study of multiple-couples groBl
therapy, yielded impressive results when experimental groups
contrasted with controls.
Of particular importance is the apparent ability of family-orienteil
techniques to increase longevity of involvement in treatment on tit's
part of the identified alcoholic. Since attrition rates have character!
istically been high in alcoholism programs, engagement of tfcg
patient becomes a critical feature separating success from failurgjl
remains unclear whether these programs owed their success
inherent technical superiority, therapeutic enthusiasm, or const,[
quences of theoretical orientation (elimination of the alcoholic asT
identified patient, shift in emphasis from alcohol consumption •«
marital interaction, etc). However, initial results are clearly pronit
ing and warrant considerably greater enthusiasm and interest ths.4
to date exists.
•
Disinterest in Alcoholism on the Part of Family Therapists

|

In exhibiting a singular lack of interest for the treatment
alcoholism, family therapists have merely been following the pre-f
lections of their colleagues in the mental health professions. Pro&j
sional stereotypes toward alcoholism and the alcoholic have te®
well-documented. The alcoholic is viewed as a distasteful, self-ind.
gent, weak individual involved in a pernicious cycle of self-destffig
tive behavior. Motivation for change is thought to be extremely
and therapeutic work therefore felt to be unrewarding. Althea
*
originally viewed as scientifically objective, these stereotypes WW
more recently been characterized as culturally determined, ant-T
applicable at all, applying only to a very small percentage ol" J
alcoholic population. Therefore, in part the family therapist:
merely suffering from cultural prejudices.
However, family therapists have prided themselves on their abS
*®
to look afresh at traditional mental health problems. Are tbt’s

particular aspects to alcoholism that have produced relative blind
spots for the family therapists? Apparently so. Alcoholism, in fact, is
a chronic behavioral process that has been demonstrated to exist
most typically in an extremely stable and often rigid interactional
context. As exhibited by the typical alcohol addict living in an intact
family, its behavioral characteristics seem paradigmatic of homeo­
static behavior in a steady-state system. In this regard it seems to be
typical of chronic disease processes as they are utilized by family
systems to stabilize bothTnternal interactions and relationships with
the external environment.
Why then the difficulty in viewing alcoholism as a family systems
problem and recommending family therapy as an appropriate course
.>f treatment? Although the answer is hardly clear-cut, several
possible suggesions can be offered. The first difficulty lies in the area
nf definition. Drinking behavior exists along a continuum starting
with total abstinence, progressing through occasional drinking
associated with social rituals, social drinking, heavy drinking, and
ending with addictive drinking. Somewhere- along this continuum
one makes the judgment that'drinking behavior has reached abusive
levels. Where to draw the line separating pathological from custom­
ary behavior, however, has been a controversial and usuallysubjective issue. Since many therapists are unclear as to where their own
drinking might fall, there is a natural reluctance to take a judgmen­
tal stance about a patient’s drinking behavior.
A second issue is the existence of the symptom in the parental
generation. Family therapy historically developed in response to
clinical conditions manifesting symptomatology in the childhood
generation (schizophrenia, delinquency, school phobia, psycho­
somatics). The concept of the identified patient, a key concept in
the development of family therapy, has traditionally been applied to
-ituations in which a child in a family becomes symptomatic in
response to a dysfunctional family system. Alcoholism in a family
context perhaps represents the reverse situation; a parent becoming
periodically symptomatic as an adaptive or stabilizing mechanism
‘”r the family system. Family therapists, by dint of their traditional
orientation, might wind up overlooking such a situation.
Another possible explanation lies in the nature of intoxicated
havior itself. Most therapists experience discomfort in the presence of intoxicated patients. The intoxicated person is viewed as
«cessive, sloppy, impulsive, and lacking in self-control. The natural

FAMILY PHOCEsj

/

121

- Berman. K. K., “Multiple Conjoint Family Groups in the Treatment of
Alcoholism,” J. Med. Soc. N.J., 65: 6-9, 1968.
- Bowen, M.. “Alcoholism as Viewed Through Family Systems Theory
iting intoxicated behavior during therapy sessions. However, if some
and Family Psychotherapy," Ann. N.Y. Acad. Sci., 233: 115-122.
of the theoretical notions mentioned in this review are correct (3,6
1974.
12. 17. 40), then abusive drinking behavior in the family context car
Bt’RTON, G.. “Group Counseling with Alcoholic Husbands and Their
only be understood if one examines carefully the relationship
Wives," Marr. Fam. Living, 24: 56-61, 1962.
between intoxicated and sober interactional behavior. Since family
-. Burton, G.. Kaplan. H. M., and Muon, E. H., “Marriage Counseling
therapists prefer to work with directly observable behavior, retro­
with Alcoholics and Their Spouses." Brit. J. Addict., 63: 151-170,
1968.
'
- ■
spective reports of intoxicated behavior are often overlooked or not
solicited, and abusive drinking rarely becomes a focus for therapeu-1
9.
Cadogan. D. A., “Marital Group Therapy in the Treatment of
Alcoholism." Quart. J. Stud. Ale.. 34: 1187-1194, 1973.
tic interest.
Chafetz, J.. Hertzman, M.. and Berenson, D., “Alcoholism: A Positive
Although the above suggestions may help explain the lack t«
View," in S. Arieti and E. D. Brody (Eds.), American Handbook of
interest in alcoholic families expressed thus far by family therapists,
Psychiatry, Vol. I, New York, Basic Books, pp. 367-392, 1974.
it also seems clear that none of these explanations represents a valid
1.
Corder. B. F., Corder, R. F., and Laidlaw, N. L., “An Intensive
reason for ignoring this condition. This lack of substantial contrain­
Treatment Program for Alcoholics and Their Wives." Quart. J. Stud.
dications. combined with the tentatively positive results reportedis
Ale., 33: 1144-1146, 1972.
this review, would certainly support a growing interest on the parW
2.
Davis, D. I., Berenson, D.. Steinglass, P.. and Davis. S., “The
family theorists and therapists in the area of alcoholism. In fact, L
Adaptive Consequences of Drinking." Psychiatry. 37: 209-215, 1974.
comprehensive studies are undertaken and substantiate the pile?
Edwards, P., Harvey, C., and Whitehead, P. C., “Wives of Alcoholics:
results reported in this review, it is conceivable that future therapj
A Critical Review and Analysis,” Quart. J. Stud. Ale., 34: 112-132,
programs for alcoholism might be split into two distinct approaches,
1973.
a family-oriented, psychosocial approach applied primarily to mid-,
t. Esser, P. H., “Conjoint Family Therapy for Alcoholics,” Brit. J.
Addict., 63: 177-182, 1968.
die- and upper-class alcoholics with intact families and a biome®
■ Esser, P. H., “Conjoint Family Therapy with Alcoholics—A New
cally oriented approach combining pharmacotherapy, behavioristic<
Approach,” Brit. J. Addict., 64: 275-286, 1970.
techniques, and group therapy applied primarily to single alcoholics-!
Esser, P. H., “Evaluation of Family Therapy with Alcoholics,” Brit. J.
The former approach would structure itself on a family systaft
Addict., 66: 251-255, 1971.
theoretical framework, while the latter approach would rentes
7.
Ewing, J. A. and Fox. R. E.. “Family Therapy of Alcoholism,” in J.
within the more traditional framework of the medical models,
Masserman (Ed,), Current Psychiatric Therapies, Vol, 8, New York,
alcoholism.
Grune & Stratton, pp. 86-91, 1968.
'■ Ewing, J. A., Long, V., and Wenzel, G. G., “Concurrent Group
Psychotherapy of Alcoholic Patients and Their Wives,” Int.J. Group
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lO ■

Phone: 0481 -3198
(Kottayam) 3332

(Sponsored by Ministry of Welfare Govt, of India)
Total Response to Alcohol & Drug Abuse

AYMANAM P O.

De-Addiction 3t Counselling Centre

KOTTAYAM-686015

(Reg. No. K. 523/87)

KERALA-INDIA.

4
Date

Ref, -VO,..50.°./92........

06.07. '92
......

TO,

Dr. C.M. Francis,
Director,
St. Martha's Hospital,
Banglore 560 009

Dear Dr. C.M. Francis,

Greetings from Kerala.
I came back safe from Banglore on 3rd of this month. I had
a plesant journey. It was fortunate that I could be in
touch with you during my visit to Banglore. We could share
a Ibt of things connected with the addiction field. May
I thank you most sincerely for your great support and
help while I was there.
As I had talked with different professionals like
you in Banglore to start a treatment centre I could very
well realise the need for it. For a follow up of further
discussions and to make a blue print for a treatment
programme I will be coming there on 27th of August. Hope
to meet you in between 27th and 29th for further discussion
and support.

Hope we can do something in this field together to
help the addicts.
Thanking you once again for your warm welcome and
the useful time you spent with me.

(Fr. George Kola
Director,
CHEMICAL DEPENDENCY IS A DISEASE - TREAT IT -

ALCOHOLISM: AN ILLNESS
FACTS tO HELP
THE ALCOHOLIC HELP HIMSELF

TABLE OF CONTENTS

Page

1.

Introduction
Alcohol and Man
Facts about Alcohol

3

2.

Alcohol and its effects
Short and Long term effects
Effects on body systems
Alcohol and Nutrition

6

3.

Myths and misconceptions

10

4.

Alcoholism
What is Alcoholism ?
Characteristics of Alcoholism
Stages of the disease

13

5.

Treating Alcoholism
Treatment procedures
Treatment at T. T. Ranganathan Clinical
Research Foundation

19

Guidelines for the family of Alcoholics

24

6.

Some Do’s and Dont's for family members

7.

Helping Hands
Alcoholics Anonymous

26

8.

A word about ourselves

27

1.

CHAPTER 1

Alcoho! and HVIan

Alcohol has had its place in the lives of men from very
early times. References to alcohol use have been made
even in ancient Vedic literature.
As time passed, man began to understand and appreciate
alcohol's effects such as intoxication, excitement, euphoria,
and tranquilisation. Large industries producing alcohol
grew up and consumption of alcohol increased and became
widespread.
It has also been understood that long term use of alcohol
proves harmful. It causes dependence, illnesses and
destroys the very fabric of man's personality and character.

What is Alcohol ?
The alcohol present in all alcoholic beverages is ethyl
alcohol. Ethyl alcohol or ethanol (C2jH6 OH) is a colourless,
slightly volatile liquid with a harsh, burning taste. It is a
product of fermentation.
3

When yeast acts on sugarcane, honey, fruits, berries,
cereals or potatoes it releases an enzyme which converts
the sugar in these materials into carbon-di-oxide and alcohol.
This process is known as fermentation.

Alcohol is the only drug which can also be classified
as a food because of its high calorie yield. It contains
negligible amounts of vitamins and minerals and contributes
nothing to the cells' nutritional requirments.

Alcohol is a mood changing drug like opium, cocaine,
barbiturates and amphetamines.
The alcohol content and source of some alcoholic
beverages is given below.
Name of the beverage

Source

Percentage of alcohol

Brandy

Distilled wine

40—55%

Whisky

Cereals

40-55%

Rum .

Sugar Cane (molasses)

40-55%

Wines
(Port, Sherry,
Champagne etc)

Grapes

10—22%

Beer

Cereals (barley)

6-8%

Toddy

Palm juice

5-10%

Arrack

Molasses

50-60%

What happens when you drink Alcohol ?
Alcohol differs from other foods in that it requires no
digestion and by the process of simple diffusion, enters the
circulatory system from the stomach and intestines. About
20% of the alcohol consumed is absorbed into the blood
stream from the stomach walls and 80% from the intestines.
Its small and simple molecular structure allows it to pass
right through the cell membranes of the stomach and
intestines. Once alcohol enters the blood stream, it circulates
throughout the body reaching every organ, including the
brain, heart and liver. Small amounts of it are eliminated
from the body through urine, sweat and the respiratory tract.
Once it enters the body, most alcohol remains there, until
it is broken down by the liver.

4

The liver plays a major role in the break-down or
oxidation of alcohol. Alcohol is oxidised by the liver at a
rate of 8-15 ml per hour. The oxidation process is brought
about by enzymes produced by the liver. Alcohol is first

oxidised to acetaldehyde by the enzyme alcohol
dehydrogenase. The acetaldehyde in turn is converted to
acetate by the enzyme aldehyde dehydrogenase. Oxidation
of acetate yields carbon dioxide, water and energy. The
energy yield of alcohol oxidation is about 7 kilo calories
per gram of alcohol.

I

6

CHAPTER 2

Effects of Alcohol

Short Term Effects : These effects appear rapidly after
a single dose and disappear within a few hours or days.
The most predominant short term effect of alcohol is that
it temporarily removes normal inhibitions. It also acts as a
psychic anaesthetiser, temporarily erasing painful feelings
of anxiety, worry, tension, hopelessness and anger.

The effects of alcohol are directly related to the
concentration of alcohol in the blood. With the first few
drinks or at a blood alcohol level of 0.03% there is an illusion
of clarity of mind. As alcohol consumption increases, and
when blood alcohol level reaches 0.06% consciousness
becomes blurred, thinking slows down and reasoning and
judgement become blunted. At a blood alcohol level of
0.09% to 0.12% physical signs of intoxication like slurred
speech, clumsy movements and impaired muscular
co-ordination are observed. As drinking continues and the
amount of alcohol in the blood rises to 0.15% behaviour
becomes irrational and the drinker becomes stuporous. At
blood alcohol level of 0.5% coma (unconsciousness) sets in
and at level of 1%, the respiratory centres in the brain are
paralysed causing death. The concentration of alcohol in
the blood depends on factors like speed of consumption, food
in the stomach, body weight and percentage of alcohol in
the drink.
6

Long Term Effects : These effects follow frequent
heavy drinking over a long period of time. These are
manifested in the form of severe physiological, social and
psychological damages. Some of the physiological damages
caused by alcohol are gastritis, fatty liver and cirrhosis,
cardiomyopathy and polyneuritis. These are explained in
detail in the chapter on "Effects of Alcohol on the Body
Systems" Psychological damages include depression,
anxiety, feelings of fear and inability to maintain good
relationship with others.

The individuals' social life is also affected. Often
the heavy drinker has poorly developed social skills leading
to frequent quarrels at home, change of jobs, social
disapproval, and involvement in crimes and violence.

Effects of alcohol on body systems
Alcohol is rapidly absorbed into the blood stream from
the stomach and intestines. Once absorbed, alcohol mixes
with blood and circulates throughout the body, reaching every
organ. Hence most of the body systems like the central
nervous system, gastrointestinal system, cardiovascular
system, reticulo-endothelium system and respiratory system
are affected. The type of damage to each of the systems
is discussed below.
Central Nervous System :
Alcohol is a depressant
of the central nervous system. In small doses, it depresses
those higher inhibitory centres in the brain which modulate
human activities. Initially alcohol removes normal inhibitions
leading to talkativeness, and excitement, associated
with a general sense of well being and euphoria.

As the amount of alcohol consumed increases, the
depressant action spreads to more and more areas in the
brain, impairing the faculties of judgement and discrimination.
At still higher doses, the vital centres of the brain are
depressed causing failure of essential functions of the
brain with resultant unconsciousness and death.
Gastro Intestinal System:
In low concentrations,
alcohol increases gastric secretion and hence acts as an
appetiser. Heavy alcohol ingestion leads to erosive

gastritis or inflammation of the mucosal lining of the stomach.
Gastritis occurs due to the twofold action of alcohol,
namely increasing gastric acid production and increasing
the permeability of the mucosal cells to the back-diffusion
of gastric acid.
Liver: Synthesis of fatty acids by the liver is stimulated
by alcohol, with a resultant increase and accumulation of
fat in the liver cells (fatty liver). A fat infilterated liver is
susceptible to damages due to infections and toxins.
Ultimately it ends in scarring of the liver tissue, an irreversible
condition known as cirrhosis.
Cardiovascular System : Alcohol is a vaso-dilatordilates the blood vessels. It increases the heart rate and
output of blood in circulation. Excessive alcohol use
weakens the heart muscle and leads to cardiomyopathy.
Respiratory System : Alcohol depresses the
respiratory centre in the brain. In cases of high doses
of alcohol intake, death could result from respiratory failure.

Alcohol and Nutrition
Prolonged use of alcohol leads to a deficiency of several
nutrients. Malnutrition in alcoholics is caused by several
factors, the chief being alcohol's interfererce with central
mechanisms that regulate hunger and appetite. A significant
reduction in the levels of proteins, vitamins and minerals
in the body of heavy drinkers is observed.

Proteins : A reduced serum protein level in alcoholics
is brought about by poor dietary intake and decreased
synthesis of proteins by the liver.
Vitamins
Vitamin A : Metabolism of vitamin A is affected by
alcohol. Alcohol causes abnormal dark adaptation resulting
in impaired vision during nights.
Vitamin Bi (Thiamin): Alcohol causes greatly
reduced levels of B, in the body, resulting in a condition
known as alcoholic beri beri. The symptoms include

8

heaviness of legs, parasthesias (pins and needles sensation)
alteration of reflexes, anorexia (loss of appetite) and
constipation. When there is severe B, deficiency, the
symptoms manifested include opthalmophlegia (paralysis
of eye muscle), ataxia (uncoordinated gait), and nystagmus
(involuntary rapid eye movement).
Vitamin B3 (Niacin) : Prolonged intake of alcohol leads to
B3 deficiency, characterised by the four D's namely
Dermatitis, Dementia, Diarrhoea and ultimately Death.
Vitamin Bs (Pyridoxine) : Another vitamin which
alcohol depletes with heavy use is B6, the deficiency of
which can cause many disorders including dermatitis, anaemia
and seizures or convulsions. B6 deficiency seizures known
as delirium tremens, can be observed during withdrawal.
Vitamin C: The level of Vitamin C is also decreased by
drinking, leading to reduced resistance to infections.

Minerals : The levels of magnesium, calcium and zinc
are greatly reduced in alcoholics due to poor dietory intake
and increased urinary loss The magnesium deficiency
syndrome consists of tremors, athetoid (repetitive and
involuntary) movements of the extremities, mental aberrations
and convulsions. Clinical features of zinc deficiency include
dermatitis, usually generalised, loss of taste and slow
wound healing.

CHAPTER 3

Myths and misconception
There are many myths and misconceptions in the minds
of people regarding alcohol and its usa. Some of these
have been clarified and discussed below.
1.

Is alcohol a nutrient ?

No. Modern brewing technology completely destroys every
dietary property in alcohol except for providing calories.
The calories in most alcoholic beverages are known as
“empty" calories since they do not provide any nutritional
benefits.

2.

Is alcohol an aphrodisiac ?

No. it is a sedative and in sufficient quantities an anaesthetic.
People mistake it for an aphrodisiac because of its inhibition
lowering effect. A large quantity of alcohol acts as a
sex-inhibitor and can render a man (who is addicted to it)
temporarily impotent.

3.

Is alcohol a stimulant ?

No, it is a depressant, especially of the central nervous system.

4.
Does black coffee/cold shower/food, help in sobering
up an individual ?
No. Only time can sober him up. The alcohol in the body
should be completely oxidised by the liver to restore a sober
state of mind.
5.

Is drinking essential in certain occupations ?

No. Drinking is never essential. Any occupation can be
carried on and very well too by a non-drinker if he has the
occupational abilities needed for that job.

6.
Is an ability to drink more than other people, a sign of
virility?
No, but it is likely to be an early symptom of alcoholism.
Most alcoholics had the capacity to drink more than their
friends when they started drinking.
10

7.

Does drinking help creativity ?

No. Alcohol releases inhibitions, and small amounts may help
some people overcome certain blocks caused by inhibition.
However, since even a small amount affects judgement, the
results are not as good as the drinker believes.

8. Can anybody become an alcoholic ?
Yes. Any type of person can and does develop alcoholism.
There is no immunity conferred by background, position in
life, money, profession or occupation. Many people think
that alcoholics are only found in slums, and are jobless,
without family and home. It is not true. Alcoholics may
also be married, employed, living with their family, just
like those around us.
9.

Is it true that beer drinkers never become alcoholics ?

No. There have been alcoholics who were almost exclusively
beer drinkers.

10.

Is it a fact that alcoholism is a disease ?

Yes. The American Medical Society has classified alcoholism
as a disease and through the years this has proved to be a
helpful concept in the treatment of alcoholism Once an
alcoholic starts drinking he may not be able to control his
compulsion to continue drinking just as T. B. patients
cannot voluntarily control their coughing.
11.

Can alcoholics go back to social drinking ?

Never It is not safe for an alcoholic to imbibe alcohol in
any form including wine, beer, certain cough medicines/
tonics, or anything else that contains alcohol even in small
quantities. Even the smallest amount of alcohol can and
sometimes does trigger the disease into becoming active
again.
12.

Will switching drinks keep one from getting drunk?

No. It is the alcohol content that causes drunkenness
irrespective of whether it is wine, beer, whisky, gin, brandy
or rum

13. Is there something wrong with people who do not
drink ?
No. Drinking or abstaining from alcohol is purely a personal
choice. Apart from religious and health reasons, a total
11

abstainer may dislike the taste or the effect of alcohol on him.
He may also be aware of the long-term effects of alcohol.

14.

Is drinking essential in certain social situations ?

No. One can always be firm and refuse. Unfortunately
there are some persistent, ill-mannered hosts who force
drinks on guests and non-drinkers, even after a polite refusal.

CHAPTER 4

Alcoholism

Who is an alcoholic?
There may be many reasons, but most often, alcohol is
consumed because it makes people feel better. People
drink for pleasure, to relax or to escape from day to day stress.
Some people like its taste, others feel a social pressure and
drink to conform with the group. Those who are highly
inhibited find it difficult to make small talk and take to
drinking as it lowers their inhibition and helps them feel
comfortable with others.

The question of why people who start off drinking for
such seemingly innocent reasons, end up as problem
drinkers remains unanswered
But it has been found out
that one in every ten people who drink for social reasons
become dependent on and addicted to alcohol.

Alcohol dependence can be both physical and
psychological. Psychological dependence exists when
alcohol becomes so central to a person's thoughts, emotions
and activities that it becomes practically impossible to stop
using it. . The ethos of this condition is a compelling need
or craving for alcohol. Physical dependence is a state
wherein the body has adapted to the presence of alcohol
13

and if its use is abruptly stopped, withdrawal symptoms set
in. The symptoms range from nervousness to tremors,
convulsions, hallucinations and possibly death.

Hence an alcoholic can be defined as 'someone whose
drinking causes a continuing problem in any compartment
of his life'—Marty Mann.

What is alcoholism ?
Irrthe year 1956, Alcoholism was declared a disease
by the American Medical Association.
According to Keller and Effron : "Alcoholism is a
chronic illness, psychic, somatic or psychosomatic, which
manifests itself as a disorder of behaviour. It is characterised
by the repeated drinking of alcoholic beverages' to an
extent that exceeds customary dietary use or compliance with
the social customs of the community and that interferes
with the drinkers' health or the social or economic functioning.
The characteristics of alcoholism are as follows:
1.
It is a primary disease : Initially alcoholism was
considered to be a symptom of a psychological disorder.
Now, it is understood that alcoholism as such is a disease,
which can cause mental, emotional and physical problems.
These associated problems cannot be treated effectively
until alcoholism is treated first.

2.
It is a progressive disease : The disease progresses from
bad to worse. Sometimes there may be intermittent periods
of improvement, but over a period of time, the course of the
disease is inevitably towards serious deterioration.

3.
The disease is terminal: A person drinking excessively
may die due to any complication, but the factor which induces
the complication itself is alcohol, and thus alcohol is the
real agent behind the death.
4.
It is a permanent disease : The disease cannot be cured
but can be successfully arrested by totally abstaining from
alcohol Ingestion of even small amounts of alcohol will
lead the person to obsessive drinking within a few days.
In other words an alcoholic can never go back to social
drinking even if he has remained sober for many years.
Hence alcoholism is considered to be a permanent disease.

Stages of the disease
As mentioned earlier, alcoholism is a progressive disease.
Three stages of progress can be identified, namely: Early
stage, Middle stage and Chronic stage.

Early Stage Symptoms:

The first warning sign for many who
later develop alcoholism is a need for higher amounts of
alcohol to produce the same degree of intoxication. This
means, needing three or more drinks to effect mood changes
where earlier only one or two was sufficient. As tolerance
for alcohol increases, the individual also starts gulping his
first few drinks, so that the intoxicating effect of alcohol is
felt immediately.

Increased Tolerance :

Black-Out : Black out is alcohol-induced amnesia, wherein
the person may go through many activities without being
able to recall even a trace of these activities later on. During
a black out, the drinker may go through his routine activities
like eating, driving etc, but later on he may not recollect
the details or may even deny doing them.
Even when the person is
not drinking he is always pre-occupied with thoughts of
how, when and where to get his next drink.
Pre-occupation With Drinking :

15

This symptom stems from
feelings of guilt about his excessive drinking.
Avoiding References to Alcohol:

Middle Stage Symptoms:

Initially there is loss of control over the
amount of alcohol consumed. Later on with the progression
of the disease, there is loss of control over the time and place
of drinking. At this stage, drinking becomes compulsive.
Loss of Control:

Justifying His Drinking : The person develops an elaborate
defensive system to rationalise his drinking and thus deals
with his feelings of guilt and remorse.
Another way by which
the problem drinker avoids the truth about himself and his
condition is by exhibiting grandiose behaviour which is
usually inconsistent with both his financial and professional
capabilities For example lending money to others when
his own finances are low.
Exhibiting Grandiose Behaviour :

Aggression: It is an expression of self hatred which is
directed towards others, whom the alcoholic thinks is
responsible for his problems.
The alcoholic may abstain from
alcohol for stated periods of time, due to social pressure,
but these periods of abstinence do not last long. A person
may stay away from alcohol for 30 or 40 days together at a
stretch due to any religions or social reasons, but after this
abstinent period he goes right back to compulsive drinking.
Abstaining From Alcohol:

16

Changing the Drinking Pattern : The person changes his
companions or places or type of drinking, with the intention
of regaining control over alcohol. This is a characteristic
symptom of this phase of the disease.
At this stage social relations begin to decay, old friends
keep away and problems at work emerge.

Chronic Stage Symptoms
This stage is characterised by overt physical, mental and
social deterioration. The symptoms include :

Binge Drinking : The alcoholic goes on a drinking spree
and drinks continuously for several days at a time. At the
end of each such "binge'' he promises never to drink again
only to return to compulsive drinking.

Decreased Tolerance For Alcohol: The alcoholic gets drunk
even with small amounts of alcohol. This decrease in
tolerance is due to severe physical deterioration.
Ethical Breakdown : At this stage, there is complete ethical
breakdown. The drinker is so dependent on alcohol that
he will lie, borrow, or steal in order to maintain his supply
of alcohol.
Feelings of Fear : The alcoholic experiences indefinable
feelings of fear. For example, he might be frightened to do
simple things like crossing the road.

Paranoia : The alcoholic becomes highly suspicious and
believes that he would be harmed by everybody. He may
refuse to eat for fear of being poisoned.
Hallucinosis : Auditory (imagining voices speaking to him),
visual (seeing things) and tactile (feeling things on his skin)
hallucinations are experienced by the alcoholic.

Psycho Motor Inhibitions : He loses most of his motor
co-ordination. He is unable to do even simple things like
tying his shoe lace until he 'steadies himself' with a few
drinks. His legs and arms do not respond automatically to
the minds desire. He also experiences tremors and shakes.
At this juncture the alcoholic's family life, job, finances,
health and every other compartment of his life gets affected.
He now has three choices open to him.
17

1.

He can seek help to give up alcohol

2.

He can continue to take alcohol and end up in a mental
asylum

3.

He can continue to take alcohol and die prematurely

18

CHAPTER 5

Treating Alcoholism
Alcoholism is a treatable disease. The objectives of
treatment are to break the alcoholics' dependence (both
psychological and physical) on alcohol and to effect positive
changes In his life style. Chances of recovery are greater if
treatment is started at the earlier stages of dependency.
People with great deal of physical and psychological problems
also have chances of recovery, though at a slower pace.
Treatment of alcoholism is brought about through medical
and psychological methods.
These are aimed at three levels.

1.

Management of acute episodes of intoxication to save
life and to overcome the immediate effects of excessive
alcohol consumption.

2.

Remedy for chronic health problems associated with
alcoholism.

3.

Changing the attitude and personality characteristics
of the alcoholic individual so that he is able to improve
the quality of his life by abstaining from alcohol.

Management of Acute Episodes of Intoxication :

When a person is acutely intoxicated, the concentration of
alcohol in the blood rises to toxic levels. Detoxification is
the process by which toxic levels of alcohol is eliminated
from the body. This process is an integral part of the
treatment procedure which requires hospitalisation and the
attention of specialists. Detoxification allows people to
recover from the effects of intoxication in a supportive and
comfortable atmosphere. People who are addicted to the
drug alcohol, depend on the continuous consumption of the
drug to attain a feeling of well being. So, sudden withdrawal
of alcohol from the body results in an abrupt cessation of
the depressant effect of alcohol, leading to the hyperactivity
of brain cells. This leads to several withdrawal symptoms
which can be mild or severe. These symptoms include
19

tremors, anxiety, sleeplessness, visual and auditory
hallucinosis (hearing and seeing things) paranoia, sweating,
fever, tachycardia (rapid heart rate) and tachypnea
(rapid respiration)
During detoxification, glucose, vitamins and other nutrients
are given to improve the general health of the individual.
Management of Chronic Health Problems:

Some of the chronic health problems associated with
alcoholism are gastritis, cardiomyopathy, neuritis, fatty
liver and cirrhosis. These complications have to be medically
treated by specialists from respective fields.
Changing the attitudes and personality characteristics of

Alcoholics.

Management of acute intoxication and health problems
associated with alcoholism does not complete the treatment
picture. Treatment should also effect changes in the
behaviour and thus the life style of the alcoholic individual.
This is brought about by psychological treatment in the
form of individual, group and family therapy. This helps
the patient to bring to light, forgotten or repressed feelings
of anger, guilt, shame, fear and low self-esteem, and also
to deal with them in the present.
Psycho-social techniques

Psycho-social techniques help in bringing about positive
personality changes which is a pre-requisite to abstaining
from alcohol.
This technique comprises of individual psycho-therapy,
group therapy, family therapy and relaxation methods.
Individual Psycho-Therapy :
Here the therapist enables the
patient to sort out his problems in interpersonal relations
and to analyse his personality make up. This helps him to
develop positive coping mechanisms.

Here the patient interacts with others who
are also dependent on alcohol. During group therapy,
members share and discuss the problems in their lives. In
these sessions they are free to confront each other.and
Group Therapy :

20

clarify the issues that are being discussed This enables
every individual to work through in actual interchanges
with others, some of the underlying emotional conflicts
that have been keeping him or her defensive, frightened,
anxious or depressed.

Family Therapy : This is directed towards the family of
the alcoholic with a view to overcome the family members'
guilt or resentment against the alcoholic.
Relaxation Methods: It is often found that the alcoholics
have problems in handling tension and anxiety. They are
unable to relax or sleep well. Relaxation methods help to
rectify these problems.

Quite often, the treatment procedure also includes the use
of drugs, namely antabuses. These drugs are especially
helpful to those alcoholic patients who want to stop
drinking but have periodic motivation to return to alcohol.
These drugs are usually administered during the initial
stages of recovery. If alcohol is imbibed when already on
the drug, adverse effects are brought about. These effects are
due to the chemical "disulfiram" in the drug. This chemical
interferes with the metabolism of alcohol, resulting in an
accumulation of acetaldehyde in the body, which is
responsible for the adverse effects including nausea,
vomitting, sweating, palpitation and at times even death.
Thus it can be seen that the treatment of alcoholism requires
a multidisciplinary approach and the help of specialists from
various fields. The co-ordinated work of such professionals
helps the alcoholic to recover.

Treatment at T. T. Ranganathan Clinical
Research Foundation
The treatment at T. T. Ranganathan Clinical Research
Foundation is based on the concept that alcoholism is a
treatable disease. By tackling each individual's problems
with a multi-faceted programme, the Foundation helps him
to take his place as a reliable and responsible member of
society.

The first stage, of treatment involves detoxification, which
requires hospitalisation, for a period of one week to ten days
depending on the severity of the patient's condition.
After discharge from hospital the patient undergoes an
intensive three week therapeutic programme at the
Foundation. Therapy at the Foundation comprises of
individual counselling, lectures, group and family therapy,
dietary counselling, relaxation and transcendental meditation
and films on alcohol use and abuse.

After treatment at the Foundation there is a rigorous follow
up programme wherein the patients are expected to call at
the Foundation once in 10 days or 15 days for at least a year.
It includes medical check up along with counselling sessions
and after care group meetings.
22

A social support system has also been mobilised to help
individuals who have already taken steps to give up alcohol.
The social support programme aims at exploring the possible
support the recovering people have, from the society in
which they live.

The patients are also encouraged to attend Alcoholics
Anonymous meetings after treatment at the Foundation.

CHAPTER

6

Guidelines for the Family of
Alcoholics
Alcoholism is an illness which has tremendous emotional
impact upon the immediate family. The disease not only
affects the alcoholic, but also hurts the people close to him.
The family members require assistance and counselling in
order to help the alcoholic overcome the disease. A few
guidelines for the family to deal adequately with alcoholism
are given below.
— Learn all the facts about alcoholism

— Accept these facts. One cannot accept an alcoholic as a
sick man in need of help if he is going to be blamed for all
actions resulting from the illness. Changing one’s attitude
and approach to the problem can speed up recovery.
— Try to remain calm, unemotional and factually honest in
speaking with the problem drinker about his behaviour and
its day to day consequences.
— Be patient and live one day at a time. Alcoholism
generally takes a long time to develop and recovery does
not occur overnight.
— Try to accept set backs and relapses with calmness and
understanding.
— Establish and maintain a healthy atmosphere in the home,
and try to include the alcoholic member in family life.

— Explain the disease concept of alcoholism to the children.
— Encourage the alcoholic to participate in leisure time
activities.

— Discuss the problem with someone you trust
Given below are a few things the family should avoid doing :

— Do not hide or serve liquor.
— Do not argue or quarrel with the person while he is drunk.
Asking him why he drank does not help in anyway.
24

— Do not accept the lies of the alcoholic, especially regarding
his drinking, expenses etc., as the truth.

— Do not allow the alcoholic to take advantage of the family
members’ vulnerability.
Such as asking the wife.to get loans from friends or her
parents; or expecting the wife to feed him when he is drunk.
— Do' not accept promises of giving up alcohol from the
alcoholic. The wives usually make the alcoholic promise
never to drink again on God or the children. This does not
help him to give up alcohol or control his drinking.

— Do not cover up the consequences of drinking. This
reduces the crisis but perpetuates the illness. For instance
when he is involved in an accident due to drinking, do not
be supportive.

— Do not attempt to punish, threaten, bribe, preach or try
emotional appeal on the alcoholic.
Punishment:

"I will not cook, if you drink”

Bribes : "If you don’t drink, I will clear debts with the help
of my father"

Threats : "If you drink, I will leave home or I will commit
suicide".

Emotional appeal : "If you love me or if you love the
children. You will not drink again:"
—■ Do not take up the responsibilities of the alcoholic; like
Paying off his debts

— Do not feel guilty for his behaviour.
— Do not put-off facing the fact that alcoholism is a
progressive illness. To do ’nothing’ is the worst choice
one,can make.
— Do not expect 100% recovery.

— Do not create an impression that he is giving up alcohol
for the family. He has to give up alcohol for his own self.
— Do not justify his drinking by agreeing with the
rationalisations of the alcoholic.
25

CHAPTER

7

What is Alcoholic Anonymous ?
Alcoholics Anonymous is a world-wide fellowship of men and
women who help each other to stay sober. They offer the
same help to anyone who has a drinking problem and wants
to do something about it. Since they are all alcoholics
themselves, they have a special understanding of each other.
They know what the illness feels like and they have learnt
how to recover from it in AA
AA members say that they are alcoholics today-even when
they have not had a drink for many years. They do not say
that they are 'Cured'

Once people have lost their ability to control their drinking
they can never become 'former alcoholics' or ex-alcoholics.
But in AA they can become sober alcoholics, and recovered
alcoholics.
They share their experiences, strength, and hope with each
other so that they may solve their common problem and help
others recover from alcoholism.

The only requirement for membership is a desire to stop
drinking.

There are no dues or fees for AA membership : They are
self-supportive through their own contributions.
AA is not allied with any sect, denomination, political
organisation or institution; it does not endorse or oppose any
cause. The primary purpose is to stay sober and help other
alcoholics to achieve sobriety.

How does AA help the alcoholics? : AA offers help to the
alcoholic in the form of friendship and understanding. AA
welcomes the alcoholic not "in spite'' of his drinking but
"because” of his drinking It provides opportunities for
sympathetic mutual discussions with other members thereby
helping the alcoholic in relieving his burden of complexes and
self recriminations. It advises the alcoholic to seek medical
help, if there are any physical problems, to turn to God for
spiritual well being and to set right all the past mistakes, as •
far as possible, in order to relieve one's inner conflicts.
26

)|

CHAPTER

8

About Us
The T.T. Ranganathan Clinical Research Foundation is the
first of its kind in the country dedicated to the treatment and
rehabilitation of people addicted to alcohol and other drugs.
It is also engaged in Research work on various aspects of
alcohol and drug abuse. The Foundation carries on
education work for prevention of alcohol and drug abuse.

The treatment programme is conducted by a team of
dedicated professionals like psychiatrists, clinical
psychologists and social workers. Individual needs of the
patients are catered to by the multi-discilpinary approach of
the professional team.

An expert committee consisting of eminent doctors and other
professionals concerned with the disease of alcoholism
advises the Foundation on the latest development in
treatment methodology.

★

★

★

For Further information Contact:
T.T. Ranganathan Clinical Research Foundation
91, Santhome High Road,
Madras-600 028.
(Opposite to Ayyappan Temple)
Telephone Number :

Working Hours :

417528.

Monday to Friday :

10.a.m. to 4.30.p.m.

Saturday

10.a.m. to l.p.m.

27

Printed at :
M. W. N. P R E SS
27. LLOYDS ROAD
MADRAS - 600 005
Phone: 4 7 18 7 6

<

A Word about Ourselves
The T. T. Ranganathan Clinical Research Foundation is the
first of its ad in the country, dedicated to the treatment and
reha; liter ' i of alcohol dependants.
At. :ic' s iicated professionals treat alcohol dependants,
hot? na
aut of hospital. The staff includes doctors,
soc
workers, psychologists and psychiatrists.
An Expert Committee consisting of eminent doctors and
other professionals concerned with the disease of alcoholism
advises the Foundation on the latest developments in
treatment methodology.
The clinic offers a course of intensive treatment for the
patient and his family. To begin with the patient is
withdrawn from alcohol through medication. The first
step involves detoxification, a process that requires
hospitalisation. The duration of stay depends on the
severity of the patient's alcoholism.
The next stage is of utmost importance. The patient after
being discharged will have to maintain his sobriety. The
T. T. Ranganathan Clinical Research Foundation assists
this process of recovery with individual counselling, group
counselling, nutrition therapy and relaxation therapy. The
patient also attends Alcoholic Anonymous meetings every
week.

The T. T. Ranganathan Clinical Research Foundation regards
alcoholism as a treatable disease. It underlines the fact that
there is no need for the problem-drinker (at any phase) to feel
that he has passed beyond the point of no return. His
family need not develop pessimistic attitudes towards
chances of his recovery. The Programme aims at changing
attitude and behaviour and developing positive traits in the
personality of the individual. By tackling each individual
problem: with a. multi-faceted programme and with care and
treatment, the Foundation, helps to put these people back
on their feet, and take their rightful place as responsible
members of the society.

T. T. Ranganathan Clinical Research Foundation
91, Santhome High Road,
Madras-600 028.

(Opp. Ayyappan Temple)

-

Bnmhjoanal ofAdJutum SO (IMS), 255-263
© IMS Society (or the Study of Addiction to Alcohol and other D

International Review Series: Alcohol and Alcohol Problems Research

4.

Canada

Reginald G. Smart
Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada.
Summary
Canada has been a leader in alcohol research for several decades. This research, both in Canada and elsewhere, is often
associated with a Temperance Movement. In Canada, several of the most important alcohol research centres were established
with the support of the Temperance Movement. The largest alcohol research agency is the Addiction Research Foundation m
Ontario and it accounts for most of the alcohol research money spent in Canada. It has a research budget of about $5 million
and about SO scientists on staff. Currently there are 31 lines ofresearch and a much larger number ofprojects. Provincial agencies
outside Ontario typically do very little research, except to evaluate their own programmes. In addition, some grants for alcohol
research are made by medical research agencies. Several important approaches in alcohol research can be identified as typically
Canadian. At present, research funding is not being expanded and actual declines in support have occurred in some areas.

A Introduction
Countries with ambivalent attitudes about alcohol tend to
have more alcohol research than those with consistent
attitudes (1]. This is the case with Canada, a world leader
in alcohol research for several decades. We have a long
tradition ofsocial support for the Temperance Movement,
side by side with traditional drunkenness among the
Indians, pioneers, miners, railway-workers, lumbermen
and soldiers who originally built the country. Canada now
has close government control of all aspects of the
manufacture, distribution and sale of alcohol, a system
which contrasts with that found in more liberal wine­
growing countries. However, popular support for
drunkenness still remains in Canada; national and local
cultural events, for example, New Year’s Eve, the Grey
Cup football game, and indeed most spectator sports,
often involve heavy drinking. As with Scandinavian
countries, there is excellent support for alcohol research
which flows out of a long preoccupation with drinking as
a social problem.
It is interesting to examine some of the historical
traditions around alcohol and the way Canadian society
supports alcohol research. Such research is done to some
extent in universities on a grant basis by the federal
government via Health and Welfare Canada and by
various provincial alcohol commissions and foundations.
Undoubtedly the largest contribution to research has been
made by the Addiction Research Foundation (A.R.F.) in

Toronto. Its research and many of its researchers have
become internationally well-known and hence its
activities are a prominent pan of this review. However,
efforts are made to examine the role of various university
research groups and provincial alcohol commissions
outside Ontario. Because of my long association with
A.R.F., biases toward that organization are impossible for
me to avoid. Readers should take this paper as a personal
view, coloured greatly by my own experience and they are
advised not to look for too much objectivity.
B Historical perspectives
(i)
Pioneer times and alcohol
Alcohol was not a problem for the first Canadians — the
Indians and Eskimos who inhabited Canada before the
Europeans. However, soon after the immigrations from
Britain and France alcohol problems arose, became
entrenched, and have remained largely unsolved ever
since. Neither Indians nor Eskimos discovered the art of

The views expressed tn this publication are those of the author
Foundation The author wishes to thank R. E. Popham, M.
Shain and A. C. Ogbomc for their comments on this paper.

D. 1. K. Rinc, a former alcoholic, concen
drunkards and skid-row derelicts in the 1880s.

Reginald G. Smart
first-hand experiences about drinking. We might not call
it ‘research’ but at least it was intelligence gathering. The
Dominion Alliance for the Total Suppression of the
government alcohol control activities and anti-drinking Liquor Traffic and the W.C.T.U. constantly bombarded
governments with statistics on alcohol sales, the extent of
movements which have continued to the present day.
Reports of early missionaries, such as the 'Jesuit drunkenness, and the economic costs of alcohol, or ‘the
*
as it was called. Although biased and
*
Relations
[2], contain hundreds of references to drink bill
drunkenness among Indians and early settlers. For unsophisticated, these reports do represent a rough early
example, 'Every night is filled with clamors, brawls, and approximation to social research.
When various provincial foundations were established
fatal accidents, which the intoxicated cause in the cabins.’
after
the
Second
World War they were often supported by
and ‘It (drunkenness) is so.common here and causes such
disorders, that it sometimes seems as if all the people of temperance leaders in the legislatures. Several of the
the village had become insane so great is the licence they foundations had temperance members on their boards or
as
chief
executives,
at least in the beginning. To some
allow themselves when they are under the influence of
*
liquor.
[2]. French authorities made many unsuccessful extent, modem alcohol agencies took over (and greatly
efforts to control drinking by Indians, as did the Hudson’s improved) the work of the temperance organizations in
Bay Company, which eventually prohibited trade in treatment, education and research. In general, countries
with a strong temperance tradition, such as North
alcoholic beverages.
Drinking was also a problem among many pioneers and America, England and Scandinavia, support more alcohol
traders whose drinking was often as heavy as that of the research than those with no such traditions, as in Latin
Indians- Pioneer inns and taverns were very numerous America and Western Europe.
and they were usually the first buildings put up in new
settlements [4]. Logging, mowing and barn-raising bees
were common and it was the custom to provide a gallon of C Current alcohol research organizations in Canada
whiskey per attending family [3]. Susanna Moodie [5]
writing in the 1840s, found that bees were, 'noisy, riotous,
drunken meetings often terminating in violent quarrels Health services in Canada are largely a provincial, rather
and sometimes even in bloodshed. ’(ii)
than a federal government concern. There is, therefore,
considerable Balkanization in health-related efforts and
(ii) The temperance movement and alcohol research
alcohol research is no exception. Provinces are responsible
The 'Temperance Movement
*
began as a response to the for the provision of most health and education services,
excessive drinking in early Canada. The movement except for some native groups and the armed forces. Also,
derived most of its support from Methodist, Presbyterian they are responsible for the education of health
and Baptist churches and became pan of the 'Social professionals through the universities, and for the
*
Gospel
movement of the early 1900s. Canadian tem­ administration ofhealth insurance schemes. However, the
perance movements had many activities similar to those of federal government does contribute financially to both
modem alcohol commissions or foundations. For exam- health and education through a complex system of grants
ple, the Women’s Christian Temperance Union to provinces.
(W.C.T.U.) tned to have alcohol education courses,
Several mechanisms exist for funding alcohol research.
called ‘scientific temperance
*,
introduced into schools and The Federal Department of Health and Welfare conducts
some alcohol studies internally, chiefly epidemiological
Temperance movements always took some interest in research and evaluations of its prevention programmes.
Also, several federal agencies, such as the Medical
this exclusively.2 In addition, temperance movements Research Council and the National Health and Welfare
frequently challenged municipal, provincial and federal Development Program, give grants to universities for
governments to change the licencing laws to make alcohol alcohol-related projects. In addition, all provinces, except
less available and more expensive. Much ofwhat they said Quebec and British Columbia, have an ‘Alcoholism’ or
was not very different from the so-called *neo-temperancc ’ ‘Drug Dependency’ Commission or Foundation, al­
approach now attributed to A.R.F., although their though only Ontario’s has ‘research’ in the title. By far the
arguments lacked scientific sophistication.
largest, in terms of both total budget and research effort
is A.R.F. in Ontario (Table 1).

fermentation but when the British brought rum and the
French brought brandy to North America they were

International Review Series
Table 1. Provincial alcohol agencies doing research in 1984

Agency
FomS>^CSC“C'‘

Location
Toronto
Ontario

Alberu Alcoholism and Edmonton
Drug Abuse Commission Alberta
Alcoholism Foundation Winnipeg
of Manitoba

Total
budget'
$28,462,460

budget2
$8,297,492

staff2
50’

$24,253,326

$350,000

9

$7,839,491

None Specifically
Allocated
(about $40,000?)
$186,000

1

Research effort
(1984)'
37 lines
171 published
books, book
chapters, papers
7 projects
6 reports
14 reports

4

7 projects

5.0%

$180,000

4

about 6 projects

3.1%

Not Available
(about
$160,000?)

4

10 projects

2.7%

Saskatchewan Alcoholism Regina
$3,668,406
Commission
Nova Scotia Commission Halifax
$5,860,400
on Drug Dependency
Nova Scotia
Alcoholism and Drug
St. John
$5,872,977
New Brunswick
of New Brunswick

budget spent
on research
29.0%

1.4%

0%

1 Foundations.

1 Scientist posiuons only.
(ii) The creation and early development of research at the
Addiction Research Foundation
Prior to the Second World War, there was almost no
research on alcohol problems in Canada. Various Royal
Commissions had collected statistical data and the
opinions of presumed experts, such as physicians, since at
least 1895. Otherwise original research did not exist
beyond a few projects on basic mechanisms at the
biochemical level. Social research, epidemiology, and the
total alcohol policy and alcohol treatment field were
largely undeveloped. In fact, temperance organizations
provided analyses ofgovernment figures on morbidity and
mortality from alcohol, together with their own inter­
pretations, but this research was often highly biased. The
major actor in the alcohol field was Alcoholics
Anonymous, an organization which had come to Canada
in the early 1940s [6]. They had no interest in alcohol
research but did help to interest H. D. Archibald, the first
Executive Director of A.R.F., in the problems of
alcoholism.
The Foundation, originally called the Alcoholism
Research Foundation, and now officially the Alcoholism
and Drug Addiction Research Foundation, was
established for a number of reasons. ‘Liquor by the drink’
had been introduced into Ontario in 1947 in bars which
had only been beer parlours before. This change led to
much criticism of the government. At that time, there
were no public treatment facilities for alcoholics in
Ontario, except for mental hospitals which took mainly

cases complicated by serious mental illness. A need for
treatment facilities was recognized by many groups. A
prime mover was H. D. Archibald, a lecturer in social
work at the University ofToronto. It is most unlikely that
A.R.F. would have been established as a research centre
without his influence. A certain number of recovered
alcoholics also argued for its creation. In addition,
Temperance interests were in favour of a new treatment
centre for alcoholics. A number of Temperance leaders
actively supported the idea of treating alcoholics and one,
William Temple, argued in the legislature that: ‘it is high
time this province did something to care for the victims of
the alcoholic traffic, instead of giving all their energy to
promoting the sale of liquor.’ The wife of the Premier,
Leslie Frost, was a prominent Temperance leader and is
said to have been influential in creating A.R.F.
The first suggestion for a name was the Alcoholic
Research Foundation and legislators agreed only to a
treatment centre. The idea that research would become so
prominent seems not to have occurred to those present at
the creation of A.R.F. Provincial governments, then as
now, were not heavy supporters of research in social or
medical problems. However, when the Act incorporating
A.R.F. was passed in 1949, it was termed the Alcoholism
Research Foundation, a change suggesting a wider mandate than research on ‘alcoholics’. Archibald has stated [6J
that the stress on treatment was a strategy developed to suit
the times as any stress on research in the debates might have
provoked hostility from the legislators.

258

eginald G. Smart

freedom for researchers generated some problems.
Sometimes the wrong researchers were chosen or some
work wandered off into unproductive areas for too long.
These problems became more obvious with time and, in
the view of some, began to outweigh the benefits.
In the 1970s a growing concern with accountability of
researchers at A.R.F. and elsewhere developed. Freedom
to ‘do one’s own thing’ disappeared as clear goals and
objectives were laid out for the organization and for the
researchers. Budgets became tighter and research
positions more difficult to find. Review of projects on an
individual basis was instituted in 1976 for both scientific
adequacy and ethical acceptability. Also, there is now an
internal review of total research effort done every few
years and a comprehensive external review utilizing
outside experts every 5 years. Clearly this has meant more
paperwork, committee meetings (and headaches) for
A.R.F. scientists. However, there seems to be no major
impact on productivity; probably the extra time needed is
taken from collegial contacts and the large amount of
informal interaction which was featured in the past.
Early influences on the research programme at A.R.F.
professionals in the addictions field. In 1979 research was included many people who sadly are now dead or have left
extended into the Regional Programs Division with the the field. In the early 1950s J. K. W. Ferguson began work
establishment ofa special unit, mandated to concentrate on on anti-alcohol drugs, such as disulfiram and developed a
the evaluation of community development programmes.
new one, calcium carbimide (Temposil), which is still
widely used. This continues to be a topic of research,
although in a greatly modified form. E. M. Jellinek was at
own projects [8]. Much emphasis was put on hiring the A.R.F. in 1958-59 and later went on to the Alberta
Alcoholism and Drug Commission. While in Toronto he
projects within the mandate of A.R.F. In the early days of generated interest in his formula for estimating the
Research Division there was little control on who could do numbers of alcoholics from liver cirrhosis mortality; this
what project. Scientific curiosity was given free reign and line continued for some years. His ‘Disease Concept of
interdisciplinary projects were fostered. Control on what Alcoholism’ was influential in that Canadian researchers
projects were done was exercised informally through often debated the existence of such an unlikely disease,
collegial relationships, rather than executive fiat.
but the ‘disease concept ’ probably did contribute to
In my opinion this system had many dividends in increased funding for alcohol problem research. In the
exciting and productive research. A number of high-risk/ 1950s we were influenced by Finnish researchers, such as
high-profile projects were begun that many administrators Pekka Kuusi and Kettil Bruun, who were interested in
alcohol policy and studying the effects of policy changes.
one of these, research assistants spent years counting and Leonard Goldberg of Sweden had an important influence
on the establishment of research on both tolerance and
dependence and drinking-driving. A further influence
to buy alcohol from liquor stores. The slips for individuals was H. Ward Smith, whose work with R. E. Popham in
were then aggregated to form a picture of the distribution the early 1950s on drinking-driving, generated a line of
of alcohol use in the population of Ontario. The report [9] research which is still vigorous. Around 1959, John
Seeley, the first Director of the Research Division, began
so-called Single Distribution Theory of alcohol consump­ to study the effect of real price on alcohol consumption.
tion, with major implications for prevention [10]. Both the He awakened interest in this line by suggesting the
possibility that the prevalence of alcoholism could be
reduced through manipulation of alcohol taxes [11].

Research was not very important at A.R.F. for the first
few years. The first annual report stated that ‘in
preference to setting up its own staff it will make grants to
universities, colleges and hospitals’ [7]. In the first year
there were three external grants given for a total of $9,450;
by 1953 there were 31. However, in 1954 an internal
research department was established with R. E. Popham
and R. J. Gibbins as the principal investigators. They had
been part of the earliest grants programme. Although the
research grants programme was maintained until 1974,
payoff in terms of publishable research often seemed
inadequate. However, grants and fellowships for graduate
students did continue, and served to encourage some
research workers who eventually became part of the
intramural research effort.
At first, virtually all of the research was done in the
Research Division, including a biological research unit
established in 1959 in the Department of Pharmacology
qnder Dr H. Kalant. By 1970, the intramural enterprise
had a staff of about 50. In 1970, research was begun in the
newly-formed Clinical Institute, a university-affiliated

International Review Series

259

(iii)
The current research programme at the Addiction
Clinical Institute
Research Foundation
Biomedical Research; Research Co-ordinator: R. Ci
Currently, research at the Foundation is done in three
main areas: the Social and Biological Studies Division; the Clinical Pharmacology: C. A. Naranjo.
Clinical Institute (a university-affiliated and teaching 10.
The pharmacotherapy of alcoholism.
centre); and the Community Programs Evaluation Centre Gastroenterology: H. Onego
in London, Ontario. For the most part, epidemiological, 11.
Clinical evaluation and treatment of alcoholic liver
programme development, and social policy relevant
research is done in the Social and Biological Studies 12.
Clinical research relating to portal hypertension and
Division. Basic pharmacological and biochemical
portal systemic encephalopathy.
research is also done there. Most research on clinical 13.
Investigations into the pathogenesis of alcoholic
problems and treatment assessments are done in the
liver disease and interaction between alcohol and
Clinical Institute. Evaluation of A.R.F. community
anaesthetic agents.
development programmes is done in the Community Neurology: P. L. Carlen.
Programs Evaluation Centre. Currently there are about 50 14.
Study of the organic brain syndrome and its
staffscientists engaged in research, with a research budget
reversibility (neurological aspects).
of $8,297,492.
15.
Ponal-systemic encephalopathy.
16.
Cellular neurophysiological studies into the
involves many different lines. In 1984 there were more
mechanisms of acute intoxication and alcoholic
than 31 Lines concerned mainly with alcohol problems and
an additional eight lines concerned with non-alcoholic Psychiatry: F. B. Glaser.
drugs. Each line involves several projects and results in a ’ ■* The development of alcohol and drug problems in a
number of publications. For example, in fiscal year
professional population.
1983-84 there were 171 publications by Foundation staff, 18. The epidemiology of psychiatric disorders in
including books, book chapters and journal articles, plus
patients with alcohol and drug problems.
a number of unpublished internal reports.
19. The treatment of alcohol problems through an
The 31 lines involving alcohol arc listed below, together
integrated pharmacological-psychological approach.
with the names of the people currently responsible for Biochemical Research: Y. Israel.
20.
Studies on the effects of alcohol in the liver.
21.
Development of markers of alcohol consumption.
Social and Biological Studies Division
Behavioural Research: H. Cappell.
Acting Head of Division: W. Schmidt. Social Policy 22.
Behavioural treatments.
Research; Acting Head: E. Single.
23.
Experimental behavioural research.
1. Compilation of alcohol and drug statistics.
24.
Neuropsychological research.
2. Studies of measures to control alcohol problems.
Health Care Systems Research: H. Annis.
.3. Adverse effects of alcohol use.
25.
Identification and assessment of alcohol probProgramme Development Research: R. G. Smart.
4.
Research on drinking/driving practices and new 26. Low-cost interventions and treatment matching.
programmes.
Relapse prevention training.
5.
The extent of youthful drinking and drug use and 28. Follow-up
....
________
systems
studies.
the effects of legal controls.
Community Programs Evaluation Centre
6.
Development and testing of educational pro­ Community Programmes Evaluation: M. Faveri.
grammes for students and other high-risk groups.
29.
Evaluation of programmes designed to improve
7.
Development of methods of preventing and treating
treatment systems in Ontario.
alcohol and drug problems in employed popula- 30.
Evaluation of employee assistance programmes.
31.
Evaluation of public education and health
Biobchavioural Research: H. Kalant.
8.
Studies of factors governing self-administration of Many of these research lines have been in existence for
alcohol and other drugs.
20 years or more, for example, those concerned with
9.
Studies on mechanisms of tolerance to alcohol and drinking-driving (No. 4), measures to control alcohol
other drugs.
problems (No. 2), mechanisms of tolerance (No. 9),

260
pharmacotherapy of alcoholism (No. 10), etc. The
projects and staff involved may hive changed frequently
but a consistent thread could be seen. On the other hand,
several lines are relatively new, for example, epidemiology
of psychiatric disorders (No. 18), identification and
assessment of alcohol problems (No. 25), and the
evaluation of programmes to improve treatment systems
(No. 29). In general, research lines change slowly and
even the ‘new
*
lines are several years old. A tendency at
A.R.F. is for scientists to have long careers and to study
their area of interest for many years. Research facilities arc
excellent and consequently A.R.F. provides one of the
few places in Canada where scientists can develop a career
in alcohol studies.
(iv) Provincial Alcoholism Agencies outside Ontario
Research in provincial alcoholism agencies is on a much

provinces with a smaller population than Ontario. Most
have as their main purpose the provision of treatment
services, with a smaller educational component and few
have any mandate or funds to do research, except on their
own programmes. Table 1 summarizes some of the basic
data on alcohol research in the provincial commissions.
Clearly, most employ few researchers and have small
research budgets. Nova Scotia, New Brunswick and
Saskatchewan each have four research positions;
Manitoba has one; and Alberta has nine. The total budget
for alcohol research outside of A.R.F. is only about
$936,000 (assuming $40,000 per position for those
provinces not specifying a budget). The total involves 22
people nationwide, or less than half the number of
researchers at A.R.F. The commissions spend between 0
and 5.0 per cent of their budget on research, while A.R.F.

'Reginald G. Smart

Very little of the research done in the smaller commis­
sions is widely available to an international audience.
Several agencies seem to confine publications to internally
or locally available reports. However, the Alberta, Nova
Scotia and Saskatchewan Commissions do make their
reports available to the general public of the province,
legislators, and those interested in addictions. Almost no
research from the provincial commissions is published in
the open scientific literature such as journal articles, books
or book chapters. This contrasts greatly with research at
A.R.F. where virtually all research is eventually
published in journals or books and internal reports are ,
discouraged.
(v) Research grants to university researchers
Currently, few grants seem to be made in Canada for
alcohol related projects. The National Health Research
Development Program funded four projects in Canadian
universities in 1984-85 for a total of $204,494. Two of
these deal with the effects of maternal alcohol use on
offspring. One is concerned with alcohol consumption
and blood pressure, using data from the Canada Health
Survey. The last examines the aetiology of fatal traffic
accidents involving alcohol and cannabis. This project is
being carried out by the Traffic Injury Research
Foundation (T.I.R.F.), a small research group in Ottawa
with a continuing interest in research on alcohol-related
accidents.
The Alcoholic Beverage Medical Research Foundation
gave four grants to Canadian researchers in 1983-84. All
were relatively small and the total amounted to $93,544
U.S. Two were concerned with the effects of alcohol on
membrane function. One was a grant to T.I.R.F. for a
study of alcohol-related accidents among youth. Finally,
a small grant ($5,000 U.S.) was given for a time-budget
study of drinking patterns.
The largest supporter of health research in Canada, the
Medical Research Council, gave six grants in 1984-85 for
alcohol projects for a total of $218,000. Four of these
grants dealt with the fetal or neo-natal consequences of
heavy alcohol intake, obviously a prime area for funding
agencies. One concerned basic mechanisms of tolerance,
and the other the effects of high alcohol intake on liver

Research programmes in agencies outside Ontario are
mostly created in order to serve programme needs. The
major purpose of most research in the commissions is to
provide an in-house data collection service for ad­
ministrators and policy staff. For example, the Alberta and
Nova Scotia Commissions have both studied their exten­
sive primary prevention programmes for adolescents and
evaluated most of their inpatient and outpatient
programmes, as well as compiling survey data on adoles­
cent alcohol and drug use. Recent research in New
Lastly, the Ontario Menial Health Foundation gave
Brunswick has been devoted to determining outcomes of two grants for alcohol research in 1984-85 for a total of
the Commission’s treatment programmes and to the $50,137. One dealt with the effects of alcohol on memory
analysis of various statistics on local alcohol use and and the other with methods of screening alcoholics in a
resulting problems. Research in the Alcoholism Founda­ psychiatric population.
tion ofManitoba is just beginning and only a few externally
In general, alcohol research is not heavily supported by
granting agencies. In 1984 a total of 16 grants can be

International Review Series
identified for a total of $566,175. Probably some grants are
missed in this accounting as smaller agencies supply little
information on the topics of research grants they support.
Also, fellowships and scholarships arc difficult to count as
there is no information on the research area in which they
arc held. It certainly seems that the majority of the
funding for alcohol research in Canada comes from the
provincial commissions, chiefly A.R.F. in Ontario.

261
opening hours, drinking age, drinking-driving laws,
modes of retailing liquor, and the like. A general aim has
been to search for the best government control solutions
to the alcohol problem. In many countries the main
problem is seen to be the drinker and he is the object of
prevention research. In Canada, the objective is much
more likely to be changes in government policies and
procedures for making alcohol available.
Another theme in Canadian research is to de-emphasize
treatment studies. With the exception of research on
pharmacotherapies and a little on controlled drinking in
alcoholics, searching for the best treatments for alcoholics
had been of little long-term interest. To some extent this
is changing as sociobehavioural treatment and treatment­
systems research is being developed at A.R.F. However,
much of this has been concerned with treatment system
efficiency or with discovering how patient characteristics
and treatment interact to produce the maximum benefit.
Treatment research in many of the smaller provincial
agencies consists essentially in monitoring the progress of
patients through the available programmes, rather than in
discovering new treatments and evaluating their effective-

D Some Canadian themes in alcohol research
Some general themes have appeared in Canadian research
on alcohol and a few have been adopted in other countries.
Many of them appeared early and have continued into the
present. One important theme is to emphasize epidemiol­
ogy, especially general epidemiology. Much research is
concerned with drinking and alcohol-related problems in
the whole population. Scientists at A.R.F. were among
the first to point out that the level of problems in a society
was closely associated with the overall level of drinking.
This research began more than 20 years ago and continues
to the present in an effort to establish a biomedical
definition of safe level of consumption. Preoccupation
with general epidemiology has led to a neglect of clinical
epidemiology, a general unrapped area in Canada. It is
also associated with a relative lack of interest in the E The practical impact of alcohol research in
‘disease concept of alcoholism’, studies of the ‘alcoholic
personality ’ and of acute social problems associated with It is difficult to assess how alcohol research done in Canada
alcohol use, such as child neglect and marital conflict. has determined policies for the management of alcohol
There has been a growing tendency among Canadian problems. Certainly there are some major successes in the
researchers to view alcoholics as not very different (except treatment area and space allows that only a few can be
in degree of drinking) from other kinds of drinkers. pointed out here. Early work on disulfiram and other anti­
Probably this is why some treatment studies of alcoholics alcohol drugs at A.R.F. led to the development of new
have involved training in social drinking. The idea that treatments for alcoholism. Research following that in
some alcoholics could return to social drinking (or try it other countries which showed that inpatient and
for the first time) after appropriate treatment does not outpatient care have equal likelihood of success has been
strike most Canadian researchers as radical.
important in controlling the growth of expensive inpatient
Another theme in Canadian research has been to care. The development of propylthiouracil (P.T.U.) by
emphasize studies relevant to government alcohol control Dr Y. Israel and his colleagues [12] as a treatment for
policies. Clearly, we have this in common with our alcoholic liver disease has shown how the length of
Scandinavian colleagues. In any case, Canadians like a hospital stay might be reduced. Research on the Ontario
high level of government involvement in their lives; they and Nova Scotia treatment systems has also clearly
expect government to be involved in the control of social contributed to local planning and community develop­
problems and to serve their interests. Interest in alcohol ment initiatives. However, some treatment evaluation
control policy began very early and by the 1850s research, such as that on Detoxification Centres [13]
Prohibition was being sought throughout the setded areas seems to be ignored by treatment agencies and policy
of Canada. All provinces had Prohibition at least for a makers [14].
short period and the present control system developed as
Observers from other countries sometimes see Canada
an alternative to Prohibition. Alcohol researchers in as the place where alcohol research clearly showed how to
Canada have often oriented their work to studies of overall prevent alcohol problems and are surprised when told that
availability, alcohol price controls, and to a myriad of it has not had much apparent impact on government
studies of small changes in the control systems, such as in policy. No province, including Ontario, has adopted the

G. Smart

basic premise that the prevalence of alcohol problems
varies with per capita alcohol consumption and that
problems can be controlled by reducing overall availabil­
ity and increasing real price. Matters of economics, such
as the need to maintain employment levels and the need
for government revenue, still largely determine alcohol
policies in Canada. However, it may be that research on
availability of alcohol slowed the liberalization of alcohol
laws in Canada and resulted in lower per capita alcohol
consumption.
There have been several instances where research has
affected policy in limited areas. Research on adolescent
drinking problems was clearly an important factor in
having the drinking age increased in Saskatchewan and
Ontario. The current concern with increasing penalties
and many prevention programmes for drinking drivers
can also be traced to research findings. Research on good
alcohol education programmes has also increased their
acceptability to schools in Ontario. Ln general, however,
researchers in Canada have been disappointed with the
impact of their research on social policies relating to
alcohol. There are many reasons for this. Research
findings are but one part of the arguments for and against
particular alcohol controls. Of course, governments worry
about reduced revenues if per capita consumption
decreases. Also, many jobs in farming, manufacturing,
and the hospitality industries depend upon alcohol sales.
When unemployment rates are high, policy makers are
reluctant to reduce the consumption of alcohol and
possibly take jobs away from even more workers.

Ministry of Health now organizes services no successor
was established to do research. Pnnce Edward Island and
the Northwest Territories have no alcohol research effort.
The British Columbia Alcohol and Drug Commission was
disbanded in 1984 and, like Quebec, many of the
functions were moved into the Ministry of Health.
However, this shift did not include the research and no
alcohol research exists at present. The A.R.F. had its
budget frozen in 1984 after several years of increases
below the level of inflation.
On the federal level too, funds for research have been
curtailed. The Medical Research Council had its budget
reduced by $30 million in 1985, although a campaign is
underway to have it restored. Also, the federal govern­
ment has reduced research funds for environmental
projects and has withdrawn funds for several large-scale
National Research Council projects in petroleum and
industrial research. It appears that money for research on
alcohol problems, and many other problems as well, may
be more difficult to find in future.
There is still considerable spending on alcohol research
in Canada, but researchers might have to do with less in
the near future. Alcohol consumption has been essentially
stable in Canada for several years and there are recent
signs of a decline. The same is true of some associated
problems, such as alcohol-related fatalities and liver
cirrhosis mortality. Little argument can be made that
alcohol research will expand in the near future as the
population ages and the proportion of young people, that
is those with serious alcohol problems, declines.
However, there are several topics requiring research input
in Canada, such as, the effects of aging, unemployment,
and family breakdown on drinking problems. No doubt
there will be more pressures for alcohol research to be
well-justified, cost-effective, and clearly of benefit to the
population as these new areas are studied.

F The future of alcohol research in Canada
Galsworthy reminds us that ‘Ifyou do not think about the
future, you cannot have one
*.
Both thinking about the
future of alcohol research in Canada and actually planning
it are quite difficult. Certainly, there is no lack of work to
be done. There is still no reliable method of preventing
alcohol problems and no generally accepted effective
treatment. Government alcohol control policies can be References
improved in all areas of Canada and treatment services 1 Makela, K. Consumption level and cultural drinking
patterns as determinants ofalcohol problems. Proceedings of
should be extended to many isolated areas. The major
30lh International Congress on Alcoholism and Drug Depen­
agencies, such as A.R.F., Health and Welfare Canaria,
dence. Amsterdam, 1972.
and the Medical Research Council, will likely continue 2 Dailey, R. C. (1968). The role of alcohol among North
American Indian Tribes as reported in the Jesuit Relations.
their support of alcohol research in Canada, bur major
10, 45-59.
increases in funding or programmes are unlikely in the 3 Anthropologica,
GuiUet, E. C. (1933) Pioneer Days m Upper Canada.
near future.
Alcohol research centres in many areas of Canada are 4 GuiUet, E. C. (1954) Pioneer Inns and Taverns. Published
by the Author, Toronto.
currently small and underfunded; only Ontario is well
5 Moodie, S. (1980) Roughing It In The Bush. Coles
served. In general, research budgets are not expanding.
Publishing Co. Ltd., reprinting of 1852 edition, Toronto.
The alcoholism treatment and education centres in 6 Journal
Interview Five. (1984). Conversauon with David
Quebec were disbanded many years ago. Although the
Archibald. British Journal ofAddiction, 79, 131-137.

International Review Series
19SI, Toronto.
8 Popham, R. E. (1966) Current Intramural Research:

Senior Staff Meetings. 1966. Substudy 6-2-66, Addiction
9 De Lint, J. and Schmidt, W. (1968). Estimating the

Journal ofStudies on Alcohol, 29,968-973.
10 Schmidt, W. and Popham, R. E. (1978). The single
Alcohol, 39, 377-399.

83, 1361-1366.

Kalant, H. (1979). Thyroid hormones in alcoholic liver
Annis, H., Giesbrccht, N., Ogborne, O. and Smart, R. G.
(1976). The Ontario Detoxification System. Addiction
research: The case of the evaluation of Ontario’s Detoxifica­
tion Centres. British Journal ofAddiction, 77, 275-282.

RAGHU RAI

and constantly abused his wife, throwing
the food she served and breaking crock­
ery. His drinking affected his son so badly
that he dropped out of college.
Mathew. Krishnappa and Swaminathan are only the froth on a tidal wave of
alcoholism engulfing the country. And
there is a cask-full of statistics to prove the
point. In the '60s only one in 300 drinkers

was considered an alcoholic. Then the
World Health Organisation (who) re­
ported that by 1980 an estimated three
million—or one in 25—of the 80 million
Indians who consume alcohol had be­
come severely addicted.
Last year the Indian Council of Medi­
cal Research (icmk) surveyed the problem
in four regions—Bangalore, Delhi, Dibru-

garh andRanchi. It found that20 percent
of urban consumers had become totally
dependent on it. while in villages the
figure went as high as 30 to 40 per cent.
Davinder Mohan, who coordinated the
icstR survey and heads the Department of
Psychiatry at the All-India Institute of
Medical Sciences (aiims) in New Delhi.
says: "Alcohol is already taking a heavy
toll in the country. It's soon going to be
evident even to a blind person."
The toll, in fact, has already become
starkly evident:
►> In major hospitals alcoholics now
form 20 to 30 per cent of the patients in
psychiatric wards when five years ago
they constituted only 02 per cent. In
Bombay's kem Hospital, which treated
309 patients in the past two years, sociolo­
gist Hetna Shah says: "Initially we got
people only from the slum areas. But soon
bank officers, managers, factory workers
and even government officers started
coming for treatment. The middle class
too seems to be affected in a big way."
► Last year's reset study indicated that
halfthe industrial workers surveyed drink
regularly, and companies report that al­
coholism has become one of the major
causes of absenteeism and falling pro­
ductivity. At Ashok Leyland in Madras.
for instance, managers estimate that
atleast 500 of the company's 7.500 work­
ers are problem drinkers. Says Executive
Director J. Joseph: "We used to have 10
per cent absenteeism, but now we find it
going up to 22 per cent and we think
alcoholism has a great deal to do with it.”
t» Alcohol is a major cause of broken
marriages. Relationships with wives were
seriously disrupted in 64 per cent of the
alcoholics. In Bombay, Bagashri Parikh, a
marriage counsellor at the city court, says
that one out of 10 divorces is because of
alcoholic husbands and adds: ‘ 'Most of the
alcoholics beat their wives regularly."
► The country’s road research insti­
tutes estimate that 25 per cent of road
accidents are alcohol-related and that a
third of the drivers on the highway are
under the influence of alcohol. In Delhi,
when the aiims did a study of accident
victims suffering from head injuries, it
found that 20 per cent had consumed
alcohol.
Surveying the damage Hira Singh,
Al'KIL ID. HBfc ♦ INDIA TODAY 73

COVER STORY

director. National Institute of Social De­ have children. In most cases they are the
fence (nisd). the Union Welfare Ministry's only bread-winners in the family. "It's
striking arm against drug abuse, says: hitting the most productive section of our
"There is no doubt that alcohol is the most society and is creating havoc.” says psy­
widely abused drug in the country.” chiatrist J.V. Devar in Madras.
That's certainly true. Alcoholism has
Researchers are hard put to explain
traditionally been associated with the the dramatic rise in alcoholism in a coun­
tribal areas in the country', where people try that has prohibition enshrined as a
brew their own liquor. Then the problem Directive Principle of the Constitution.
spread to the hilly areas and the north­ But prohibition as a policy has been
east. and to industrial townships and the steadily given up by one state after an­
coalfields. Now other areas too have got other, and liquor is now as easily available
ensnared, hitting people from all walks of as tea leaves in most parts of the country.
life: professionals, businessmen, indus­ Alcohol consumption, inevitably, has
trial workers, government servants, arm­ gone up quite dramatically. In 1976.
ed forces officers and farmers. The statis- ’ t liquor manufacturers used up 169.4 miltics reveal that most ofthepatients (98 per ' lion litres of .pure alcohol, enough to
cent) are predominantly male, and usu- . manufacture 350 million bottles of rum.
ally in the prime of their lives at 25 years ‘
and above. A majority are married and
Police test driver for drinking:

-Shattered Lives
Tp^HASKER Maben, 49. a machine
B-sl operator in a Bangalore factory.
JLJbegan drinking heavily 15 years
ago after be was superseded at work and
his youngest son. Dinakar. died the same
year. Maben recalls: "At work I had no
peace and at home I was unhappy. Booze
was the only way I could forget my
sorrows." Instead it brought him more.
Maben became a chronic alco­
holic and began sleeping with a
bottle under his pillow. He started
absenting himself from work regu­
larly. His increments and promo­
tions were stopped.
With liquor burning up all his
money, Maben was invariably
broke. His favourite clarinet, guitar
and camera found their way to the
local pawn shop, as did his wife
Evelyn's jewellery, including her
mangalsutra. The worst came when
he was exacted from his rented twobedroom house. Arun, his son. re­
members that incident with a shud­
der and says: "I can never forget
how ashamed I was. All our furni­
ture and clothes were lying on the
footpath. I just ran to my friend's
house and hid.”
Someonesuggestedthathesend
Rs 50 to St Francis Xavier’s tomb in
Goa. but ±at did not help. Nor did
money' sent to Tirupati Temple, or
consulting a Mantravadi. who made

him wear a charm around his waist and
charged him Rs 1.000 for his pains. He
was admitted to nimhans as many as 18
times for treatment, and the doctors
refused to admit him any more.
Frustration and desperation drove
him to drink a bottle of varnish last year.
which nearly killed him. After that he
vowed to give up drinking and over a

period of one year, Maben's transforma­
tion has been dramatic. He has started
doing yoga, which helps him sleep well.
He goes to work regularly.
At home things have improved con­
siderably, and Evelyn now goes shop­
ping with him—something they had not
done for years. Every Sunday all of them
sing bhajans at a nearby spiritual centre.
Daughter Chandrika says: "There is so
much peace at home now."
□ Narayan. 44. a peon in a bank in
Maduraiisnotsohappy.Analcoholicfor
the past 10 years. Narayan was brought
in a delirious state to the ttrc for treat­
ment last month. His office had
suspended him for coming drunk to
work and warned him that unless
he gave up drinking they would
dismiss him.
While Narayan is still unable to
speak coherently about his addic­
tion. his wife Malini. who faced the
brunt of his drunken bouts, has a
sorry tale to narrate. She remem­
bers that initially when Narayan
drank she thought he was just try­
ing to forget his worries. But soon he
was coming home drunk every day,
beating her regularly, and always in
a foul mood. He threw away the food
she made for him, he was nasty with
the children and prevented them
from studying at night. He did not
give her money and pawned all her
jewellery.
She was forced to take up work
as domestic help to feed the children.
And when her children worried her
Maben: back from the brink

But despite tough measures by the puri­
tanical Janata government and the Congressdl’s resolve to hold production at the
1981 level of 207.9 million litres, the
consumption of pure alcohol climbed to
331 million litres last year—sufficient to
produce 1.134 million bottles of rum!
Indians now have more than 200
brands of whisky. 50 brands of rum. 30
kinds of brandy. 10 brands of gin, 15 of
wine. 50 beers and a couple of hundred
varieties of country liquor to choose from.
"People have become more brand con­
scious and are willing to pay more for
better quality liquor these days,” says
Ra vi J ain. general manager of McDowells.
a subsidiary of United Breweries, which is
among the big five in the liquor business.
McDowells has registered a 10 per cent
growth every year.

for money to see films, she told them
sharply: "Your father is taking my life
out of me, now you don't start." The
office suspended Narayan several times,
but Malini used to go and fall at the bank
manager's feet and beg for mercy. Mean­
while Narayan became so weak that
according to Malini "he is now only eyes
and stomach. I don't know how much
longer he would live."
£3 Anand.33.unlikeNarayanwhohas
not yet lost his job. finds his life has been
completely shattered and is only now
beginning to pick up the pieces. Anand
has been an alcoholic for the past 13
years. Last year his wife walked out
on him, taking their two children
with her. Immediately after that he
lost his job as a sales executive in a
Delhi travel agency.
Anand, the son of an air force
officer, started drinking when in his
second year at college in Nagpur.
Since his father was in the armed
forces, drinking was considered
normal. Anand found himself in­
creasingly attending parties where
liquor was served and he says: "I
used to be the first to start drinking
and the last to leave. I had a tremen­
dous capacity, and even if I had five
large pegs I would never get drunk."
After graduation, his job as a sales
executive offered even more oppor­
tunities to drink and. as he puts it:
"It was an ideal job for an alcoholic.
became a 24-hour drinker."
For a while he thought he could
handle his liquor and he made sure
David: groping for help

that his work was not affected. When his
wife, a doctor, told him to give up
drinking, he said: "I thought she was a
bloody nag and I used to get the feeling
that the whole world was after my
blood." Soon he became irregular at
work and extremely irritable at home.
hitting his wife once in anger. That's
when she left him. He was forced to give
up his job because, as hesays: "I couldn’t
handle two careers at one time: my
drinking and my job.” Last year he
touched rock bottom: “I had become like
a caged tiger. I didn't know how to
escape and all I did was hide myself in the

That Indians are drinking more than
ever before is evident by their revolution­
ary change In attitudes towards drinking.
The traditional taboo against liquor is
rapidly vanishing. More and more homes
serve liquor to guests, 'dry' parties are
considered boring, and traditional festi­
vals like Ganesh Chaturthi, Diwali and
Holi are used as excuses to go on drinking
bouts. Salesmen and businessmen prefer
to do business over lunch lined with
liquor. Among youngsters, to drink is to
be manly. “We are becoming more of an
alcoholised society." says psychiatrist
Rajat Ray of nimhans. And in Lucknow.
psychiatrist B.B. Sethi says: “A house not
serving liquor is now an exception."
Drinking in bars, once the haunt of
only the hardened alcoholic, has gained
increasing acceptance. In the outskirts of

bottle." He finally joined an Alcoholics
Anonymous group in Delhi, and now he
says: “My obsession is gone. But I'm not
going to take up a job till I'm fully
recovered.”
□ David. 32, a packer in a Bombay firm.
has had equally traumatic experiences
with alcohol. Living in a dirty slum in
Ghatkopar, David, who looks older than
his age, is slowly recovering from the
damagingeffects ofalcohol. His speech is
still slurred and he gropes for words. His
hands tremble uncontrollably. Doctors
attending on him say his brain has
suffered some damage and it may be a
year before he is able to recover.
David, who is married and has
two children, remembers that he
started drinking when he was
around 15 years old: "At that time
we drank because after a hard day's
work we had nothing to do and we
wanted to forget the strain of
living.” Initially he drank only on
week-ends, but: "After some time all
I did was to drink, drink and sleep."
He refused to go to work, and last
year was absent for 140 days. His
office -sent him a charge-sheet,
which he ignored. His entire pay
packet of Rs 1,000 went towards
liquor: “I used to be so desperate that
I even sold my shoes and shirt." His
wife left him twice to go and live with
her father.
David was admitted last month
to the kem Hospital for severe with­
drawal symptoms of alcohol like
hallucinations and shakes. Says Da­
vid: “Alcohol has ruined my life."
—RAJ CHENGAPPA

APRIL III. IRRA ♦ INDIA TODAY

COVER STORY

Patna, for instance, roadside bhattis. the
poor man's bars, have become popular
drinking places. One of them on the by­
pass road to Patna is a huge, sprawling
dimly-lit shack reeking with the stench of
liquor, rotten fish and frying eggs. Around
250 people, among them teenagers, sit
around in groups chatting and shouting.
They come from all social groups—rick­
shaw-pullers, factory workers, profes­
sionals and even police constables in
civilian dress. Babu Lalrai, 35, a tailor.
chirps up: "Yes, I drink daily and go to the
Ganga for a holy dip daily."
HE WAVE of alcoholism is by no
means confined to the cities. While
the sale of country liquor in most
states has risen slowly, this masks the fact
that people have increasingly moved to
cheaper, illicit liquor because even coun­
tryliquorcosts as much as Rs 8 for a bo ttle.
In Bangalore, arrack king H.R. Basavaraj
estimates that "illicit liquor sales equal
that of country liquor". The repetitive
liquor tragedies testify to this. In Banga­
lore more than 300 people died of liquor
poisoning in 1981. The next year in the
island ofVypeen in Kerala. 72 people were
killed. On an average more than 200
people are killed in the country from
liquor poisoning every year.
What worries many psychiatrists is
the widespread acceptance ofbeer and the
current boom in beer sales. In Maharash­
tra. beer sales have jumped from 14
million bottles to 24 million bottles in the
last five years. And in West Bengal, more
beer is consumed than whisky, rum and
brandy put together; last year’s beer sales
totalled 12 million bottles. But if people
regard beer as some kind of milk product.
the harsh truth is that one bottle ofbeer
has about the same alcohol content as a
peg of whisky, and psychiatrists say that
beer drinking not onlj' opens the flood­
gates for more potent liquor but is addic­
tive and in the long run can do as much
damage as whisky or rum.
The splurge in drinking is reflected in
the high per capita consumption ofliquor.
W'hile the annual per capita consumption
of alcohol by adults in India hovers
around one litre of pure alcohol (equiva­
lent to two-and-a-half bottles of rum), a
little lower than Australia’s 1.5 and a lot
less than the US’s 4.1. this figure is
misleading. Unlike Australia and the US.
women in India hardly drink. So if only
the male population's consumption is
calculated, the figure jumps to around
two litres of pure alcohol. And if only the
drinking male population is taken into
account, the figure is as high as4.1. or 10

T

APRIL JO. 19R6

On the production line: 350 brands
to choose from

bottles of rum per head annually: high
enough for the alarm bells to be ringing.
Even this excludes the millions of litres of
illicit liquor that goes down parched gul­
lets. And in states like Punjab, the per
capita consumption is 6.5 litres of pure

INTOXICATION

ALCOHOL is formed by fermenting
Z2\ sugar with yeast spores. Ethyl
X JL alcohol, or pure alcohol, is the
basic raw material for the various li­
quors available. It has no nutritional
value but produces feelings of sedation.
euphoria, intoxication and finally .un­
consciousness. Whisky, rum and gin
have around 40 per cent pure alcohol.
wines 8 to 15 per cent and beer 4 to 8 per
cent alcohol content
Depending on what the person has
eaten. 20 per cent of the alcohol that is
drunk is absorbed immediately by the
blood stream through the walls of the
stomach and the rest from the small.
intestine. Eating peanuts or cheese helps
line the stomach walls and slows down
the absorption of alcohol

alcohol, or 16 bottles of rum.
.
All drinkers are not drunkards. Sa when
does a normal drinker turn alcoholic? The
popular concept of the drunk is one who
falls into gutters or staggers around on
streets mouthing obscenities. Butthat. say
psychiatrists, is only the last’stages of
alcoholism. A social drinker becomes a
problem one when, according to Shanthi

Until the liver oxidises all the alcohol
it keeps coursing through the'.bpdy,
including the brain. The effects of alco­
hol depend on the blood alcohol level (see
illustration). It is in the brain that the
effects of intoxication are produced. Re­
search has shown that alcohol primarily
depresses the central nervous system
resulting in thought becoming jumbled
and disorganised and the faculties of
discrimination, memory, concentration
being dulled and then lost.
The early warning signs :of alco­
holism include an increasing tolerance
for alcohol, the quick gulping of pegs.
blackouts or temporary amnesia and an
intense preoccupation with drinking.
The crucial stage comes when the
drinker loses complete control over the
amount of alcohol he consumes and
when to have a drink. He. has ready.
excuses for his drinking. He exhibits
grandiose behaviour, spends money lav­
ishly and starts showing signs of aggres-

drink it was like setting off a nuclear
reaction. I didn't stop drinking till I be­
came unconscious." And in Bombay, a
factory supervisor initially started drink­
ing during week-ends with friends. Then.
as he says, "after a while I drank once in
threedays, then every alternateday. then
every day and then every hour".
Researchers now agree that alco­
holism is a disease, because alcoholics
exhibit predictable symptoms and suffer
the same physical and mental trauma:
severe shakes, damage to vital organs like
the heart and liver, and psychological
breakdown. Society, which always dis­
missed alcoholics as weak-willed or im­
moral people, is only now reluctantly
beginning to accept this home truth. In
Bangalore. Malavika. a 30-year-old man­
agement consultant married to a lawyer.
confesses: "I thought al! drunkards were
bums till my husband became an alco­
holic. Initially I was bewildered and
thought he drank because he was not
happy with me. But I soon realised that
although he desperately wanted to give
up alcohol he couldn't. It was as though
he had caught a disease."

Ranganathan of ttrc: "His drinking starts
affecting oh a continuous basis his health,
his job efficiency and his relations with his
. family and friends." The who estimates that
one but of 10 drinkers turns alcoholic.
■ ' 'Most drinkers do not realise when
they have crossed the thin red line be: tjveen social drinking and alcoholism. In
Maclras, Udayakumar. 37, a former pack­

ing manufacturer, thought he had his
drinking well under control till one day he
realised that "a quarter of a bottle of rum
was a mosquito bite”. In Bangalore, a
salesman remembers that while initially
he could hardly hold a peg of whisky he
suddenly found himself going on long
drinking bouts. Says he: "Every cell in my
body craved for alcohol and when I took a

sion. He begins to stock up alcohol and if
threatened hides his stock. He drinks to
prevent withdrawal symptoms.
The chronic stage is reached when
the drinker goes on binges for days
together, followed by abstinence for a
short period. He develops suspicious
ideas, fears and doubts about both him­
self and his family members. He loses his
tolerance for alcohol and gets highly
intoxicated on small quantities. If he
does not take alcohol his body develops
severe withdrawal symptoms like hallu­
cinations. tremors and shakes, profuse
sweating and irritableness.
In the chronic stage, apart from the
severe breakdown of relationships with
his family, friends and colleagues at
work, the alcoholic also suffers from
acute physical damage. Prolonged
drinking can lead to cirrhosis of the liver.
jaundice, stomach ulcers, heart and
brain damage. Little wonder then that
alcohol is called the demon drink.

NCE the disease catches on it moves
with terrifying rapidity, reducing
its victims to physical, mental and
moral wrecks. Try as they will, they find it
impossible to kick the habit even though
they know that it is steadily destroying
their lives. A Bombay naval officer re­
members with tears how he tied his
favourite Labrador and whipped it merci­
lessly in a drunken fit. The next morning
the dog seemed to forget the beating and
wagged its tail, but he was so insane that
he whipped it again. Mathew, the Delhi
copy-writer, remembers how he threw up
a Rs 5,000 job in a leading advertising
agency when he quarrelled with hts em­
ployer over a tririal matter.
Probably the most damaging effect of
this wave of alcoholism, according to a
doctor, is that "not only the drinker but
everyone in the family suffers. Alcoholism
is a family disease." As the alcoholic
becomes more and more obnoxious, the
wife and children get seriously affected.
Malavika, the lawyer’s wife, recalls the
traumatic experience when guests
dropped in one morning and found her
husband lying on the floor dead drunk.
The naval commander's wife once tried to
j ump out of a fourth floor window after he
slapped her in a drunken rage. Children
too are badly affected. In a typical case in
Bangalore. Arun. 17. whose father has
been a chronic alcoholic, dropped out of
school and took to drugs and alcohol. In

O

APRIL <0.1936 ♦ INDIA TODAY

VER STORY

fact studies abroad indicate that alco­
holism could also be a familial disease.
with children of alcoholics being more
prone to becoming alcoholics themselves.
If more families have not broken up. it
is because most Indian wives fear the
stigma attached to divorce. Last fortnight
Malathi. 38. the wife of a former supervi­
sor in a printing press and mother of five
children, came to social workers at the
Maharashtra State Women's Council for
help. Her husband had beaten her so
badly that her cheek and shoulder were
blue-black. She said her husband had lost
his job because of his drinking, and when
she wanted to take up a job her husband
refused to allow her and suspected her
fidelity. Her eldest son had become a
vagrant and a petty thief. But when the
council suggested she divorce her hus­
band. she flatly refused. Says the council's
social worker Anila Merchant: "For most
sufferers marriage provides some form of
security."
A just-published study of workers at
the Madras Port Trust, done by sociologist
Saraswathi Sankaran. shows how dam­
aging alcohol can be.Of the 162 workers
surveyed, more than half of them drank
heavily, and a third were addicts.

Creditable Successes
f HEN Shanthi Ranganath­
an. a Madras housewife, de­
cided to set up an exclusive
centre for the treatment and rehabilita­
tion of alcoholics five years ago, many
people dismissed her efforts as the des­
perate actions of a grief-stricken wife.
Her husband, an industrialist, had just
died from alcoholism and Shanthi re­
calls: "People ±ought I was crazy. They
could not accept that alcoholism could
be cured, and doctors warned me that it
was a disease of only relapses and
remissions." But Shanthi was deter­
mined. She did a course in the US on the
treatment of alcoholics and started a
centre in her sprawling home on the
quiet Santhome High Road in Madras.
Today the T.T. Ranganathan Clini­
cal Research Centre (rrac) has grown
into an instituteof national repute and is
the only one of its kind for treating
alcoholics. Given the excellent cure rate
of almost 60 per cent, the annual inflow
of patients has gone up from 62 in 1981

W

to 320 last year.
Before the centre was established.
there were hardly any treatment facili­
ties for the country’s three million alco­
holics. most of whom were admitted to
the general wards of hospitals and
treated for symptoms like jaundice or
hallucinations. The centre’s success lies
in the fact that it offers treatment for the
basic problem of alcoholism. It first
admits patients to a nursing home for
withdrawal symptoms like hallucina­
tions. vomiting and severe shakes.
Once the "detoxification program­
me" is over, patients undergo intensive
individual and group therapy sessions.
Surprisingly, most patients blame their
problems on others. A bank manager
undergoing treatment blamed his son
who dropped out ofcollege as the reason
for his heavy drinking.
The group therapy sessions help
patients to confront their problems head
on. In these sessions, recovering alco­
holics narrate their problems, providing

hope and making it easy fornew patients
to identify with them. Says psychologist
Christina Chakravarthy: “Group ther­
apy helps in assuaging their guilt and
releases their bottled-up feelings." The
patient is able to admit both to himself
and others that he is an alcoholic.
But to ensure that he does not yield to
fresh temptation, the patient is put on a
drug called Antabuse which causes a
violent reaction if he consumes alcohol
while on the course. The reactions could
even result in death unless an an tidote is
administered within 24 hours.
However, getting an alcoholic to
admit that he is one and keeping him off
liquor for a month is. as psychiatrist
J.V.Devar puts it. "only half the battle
won". The more difficult partis rehabili­
tating him so that he can start living a
normal life. Most alcoholics have snap­
ped ties with their family and friends and
have probably lost their jobs too: One of
the major hurdles psychiatrists face is in
getting the family to be more under­
standing towards recovering alcoholics.
This is easier said than done as the wife of
a salesman-turned-alcoholic narrates.
Her husband found that he hardly had
any role to play at home because she did
all the work and the children held back

Alcoholics Anonymous meeting

Sankaran compared the work perfor­
mance of the drinkers and non-drinkers
and was stunned to find that the heavy
drinkers were absent every sixth working
day. As a result, the non-drinkers took
home 50 per cent more money than the
d tinkers. spentS per cent moreon food. 30
per cent more on clothing. 168 per cent
more on health care and a whopping 300
per cent more on children's education.
Says Sankaran: "Whether it is poverty.
malnutrition, marital disharmony or de­
linquent children, alcohol seems to have
been themajorcauseofall theirmiseries."
While alcoholism and its related prob­
lems increase alarmingly, progress on the
treatment of sufferers has been tardy.
Most alcoholics find that doctors treat the
problem as a moral issue. Said one alco­
holic: "My whole world had crumbled.
and here was this doctor telling me I must
develop the will power to stop drinking."
Only now are hospitals recognising alco­
holism as a major problem and setting up
specialised clinics for treatment (see box).
As a consequence, there arc facilities for
treating hardly 3.000 of the estimated
three million alcoholics in the country.

from him. To overcome these problems.
the centre holds regular family counsel­
ling sessions where the families are
taught how to cope with recovering
alcoholics.
While centres like ttrc may be diffi­
cult to replicate in the country,
elsewhere, hospitals which have
set up de-addiction clinics (and
there are very few) have also been
Reporting encouraging results.
One of them is the de-addiction
centre run by the kem Hospital in
Bombay. Using a judicious com­
bination ofgroup therapy, individ­
ual counselling and an Antabuse
course, the clinic reports that in
the past two years it has been able
to achieve a cure rate of 46 per
cent. And in Bangalore, nimhans
psychologists using aversion have
reported an encouraging 45 per
cent cure rate.Says psychologist
V. Kumaraiah: "We found that
married people responded to treat­
ment better than the rest, and the
recovery rate was the highest
among the older groups.
But probably one of the most
successful ways of treating addicts
is the Alcoholics Anonymous (aa)

programme which is fast gaining popu­
larity in the country, aa is a non-profit
world-wide organisation of recovered
alcoholics trying to help others in the

Aversion therapy: effective

same plight. There are already 100 such
groups in the country, with Bombay
alone boasting 55. Other cities with aa
groups are Bangalore, Goa. Madras.
Secunderabad. New Delhi. Cochin.
Mangalore. Nagpur. Pune and Mysore.
aa members find that the
group sessions help alcoholics to
come to terms with their prob­
lems. fn fact the first step for all aa
members is to admit that "we were
powerless over alcohol, that our
lives had become unmanage­
able". The sessions also help other
recovering alcoholics by con­
stantly reminding them of their
earlier plight. Said an aa member:
"By trying to help others we are
actually motivating ourselves to
keep away from liquor." For the
families of alcoholics, the aa has a
separate group called Al-Anon
where members hold similar
group therapy sessions. Rather
than impose a set period of absti­
nence, the aa’s golden rule for its
members is: Get up every morning
and tell yourself that you will
remain sober for the next 24
hours. It seems to work.
—RAJ CHENGAPPA

AVRIL KI. IW • I SOI A TODAY 79

. COVER STORY
But even hospitals that have clinics are
Ironically, although the Constitu­
faced with problems like the lack of tion has made prohibition a Directive
professionally trained staff.
Principle, the states have made only
The problem is compounded by the feeble attempts to make prohibition ef­
fact that most alcoholics do not get fective policy. Most governments In fact
themselves treated till at a very late have given up prohibition altogether.
stage, because most people do not like to Tamil Nadu and Maharashtra, which
admit they have an alcoholic in their had imposed prohibition at different
family and try to conceal the fact as long times, ran into trouble and were forced
as possible. A factory supervisor in Bom­ to relax their rules.Tamil Nadu needed
bay. who had been an alcoholic for five the excise revenue to run its midday
years, first tried to give up drinking meal scheme. Maharashtra, which st­
himself. When that failed his wife sent rangely enough has placed prohibition
him to the local mantravadi to exorcise and excise under the same department,
the spirit that seemed to have possessed is quite happy counting the take from
him. It was only when he was admitted liquor sales while running a prohibition
to the kem Hospital with an attack of programme to educate people on the
jaundice that he learnt the hospital had a evils of drinking. Bihar was forced to lift
de-addiction programme. Infact, mostof prohibition after a large number of peo­
the patients usually go to hospital when ple died in of illicit liquor in the Dhanbad
they have serious health problems such coalfields. Right now Gujarat is the only
as cirrhosis of the liver or fits of delirium. state where prohibition is enforced, but
If the psychiatrists find it difficult to liquor is still easily available and the
cope with the problem, the Government policy is commonly seen as a farce.
seems equally helpless. The state gov­
ernments. which control alcohol supply T fl 7 ^SER fr°m these experiences,
tt/A/many states have set up temand distribution, indirectly encourage
W V perance boards in the fond hope
people to drink more because revenue
from excise forms a major part of the that if they cannot prevent people from
income of most states. In Karnataka drinking they can convince them to
liquor is the second biggest money- drink moderately. But most of these
spinner for the state, netting Rs 50 crore boards do little more than release ad­
last year, while in Tamil Nadu it ac­ vertisements in newspapers showing a
counts for a good 8 per cent of the bottle marked with the familiar skull and
revenue. Total liquor sales in the coun­ crossbones.
try would amount to something like Rs
With governments unable to curb
3,000 crore, and liquor companies form
a powerful lobby group.
Youngsters drinking: vulnerable age

the menace, people have taken matters
into their own hands. In distant Imphal
in Manipur, women were so disgusted
with their menfolk’s excessive drinking
that they formed themselves into an
association against drunkards and kept
vigil at nights in front ofliquor shops and
bars. Any drunkard they catch is pub­
licly humiliated by making him walk
with a string of bottles tied around his
neck, and then handed over to the police.
In the hills of Uttar Pradesh and tribal
areas of Bihar similar people's move­
ments have met with notable success in
an area where drunkenness has become.
a major social problem.
Meanwhile, to formulate fresh strat­
egies against drinking and drug abuse,
the Welfare Ministry two years ago set
up a working group chaired by its joint
secretary. This is likely to stress educa­
tion programmes on the evils of drink­
ing. As Rajendra Kumari Bajpai. minister of state for welfare says: "A stroke of
the pen, like imposing a total ban, is not
going to help. If we have to bring alco­
holism under control we need to use
persuasion, create awareness and show
a strong determination to implement
our programmes.”
But with both the Central and state
governments failing to make a serious
dent in the two vital factors that the who
says leads to an increase in alcoholism—
easy availability and increasing demand
for alcohol—the battle of the bottle may
be well and truly lost.
—RAJ CHENGAPPA with bureau reports

ALCOHOL AKE? T08ACC0
COURTESY OF THE BOSTON BEER COMPANY

..and a word
rom a brewei

vho cares
S ‘boutique breweries ’
g go for quality, not quantity
r'd By Nicolene Hengen
in Boston, USA

‘ AMERICANS ARE beginning to take beer seriously,” says a content
Janies Coch, brewer of
!■ iiK T
the new, upscale Samuel
Adams Boston Lager. He
should know, his Boston
Beer Company is one of a
wing number of small, regional brewes that are springing up across the
entry to meet the demands of what
perts describe as an increasingly re­
td consumer palate. Americans beae educated consumers of wine from
nil vineyards about 10 years ago; now
lericans are refining their ability to disminate among fine beers.
The typical Samuel Adams drinker,
tending to Coch, is someone who ‘ 'has
Idle more sophisticated taste and
derstands enough about beer to know
'.it freshness matters.” As he sees it,
‘rh is never going to be fighting big
averies for a piece of the market. “I'm
j going to reform any Coors drinkers,’'
A brewer and a patriot who is trying
to throw the foreigners out.
.pkes^jerring to a giant brewery. “A
■ »rs drSRr has to be hospitalized after
jy drink my beer.”
beers tend to be stale and their recipes years as the best American beer by the
American beers, he says, have become often include undesirable stabilizers and 5,000 brewers, distributors and beer
sdily less flavorful, a trend he attributes preservatives. While the Reinheitsgebot, lovers who gather at the Great American
":the drastic decline in the number of the West German beer purity law, for Beer Festival held annually in Denver,
' ierican breweries during the last 40 example, requires that no German beer Colorado. Everyone is given a single vote
■'ars (from 800 in 1948 to 80 in 1986). slated for domestic consumption contain and two evenings to sample as many as
. iraling production costs have forced more than water, yeast, malt and hops, 100 different American beers,
' •■
'sst of the smaller, specialized breweries exports are under no comparable re­
“Samuel Adams proved that there was
itof business.'‘Twenty years ago,” he strictions. .
a market for high quality American beer,’ ’
’igs, “people wouldn’t have touched • For Coch, the American market is Coch says proudly, and a lot of entrepre­
jots.”
divided between consumers who drink neurs agree—as evidenced by the blos­
Under such pressure, what is a beer more flavorful but stale imports and those soming of small breweries nationwide.
■ iinoisseur to do? There are always the' who opt for fresher, domestic brews. Around two dozen small breweries have
ports but, for Coch, "some of those ‘ ‘That's why I started Samuel Adams, to been launched ip just the last year. The
ste like they were shipped over in a give beer drinkers flavorful beer that's' "boom phase” should last for another
jsketball.’.' He argues that imported fresh,” he says.
two or three years before competition
His efforts have not gone unnoticed. narrows the field.
talene Hengen is a Boston-based writer and
Samuel Adams was the first American
Currently, the Boston Beer Company,
kor. This is her first piece for WbrldPaper.
beer to be selected for two consecutive with only 12 employees, brews 25,000

S&Vfe

Businesslndia March 9-22, 1987 113

Worldpaper
ALCOHOL AND TOBACCO

cases of Samuel Adams each month in
Pittsburgh, Pennsylvania. “I make in a
week what Anheuser-Busch makes in 20
seconds,” he adds, referring to another
market giant. But Coch and his investors
are in the process of renovating the for­
mer Heffenreffer brewery in Boston—
a project that will eventually cost US$5
million. “I wanted the brewery in Bos­
ton,’ ' he says. It has not been decided yet
whether the Pittsburgh brewery will
remain open but, he says, “it would be
nice to have a backup in case something
blew up.”
Samuel Adams is snapped up by about
250 restaurants, clubs and liquor stores in
the Boston area, where a bottle sells for
$2 to $4. Besides the American North­
east, Samuel Adams beer is also avail­
able in Australia, through yacht skipper,
hotelier and brewer Alan Bond. James
. ^och reflects on the inroads into a new
'Rarket by commenting that “Basically
we can decide how much, and how fast,
we grow.”
Right now, he is exdted about the reno­
vation of the old brewery, scheduled to be
completed in October. “There’s some
romance in being in an old brewery. There
are good vibes.” And good vibes are not
something to be ignored when felt by a
man who represents the fifth generation
of his German immigrant family to work
as a brewer.
■
Coch was the first in his family to go to
college. After three years as a .mountain­
eering instructor and seven as a consul­
tant he decided to make beer. His father
was incredulous, but Coch argues that he.
“grew up on beer and making beer is
what I wanted to do.’ ’ The recipe he uses
is his great-grandfather’s.
.As a brewer, Coch now spends one
* For two days each week in Pittsburgh. The
actual brewing process takes a single day
but the fermentation and aging process
takes six weeks. “It’s like baking, once
it’s in the oven you don’t have to think
about it.” Because it has no perserva•tives, once the process is complete, it
has to be consumed before it has time to
get stale. “1 want the stuff in people’s
stomachs within two or three-months,”
Coch says.
According to him,1 ‘Americans have an
inferiority complex about beer’ ’—some­
thing he is out to change. Coch’s beer is
aptly named for one of America’s favorite
firebrands, a man who, as Coch explains,
| "was a brewer and a patriot who threw
the foreigners out. What could be more
I fitting?”*
114

Businesslndia March 9-22, 1987

Small type and flint glass'
India beats the ban on liquor ads
foreigners for business reasons. . A WHITE ROLLS ROYCE with a
Even though one can sell liquor, one
chauffeur stands waiting in front of a
stately white mansion. The advertise­ cannot openly solicit people to use it;
ment's copy reads “When the imma­ thus there are advertisements like the
culate taste of aristocracy spills beyond one showing three elegant young peo­
ple holding liquor glasses, photo­
stately mansions and white Rolls
Royces, it finds colour in Aristocrat— graphed through the amber liquor of a
whiskey bottle. One of the three is
the spirit of excellence. ’ ’ Miniscule
pouring McDowell’s soda into his
type at the bottom states “For your
requirement of coloured and flint glass, glass. The legend reads, “Unmistak­
ably number one—McDowell's.”
write to Jagatjit Industries Limited.”
Needless to say India’s premier liquor
This odd ad is a liquor company’s
attempt to sell liquor despite a national manufacturer is not advertising its likeprohibition against the advertising, but named soda water—a product made
not the sale, of distilled alcohol. Aris- ’ explicitly to beat the advertising ban..
“Liquor manufacturers,” says
tocrat is a popular Indian whiskey pro­
duced by Jagatjit Industries. The com­ Kusum Dudlani, an advertising consul­
pany’s sales of colored and flint glasses tant with considerable experience in
liquor campaigns, “invariably go in for
could never justify the cost of the ad.
thinly disguised, indirect advertising.
Liquor is a booming business in
There is always a saving device to beat
Rajiv Gandhi’s India—the prohibition
of it is a hangover from Mahatma Gan­ the government or excise the ban on
advertising. But the ads always create
dhi’s India. While most of what the
an awareness of the product’s name,
Mahatma stood for has fallen by the
giving it a certain image.”
wayside, he remains the father of the
In their constant push against the
nation, and lip service is still paid to his
lawfid limits, ‘ ‘when the manufac­
values.
turers see no government action
Some states still observe the pro­
forthcoming, they get more and more
hibition, but even there you can find
your way around the ban by getting an blatant,' ’ explains Dudlani.
alcohol permit (for medical reasons),
By Anin Chacko, WorldPaper’s associate
by being a non-resident Indian or. by
being approved because you entertain editor in South Asia.

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Management Science

RVB

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offers the following diploma courses at post-graduate level:

STARTING ■
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;

• Management Control
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These courses are offered by RVB, a recognized insitute in managerial capa­
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For further information please wirte or telex to: Dr. R. Wirtz,
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WorldPaper

ILCOHOL AND TOBACCO
crease of 893 percent, followed by South
Africa with 723 percent and the Ivory
Coast with 506 percent. Kenya recorded
an increase of 247 percent. The. same
study found that during the same period,
world production had risen by 124 per­
mption has increased by as much as 900 percent
cent, with the rise in Asia and Africa
recorded at 500 percent and 400 percent
respectively.
By Macharia Gaitho
I dents were alcoholics. The study found
In 1982, Kenya hosted the fourth world
that alcohol is widely available in the com­ congress of the International Commission
in Nairobi, Kenya
munity and that most households brew or for the Prevention of Alcoholism and Drug
OL IS BIG business in Kenya. distill their own alcohol and sell their Dependency (ICPA), yet it took three
lean Breweries Ltd., the biggest I surplus.
years for the Kenya National Committee
in the country, produced 22.2
Drinking is a primary social activity for to be founded in 1985. .
■ns of beer, more than one ton for all classes. Kenyan President Daniel Arap
The committee organized seminars and
m, woman and child in the coun­ Moi early this decade decried the drink­ workshops to highlight alcohol-related
recorded profits of 394 million ing habits of Kenyans and ordered the problems and noted the need to introduce
ihillings (US$24 million) in 1986. closure of-all beer halls in the country— alternative social pastimes. Other mea­
an half of the company’s profits to no avail. In his 1987 New Year’s mes­ sures such as curbing the availablity of
the gc^knment as taxes. East sage, the president returned to the theme alcohol, providing adequate facilities for
irewe^K, which holds Kenya’s once again when he ordered the closing the treatment of alcoholism and imposing
nopoly, is now making efforts to of all unlicensed drinking establishments stiff penalties for alcohol-related crimes
lets in neighboring Uganda and in the country, but observers were skep­ were also suggested. WHO recommends
, as well as in the United States tical that it would work. The only bene­ national regulations of alcohol production,
United Kingdom.
ficiaries would be the proprietors of li­ control of alcohol imports and the reduce
has a major alcohol problem and censed bars who would have more tion. of alcohol sales by limiting sales
beer presents just the tip of the patrons.
outlets and banning alcohol advertising.
No nationwide survey has been
While many feel that such strong mea­
Studies show that alcoholism is not a
mt but in one study done in the problem unique to Kenya; it is a feature of sures are necessary, they have yet to
.ict it was found that up to 27 per- the developing world. In a 1985 World reckon with the corporate might of the
e men, 24 percent of the women Health Organization (WHO) study it was alcohol industry. East African Breweries’
rcent of secondary school stu- found that beer consumption in a number sales contribute substantially to govern­
of African countries had risen by stagger­ ment coffers and employs over 4,000
laitho is a reporter with the Weekly
ing amounts between 1961 and 1981. The Kenyans directly and another 40,000
Nairobi, Kenya.
*.
Republic of the Congo recorded an in­ indirectly.

joholism has begun
ravage African nations

A major alcohol problem, where the legal beverages
represent just the tip of the iceberg.

Businesslndia March 9-22, 1987 111

World Paper

ALCOHOL AND T03ACC0

L. America
is going
up in smoke
Cigarettes are the region’s
main public health problem

GRAPH BY ANTHONY SCHULTZ

Got a Sight?
Cigarette consumption worldwide

Trillion
cigarettes

By Myriam Bautista
in Bogotd, Colombia
LATIN AMERICA HAS PROBLEMS. As
if the well-known financial and social dif­
ficulties in the region were not enough, it
now seems that the health of Latin Amer­
icans is going up in smoke.
This is the unavoidable conclusion to be
drawn from the statistics on tobacco con­
sumption in the region. In contrast to
what is happening in developed nations,
where campaigns and legislation against
smoking have managed to reduce the
numbers of smokers, what happens here
is precisely the opposite.
According to the Latin American Com­
mittee for the Control of Tobacco Use, an
organization of twelve countries, smok­
ing-related diseases are the number one
. public health problem in the region. In
Colombia, for example, 30 percent of all
cancer victims are smokers.'
But the "pernicious effects of tobacco
are not limited to just one area: South
American governments spend twenty
times more in treating patients affected by
cigarette-related diseases than they col­
lect in taxes on tobacco products. Absen­
teeism from work, illnesses and prema­
ture deaths, as well as subsidies and pen­
sions for disabilities, are also related to
tobacco use.
The figures are alarming. In Colombia,
according to a survey conducted by the
Ministry of Health, there are 7.650 million
smokers in a population of 27 million, and
of these over 1.2 million smoke more than
one pack a day. In other countries the
situation is very similar. '
In 1984, the annual consumption of
cigarettes in Argentina was 1,220 ciga­
rettes per inhabitant. In Brazil, it is esti­
mated that there are 27 million smokers,
consuming annually 1,191 cigarettes. In
Chile, the -figure is 1,014 cigarettes, and in
Uruguay 1,146. The latter is the only
Myriam Bautista is an investigative reporter with
I the Bogota-based weekly Semana.

112 Businesslndia March 9-22, 1987

country where the situation looks a little
less grim. From 1971 to 1985, the per
capita consumption went up only 33 per­
cent, while in Brazil, in the 1970s, it went
up 80 percent.
Experts say that the main reason why
Latin Americans smoke so much is the
marketing strategy used by the tobacco
multinationals.
Juan Manuel" Zea, director of the
Cancerology Institute of Colombia, points
out that multinational corporations such
as Phillip Morris have brought their hard­
sell advertising to these new markets
after legal restrictions and anti-smoking
campaigns started to take place in devel­
oped nations. Advertising in Latin Amer­
ica is aimed at 12-18 year olds, the age
when it is determined if an individual is or
is not going to become a smoker.
Even though there are no official sta­
tistics, it is believed that the large, multi­
national tobacco corporations doing busi­
ness in Latin America have made enor­
mous profits. It is estimated that in 1986,
the proceeds of cigarette smuggling in

Colombia reached $151 million. The
Colombian Tobacco Company, which sells
domestically produced cigarettes, topped
its 1985 profits by 166 percent in the first
half of 1986.
In an attempt to address the smoking
problem, some countries in the region
have launched timid prevention cam­
paigns. In 1979, a “quit smoking” course
was taught in Argentina. The follow-up
found that 20 percent of those who took
it did not quit smoking, 40 percent quit for
good, and 40 percent quit for six months.
In Colombia, the National Council for
Cigarettes and Health recently published
a pamphlet called The Pleasure of Not
Smoking. It was addressed to elementary
and high school teachers nationwide.
“Most tobacco advertising,” says the
pamphlet, “sends messages that have no
relation whatsoever with the product they
want to sell, and often expresses ideas
opposite to the intrinsic qualities of the
product. For example, many cigarette ads
talk about fresh air, nature and freedom.
This directly contradicts reality because
the cigarettes we bum produce dirt and
pollute the air. Furthermore, instead of
freeing the individual, they enslave him to
this addiction.” .
Undoubtedly, advertising is one of the
most influential factors affecting the in­
crease of cigarette smokers. In this
regard, Latin American countries are
starting to pass very clear laws, even
though they are not strictly enforced.
In Colombia, the government of Presi­
dent Belisario Betancur ruled that no
cigarette commercials could be aired on
television until after 9:30 p.m. and for up
to 30 seconds in length, 20 seconds of
which would have to be used to inform
viewers about the ill effects of smoking.
In Chile, 69 percent of all tobacco adver­
tising is on television, 20 percent in
magazines, and 11 percent in newspapers.
Restrictive measures are not limited to
advertising. Even though it is not fully
complied with, in most Latin American "
countries smoking is forbidden in public
places such as buses, theaters, schools,
hospitals and public offices. But the
magnitude of the challenge is such that
experts insist that corrective steps must
be taken before it is too late.
Thus, to the economic recession, the
unpayable foreign debt, the wild growth
of the informal economy and the deter­
ioration of the standard of living on the
continent, we must add the enormous
public health problem created by wide­
spread tobacco use.
*
■ |

CHAPTER

15
ALCOHOLISM IN INDIA
BY

DR. GURMEET SINGH

HISTORY

India has always been described as an abstinent culture, i.e_.
a society, where the majority do not drink and have clearly negative
attitudes towards the use of alcohol. In such a situation one would
expect the overall consumption level to be generally low. There is
little information on the habits and culture of the earliest inha­
bitants of this subcontinent, who were probably negroid in. type..
They were followed by the Dravidians, whose staple diet was meat
and fish with rice, and who consumed two intoxicating drinks ‘Ira’
and ‘Masura’. In the Rig Veda, two types of beverages are described:
(a)
‘Soma’ juice was most important, but there is controversy as to
whether this juice was used as such, or after fermentation, since
the word ‘Soma’ has been used occasionally by subsequent authors
as a general term for all intoxicating drinks. Evidence from Vedic
hymns indicates that Soma was identified as a mushroom and a
cannabis like substance (Sethi, 1978). However, it is generally agreed
that ‘Soma’ was a juice extracted from a plant brought from the
mountains where it grew wild, particularly ‘Maujavanta’ : in the
Himalayas. It was often drunk as such, or with clarified butter,
milk, or curds to improve its taste. It was believed, to inspire
confidence, courage, faith and bestow powers of eloquence and
immortality.
(b)
The other beverage was ‘Sura’ an intoxicating drink prepared
from fermented barley .after distillation. Its popularity was . evi­
dent from a verse in the Atharvaveda, where it was mentioned, as
a reward for performance of sacrifices. The praise of Sura in the
Aitareya Brahmana, and the placing of a Sura vessel in the hands
of a king suggested that the Kshatriyas were in the habit of drink­
ing Sura.

240
CHAPTER XV

tradihon. Drinking was appar^X ™ “
exactly a Kshatriya
as he mentioned words mffninT?
U m
days of Panini
ment. A number of SoCiaiIy XXX J'StUlery’ must- and ^edim the Sutras, when liquor was served tn
Were menti°ned
a new house,', on the arrival of the tXX guests eS- when entering
to the women dancers at the time of m
gr00m’s Place- and
number of other drinks weX iXrod.m■Besides Sura- a
•Kilala’-a spiced drink nrenaiX f
lng this period- e.g.

* iSc -re°psr“ X^m
a?s:
andSUmedd0U a large scale-1STaverns1weX prXentXn'nmstXtX"

fesMseandStfngUt1ShrTd
°ther Sh°PS by flags' At the timo °'
festivals and feasts drinking was permitted and friends invited.
Buddha and Lord Mahavira did not allow their followers,
especially monks, to indulge in wine. In fact the Jain Canon does not permit a monk to even reside at a place where jars of wine
are stored, but other believers were allowed to drink on certain
special occasions, or in the case of illness. The evil effects of
drinking were mentioned at several places, and the example is
given of the princes of Baravi, who were ruined because of their
addiction to ‘Kadambari’ wine. For the Maurya and Sanga period
we have information from the Arthshastra of Kautilya, the edicts
of Ashoka, the writings of Patanjali, and accounts of great histo­
rians, about alcohol during those periods. From the writings of
Kautilya it is apparent that drinking was fairly common and well
organised. There was an official superintendent of liquors, and
the manufacture and sale of wine was a state monopoly although.
on festive occasions, the right to privately manufacture beer for
four days was recognised on payment of a licence fee. There were
well appointed liquor shops providing rooms, beds, and seats, with
other comforts like scents and flowers. These shops were located
at specified intervals, and liquor was sold only to persons of good
character and in small quantities. During this period a
new wines, particularly from grapes, were introduced although
the two most popular varieties ‘Kapisayam’ and Harahuraka wera
still imported from Afghanistan.

In the Epics there are numerous references to drinking. Lord
Krishna is said to have enjoyed drinking freely with Arjuna, and

ALCOHOLISM IN INDIA

24i

we' are told that the Yadavs were killed in a drunken’ brawl/ Even
virtuous ladies, like Sudesna, drank wine and some of them drank
ho hard that they could not walk straight.
Inspite of its wide­
spread use even the Kshatriyas, who drank the most, considered it
sinful. It is during this period that social class differences appear­
ed concerning alcohol use, e.g. drinking - liquor prepared 'from
molasses was considered inferior to the use of other types of
liquor and wines. ‘Maireya’ seems to have been the most popular
■drink and is said to have been the wine served by the sage Bhardwaj to the party of Bharat.

The principal sources of information for the Kusana and Saka
Satarahana period (75 A.D. to 300 A.D.) are the medical treatises
of Charak-and Susruta, as also the Samhitas of Bhela and Kasyapa. All the medical works prescribe a limited use of wines and
■ consider the habit good for health especially in the winter season.
Charak for the first time made a distinction between drinking in
moderation and excessive drinking. Whereas the former was re­
garded' as ‘pleasing, digestive, nourishing and providing intelli­
gence’, the later was said to cause ‘various ailments’. Charak com­
mented thus, “Food, which is the life of living creatures, if taken
in improper'manner destroys life, and even poison,'which by na­
ture is destructive of life, if taken in proper manner acts as an
elixir”. Then in reference to alcohol he went on to state, “if a per­
son takes it in right manner, in right dosb, in right time and along
with wholesome food, in keeping with his vitality and with a
cheerful mind, to him, wine is like ambrosia”. On the other hand,
“to a person who drinks whatever kind comes in hand to him, and
whenever he gets an opportunity and the whole body is dry on
account ot constant exertion, this very wine acts as a poison”
Charak described in detail the different modes of consumptions'
Dm-snnP0SfOur7JneS' “nd lb0 acconlPan>inS f°°ds to be taken by
of the dtr°rf dl/fOvcnt n,OI-bld humours (Kapha, Pita, and Vata) and
of the different psychic types (Sattvic, Rajasic, and Tamasic). He

siderable number of
,s,= estecl that there had been a conalcohol in e®J
Pe°P'° Wh° W in the
of drinking

During u10 Gupta peHod
Anga vijja and the works of there were many references in the
alcohot during this period was ^ahdas suggesting that the use of
mmon. ft was even believed that

242

’ .CHAPTER’ XV -

^anriadLMrt^rr

°harm to women and that
"“/T
yaI famiIles (e.g. Indumati—the queen of Aia)
wer'rsinsleToT11115’ .P°liCe officers- soldiers and their friends
shons
Th d^r laS enjOylng' themselves by drinking at the liquor
shops. The Matsya Buran described Krishna as drinking with
.urteen thousand ladies and did not consider him a sinner. Yuan
Chwang mentioned that the Kshatriyas preferred wines made from
the juice of grapes or sugar-cane, whereas the lower cases, Vaish
and Sudras, drank strong fermented drinks. Shastri reported that
in South India too drinking- was common except among the
Brahmins., whereas the rich drank liquor imported from the West,
the poor enjoyed country wine.
During the post-Gupta period, it appeared that the habit r'
drinking had spread to a considerable section of Indian society.,
even Brahmin youths were described as wasting their time in the
company of dancing girls who were addicted to drinking. Soma­
deva gave an interesting account of such a drinking place in his ■
Kathasaritsagara. At marriages and other festive occasions, drink­
ing was common among the Kshatriyas. Medhatithi also confirm­
ed that while on such occasions Brahmin women did not drink,
Kshatriya and other caste women often indulged in excessive
drinking.

Drinking is expressly forbidden by the ‘Quran’, but was re­
commended by Persian tradition. All the Mughal emperors drank
heavily .and it was but natural that their subjects should follow
their example. The state looked upon the evil of drinking with
indifference. Ala-ud-din Khilji was the only monarch who tried
to completely suppress drinking by instituting rigorous control
on the manufacture and sale of alcohol. In response to thorio
prohibitive measures people resorted to the
in wuterbottlegging—they began to smuggle «Pv„lH oomp(,n<5d
skins under loads of hay and firew j .
r(.(/,ulttllorl v/aw in­
to modify and relax his
manufacture and use of drink
troduced which did not
and organisation ofWg
in private but made its public
Mukb,r(ly. Hhah,
dr^StJa2iSe mSified rules.
motTut of
mTm^X

moderate drm^S

$

3M IN INDIA

hit-, health and also provided that
nc. commission of a public nuisance.
>r the ‘common drunkards’ where
were enforced. Mis son, Jahangir,
Inker, attempted to go a step further,
jly prohibiting the sale of wine and
,o break the law were punished severont that this attempt, like the previ­
seful, and by the time of Shah Jahan
, "people took wine like water”.

extent of the problem
I Im chronlo Intake of largo
Aloohollnm is ohnrnotorlHed by
"
d oxpoot tbe drinking
mnlx of alcohol. Aoood 1^.°
bo rerloclod in the overall
nvlour ot nlooholloH n
population. This expectaimlo of uloohol "°^“nXorvalion that the apparent per capita
tion in borne out by 'J0 ° ’
lbo pi.oporlion of heavy drinkcon num pile,.- >s dire y
strength of this association, it has
p“ o‘ p™ t»S..n.p..on •= «»
°<
X™ SS!
or Alcohol
won .. .1.0 Loaemon E?„0.
non to osunmto the numbers of mild, moderate and heavy drinkers
in any population. According to the Lederman hypothesis it is
boliovod (a) that the distribution of alcohol consumption is log
normal in all populations and (b) that there is a constant relation
between per capita or mean consumption and the prevalence of
heavy drinking in that population. Apart from criticism of the
Lederman hypothesis made by some workers on theoretical
grounds, it is important to remember that the Lederman Equation
based on samples of drinkers from western societies in which
drinking is socially approved and indulged in by the majority
(approximately 70% of the population)—with the result that only a
minority are abstainers, while the majority are moderate drinkers
and a few are heavy drinkers. It is possible, therefore, that this
state of affairs may not hold true for a society or culture where
drinking is neither socially approved nor widespread e.g: India
where less than 30 per cent of population is estimated to be drinkirs, and where we will have a large number of abstrainers, and
ome moderate drinkers though among the drinkers, this author
>und in field studies a proportionately higher number of heavy
■inkers
much’ more than was predicted by the Lederman
(nation based on mean alcohol consumption of the total popuion, which, in fact, tended to underestimate the number ■ of

....... :

.

\O*I

?2«
moderate and heavy drinkers in the Indian setting.’ Whereas it
was generally believed that only 4-5% of all drinkers became alcol/ holies, our studies (1978, 1979) in India had shown that the num­
ber of heavy drinkers was much higher than predicted (it being
nearer 10%) on the basis of mean consumption. Another factor
which might contribute to this distortion from the expected log
normal distribution was the marked sex difference in drinking
habits in our society. Whereas in Western countries the ratio of
z male to female drinkers is roughly 3:1, in India it is estimated
that roughly 50 per cent of adult males drink but the number of
female drinkers is negligible (i.e. less than 1 per cent of all
females.

/A9*';

reported that ‘alcohol addiction’ Z ™ niorbldlty <» Pondicherry
Elnamar, Moitra, and Rao h 970 i
M-P<”’ thousand- Similarly,
rural population to W„i n °
“ Sludy °f n,ontal 110IlUb <» « »
was 10 8 per thousand v
reported that ‘alcohol .addlotion’
studJ nf
tI?OUSand- Verghese ot al. (1072) In an epidemiological
„
Psychonouroses in Volloro town reported that ‘alcohol
addiction was 2.1 per thousand. Nandi. AJmany, Ganguli, Bniiorjoo.
. Boral, Ghosh and Sarkar (197b) in a study ot the incidence or men­
tal disorders in one year in a rural community in West Bengal
reported that there were nineteen alcohol addicts per thousand.
Dube and Handa (1969) in a study of the drug habit and mental
disorders in a population of Agra reported that 0.77 per cent out
of 29,468 in general population habitually used alcohol. Dev and
Jindal (1974) in a study of the pattern of alcohol use In villages In
'
Ludhiana district of the Punjab found that 74.1 por cent of adult males
' used alcohol. Mohan et al. (1980) in a study of prevalence of drug
use in young rural males in the Punjab reported that alcohol use
was very high (58.3 per cent). Sethi and Trlvedl (1979) In u survey of u
rural area adjoining Lucknow found that 32.1_por cent of males
above ten years of age and none of the females took alcohol at least
once a month. Venkoba Rao (1978) on studying 178 cases of drug
addiction in Madurai reported that 27 per cent of the sample
studied was addicted to alcohol and 29.2 per cen; of the sample was
addicted to both Cannabis and Alcohol. Lal and1 Smgh (1978)|ma
detailed study of a large village in - Sangrur dtstnet of 1Punjab
reported that approximately half

fifteen years and above were taking a

Jeing Oniy ono

Alcoholism in india

245

female alcohol user. In this study it was found that an overall rate
of drug abuse for current users was as 20.4 per 1000 population.
There were only two drugs that were commonly used (a) alcohol by
approximately 50 per cent of adult males (rates being 174.4/1000)
and (b) opium by approximately 35 per cent of adult males (rate
being 125.5/1000). It was found that a large majority (89 per cent)
of alcohol users were occasional drinkers and only 11 per cent were
regular or dependent user’s. The alcohol users took it for recrea­
tion or pleasure. An attitude survey was also carried out. Out of a
total of 497 persons interviewed, an attitude of strong approval was
expressed by 13, qualified approval by 139, indifferent or non­
response in 51, qualified disapproval by 223 and strong disapproval
by 71. Thus, approximately 31 per cent could be said to have a gene­
rally positive attitude of approval to alcohol consumption, and 55
per cent an attitude of indifference or qualified disapproval, leav­
ing a hard core group of only 14 per cent who were clearly and un­
equivocally against the use of alcohol under any circumstances.
Varma, Singh, Malhotra, Das and Singh (1981) reported that out of
the 1031 subjects they interviewed, only 23.7% of them were current
users, and 45% thought people could drink ‘none at al’ without it
having a bad effect on their health and 26.2% felt that they could
have a few drinks once or twice a month. 59.2% of the sample
perceived alcoholism to be a very serious problem in this part of
the country (North India) and another 33.1% considered it to be
serious enough.

It is evident that most of these studies were. carried out in
North India. Since there is bound to be a considerable difference
in alcohol consumption in different parts of the country it would
' not be realistic to generalize the finding to the whole country but
they do serve as an indicator of the extent of alcohol consumption
in the existing Indian socio-cultural setting. In this context it has
been documented recently that the world patterns of alcohol use are
changing and the production and consumption of alcohol are in­
creasing. A recent statistical analysis of data from 97 countries
show that between 1960-1972 production of alcohol beverages rose
by more than 60 per cent. This has been attributed to a rise in the
’: prevalence of alcohol drinking in western countries, and secondlyto a marked increase in drinking in third world countries. With
.increased'alcohol consumption there evidence of . widespread up. surge of alcohol related problems, particularly in many parts of
'Africa and Asia, where alcohol was previously forbidden by religi­
ous rules or’social customs. I shall now briefly list some of the
■alcohol related problems that are likely to result in a community
where alcohol consumption is widespread. Alcohol consumption
produces certain physical and mental changes, some of these are

24g

a°ute
others

'S^ns -,

«nder !
r
—
ported
°o'iethano1 Per^^ °f ^bj

^Sed^0 a«d

st

c°nipli<

’ -Raoja,-

^pert

f°r

:tes=^

•“>»
«««ay“ ™r
«sr.,°
.• -Z°
■«■»=■r *-;"«■■■ -tai:na ..... p„.•'■•
' ^££F"
.......

^testinaj tLe °.

nervous system.

dysfun ", “

liv^ Cllllooi’

adversab' the functioning of

°

iv)

■ v)
vi)
vii)

holic cardioinyopaUiy
‘^-Berr heart and alcon £hShe? ?seases of tho — lo.
oxXn
SeCretiOn-_°f “--U-diurotio hormone and

n leTtn6830? th0 f°rmtlUon °f l“° red blood oorputa
of fL rt"1 r
' by iniP°rtin8 th° normal procoeeea
of food -digestion and absorption. It also reduced Intake
tnrough loss of appetite.

There have been a large number of studion on tho rolutlonehlp
between the problem drinker and his family. In general, they con­
firm that family relationship and social roles are affected by and In
turn affect the problem drink. In addition to the other factors,
such as the composition of the family, their personality and nature
of interpersonal relationships, I would like to stress the over-riding
importance of the socio-cultural environment. Not only the nature
of various coping mechanisms employed but also the degree of dis­
integration or breakdown of the family will vary from one society

-a

ALCOHOLISM IN INDIA

247

to another depending upon the extended family, social and institu­
tional and religious supports available, which would explain the
absence of the typical skid-row alcoholic in India. Much has been
written about the emotional repercussions of alcoholism on the
family members, especially the spouse and children. A point worth
making is the difference in the types of alcohol related problems
likely to occur in a family depending upon their socio-economic
and educational status. There is evidence that among the socially
and economically weaker sections the health and social conse­
quences are more severe since alcoholism is one of the most ex­
pensive diseases that can be acquired. On the other hand, among
this group, the local community in general, and wives in parti­
cular, are more tolerant of excessive -drinking and antisocial or
violent behaviour, by the males. They are inclined to accept this
as inevitable and a part of life, and attribute it to their frustrations
and hard manual work. On the other hand, an educated suburban
housewife, is more likely to protest and create a tense atmosphere
in the family with its adverse effects on the spouse and children.

Traffic accidents are one of the leading causes of death in
most western countries, and high on the list in most developing
countries. India reportedly has the highest death rate per unit
vehicle in the world — the death toll being 10 to 15 times that in
the U.S.A, or U.K. According-to-a-recent W.H.O. report, India
records the highest road fatalities at 61.1 deaths per 10,000 motor
vehicles, compared to just 4.7 deaths per 10,000 vehicles in the
U.S.A.', Spain 20.8, Australia - 22.8, Denmark - 10.6, Netherlands 11.7, and Norway - 6.1. Errant drivers were primarily responsible
for 70 per cent of these accidents, the main reason being that there
was hardly any traffic control on our highways. In western coun­
tries, a majority of accidents involve private cars, and mostly in­
volve the young or adolescent drivers. Bus and transport drivers
are generally having the best safety records. According .to figures
■available for. India, however, the trend is just the opposite.; Goods
vehicles contributed the maximum towards the total road accidents
(24;per cent) followed by buses (19.9 per cent). Motor cars’and two
wheelers came next with 19.77 and 9.5 per cent respectively. A
number of factors are responsible for these accidents including (a)
the drivers - their driving skill and road behaviour. This in turn
depends upon their training, age, sex, marital state, ..education,
socio-economic status and religious beliefs etc, alcohol, being only
one of the factors affecting their driving ability. The other factors
being! (b) the mechanical state or road worthiness of the vehicle
and (c) the conditions prevailing on the road, (d) an inadequate and
ineffective system for enforcement of road rules on highways.

248

CHAPTER XV

ALCOHOL CONTROL POLICIES

-

■
■ general terms, alcohol control policies . aim at either:
W total abstinence, or (2) minimizing heavy or harmful use. Total
prohibition at first sight appears to be the logical answer and the
money so saved will hopefully be spent on other useful purchases
m the market. However, this simplistic view does not take into
consideration the use value that alcohol has for the individual. If
he is drinking mainly to quench his thirst then his money will be
diverted to purchase of soft drinks, but if it is to get high or drunk
then it will most probably be diverted to purchase of illicit, and if
this is not available, to drugs of similar use value. It is also known
that the consumption is closely related to the price of pure ethanol
contained in a particular alcoholic beverage variety. Since coun­
try liquor is the main type of beverage consumed and the fact that
84 per cent of our population live in villages (i.e. rural areas),
sales are not going to be dependent on the relative costs of diffe­
rent types of beverages available, but on the price of the cheapest
brand in that type. Hence if good country liquor is available at
Rs. 20/- per bottle, the overall consumption is more likely to be
related to the availability of this than the price controls on so
called ‘foreign’ liquor sold by official vendors.

•Prohibition is now in force only in the States of Gujarat and
Tamil Nadu, and in selected areas in Rajasthan, Uttar Pradesh,
Karnataka and Maharashtra. In 1960, the Ministry of Home Affairs,'
in consultation with the State Governments, set up a Central
Prohibition Committee to advise the Government on a phased
introduction of Prohibition.
A study team of Prohibition
was appointed in 1983, headed by Justice Tek Chand, to
study the working of Prohibition in the different States.
Various aspects of alcohol problems were scrutinised and propo­
sals made for offsetting financial losses where state revenue was
diminished through prohibition, and recommendations were given
for strengthening the legal framework. A plea was made for in­
volving voluntary agencies in the implementation of prohibition,
and a plan was developed for extending relevant educational wort
Parts of only three states availed themselves of this offer, and one
became wet again after a short time. li 1973, 1974, and 1975, the
Government of India approved of a series of measures aimed at
reducing alcohol consumption and preparing for total prohibition.
They did not have the desired impact and the Government resolved
that from October 1975 a minimum programme for Prohibition
should be pursued by the states. A set of prohibition guidelines
was formulated and distributed in 1978 baaed on the Government’s

,
the recommendation
^'prohibition
xieeptunew <>1 tn
i977. tor eniorcemcnt oibat tbese
°"',,"‘n5 Howevor. by 1980 it wa»
according to
‘‘tope wore not attaining the>
March, 1980. under 1the

or’u.oVrLhiWtion ^^J^nsXtion^^counS \^or (touching a

increase o£ 30 per ce^X) to 1979-80 over the previous year
record o£ 4 crores
of\iauor from neighbouring states and
Further, the smuggling
.
„ed ln view of such reports and
illicit distribution nad also m
’
governments on account
the great revenue loss entailed toHx t
S
prohibition
of reduced official production and sale oi
Programme was revoked in most states y

TREATMENT OF ALCOHOLISM

' There are two approaches to the treatment of alcoholism,
(1) conventional methods, (2) learning theory techniques.

1.

•
'
'

Conventional methods

Conventional treatment approaches imply an eclectic approach
using several treatment modalities including, Drugs, Psychothe­
rapy - (Individual or Group) and Eclectic treatment. Firstly the
patient is examined for medical - biological problems; secondly
bls social history may be taken and he may be given psychological
tests. Finally, ho can bo placed in a therapy group with other alco­
holics, or havo individual interviews with a psychotherapist or
counsellor. Tho patient may be prescribed vitamins (particularly
vitamin B, which is of ton deficient in alcoholics) as well as tran­
quillizers and antidepressants. He may also receive Antabuse
(disulfiram) or Tomposil (citrated calcium carbimide) - drugs that
produce nausea if tiro patient drinks after taking them. Individual
Psychotherapy involves trying to help the patient to overcome his
various personal problems. Group Therapy is thought to be parti­
cularly appropriate for these patients who have limited verbal
abilities. It can also provide an opportunity for patients to receive
Z
ST°r7rO“ individuals suffering from similar problems.
oonventional treatment programmes are first
social
h
n
abstinence as well as alleviating. other
social and interpersonal problems.

250

2."

Chapter.1 xV"

Learning’theory techniques ’

Learning’theory has contributed - the - aversive conditioning
.technique: This "procedure involves giving the patient alcohol and
electric shock,' in an attempt to change the' alcohol from-a positive
to a negative stimulus. In addition • to- conditioning 1 procedures
based on electric" shock; the same-principle has been utilized with
chemicals.' InLthis procedure, a-chemical (e.g. emetine-or -apomor­
phine) is administered and when the patient begins to drink-shortly
afterward,'he "experiences nausea and-vomiting. This procedure-is
an ’ attempt to" associate alcohol with ■ nausea. The- reader- is
cautioned against ’ assuming that one- treatment isj known- to be
“best” for all alcoholics. Pattison makes ■ the- case that ■ alcoholic
patients, treatment’ facilities, and treatment outcome vary. He
argues that by taking such variations-into account, and thereby
making better use of existing facilities, considerable improvement
could be achieved without an increase in available resources.
Gopalan Committee Report

Subsequently in view-of the .increased consumption.-of . the
alcohol and other drugs, the Government of India constituted
another expert commirtee under the chairmanship of Dr. G. Gopa­
lan, Director-General, I.C.M.R., New Delhi. The committee sub­
mitted its final report along with their recommendations in Octo­
ber, 1977. The recommendations fall into four main categories.
1.
2.
3.
4.

Legal and Penal measures
Educational measures
Social action
Setting, lip of a specialised centre in each state.

In essence, the functions of this unit would be:

(a) - Treatment of’alcohol and drug addicts.
(a) - Training of -paramedical and other social and voluntary
agencies in . handling alcohol and drug problems.
(c) To conduct ongoing research into the causes and treatment
- of alcohol and drug addicition.
(d) It will also function as a central registry and reference
centre.
Unfortunately, no concrete action seems to have been taken
so far on these recommendations, either at the central, or state
level.

ALCOHOLISM IN ■ INDIA

’ 251

REFERENCES'
1

DEV P.C., & JINDAL, R.B. (1974); Drinking in Rural
Areas — A Study in Selected Villages of Punjab, Ludhiana:
Punjab Agricultural University.
.

2.

DUBE, K.C., & HANDA, S.K; (1969). ‘'Drug Habit in Health
and Mental Disorder”, Ind. J. Psychiat., 11, 23.

• 3.

EL'NAGAR, M.L., MO1TRA, P., & RAO, M.N. (1971) “Mental
Health In an Indian Rural Community”, Brit. J. .Psychiat.,.
118, <199-501.

4.

LAL, B., Sc SINGH, GURMEET., (1978). “Alcohol Consump­
tion in Punjab”. Ind. J. Psychiat., 20(2), 212-216.

5.

MOHAN, D., et. al. (1980). “Pattern of Alcohol Consumption
of Rural Punjab Males”, Ind. J. Med. Res., 72, 702-711.

•
6.

NANDI, D.N., AJMANY, S., GANGULI, H., BANERJEE, G„
BORAL, G.C., GHOSH, A., & SARKAH, S., (1975). “Psychia­
tric Disorders in a hural Community of West Bengal: An
Epidemiological Study”, Ind. J. Psychiat., 17; 87-99.

7.

SETHI, B.B. (1978) “A New Era of Prohibition: Editoral”,
Ind. J. Psychiat., 20(2):105-106.

8.

SETHI, B.B., & TRIVEDI, J.K., (1979) “Drug Abuse in a Rural
Population”, Ind. J. Psychiat., 21, 211.

9.

SINGH, GURMEET, & LAL, B. (1978). “Culture and AlcoholCultural Tradition and Alcohol Consumption in India”,
Comparative medicine-East and West. 6(3) 229-236.

10.

SINGH, GURMEET.- (1978). “Social Attitudes, Religious '
Beliefs, and Alcohol Consumption”, Paper read at U.G.C.
National conference on Drug abuse. Varanasi, Feb. 13-14.

11.

SINGH, GURMEET. (1979). “Alcohol in India — Cultural
Traditions and Alcohol Consumption with Special Reference
to Punjab”, Ind. J. Psychiat., 21, 391-398.

12.

SURYA, N.C., et al. (1964). Mental morbidity in Pondi­
cherry. Trans. All India. Inst. Mental Helath. 4. 50.

V; K. TALITHAYA

Phone : Office 361886, Res. 608307

CHIEF ADMINISTRATIVE MANAGER

BHARAT ELECTRONICS LTD.
JALAHALLI P.O.. BANGALORE-560 013

Dear

J)r -

Date

„

Z.th...D.ec

19.8.8,.

Absenteeism in our industry has been posing a threat to our growth.
An analysis revealed that one of the major reasons for this was emplo­

addiction

yees

to

and

alcoholism

Management

was

very

concerned

much

It was most revealing when it was noticed that the

over this aspect.

rate of death in the factory was on the increase, one of the major rea­
sons for this was alcoholism.
ing out

various

Schemes

Since then our Management has been work­

to

reduce

the

number

of

alcoholics

and

thus

saving the precious lives of our employees who are still needed to their
Three years ago, we chalked out our own programme for alco­

families.

holics

correction.

We

period.'

With

a

view

have corrected

to

share our

over

100 employees

during this

other

industries,

experience with

we propose to organise a Workshop on Alcoholic Correction and Rehabili­

tation in Industry on Saturday the 17th Dec.

Bangalore-560001.

Road,

with Employees'

in

Bangalore,

this

work,

We

plan

to

1988 at.Hotel Rama, Lavelle

invite

senior

connected

officers

Welfare in both Private and Public Sector Organisations

besides

social

professionals

workers

of

from

repute

etc.

medical

The

field

connected

Workshop

is

with

divided

into four sessions where papers will be presented by eminent persona­

lities.

We enclose a copy of the programme for your kind information.

I shall be grateful if you kindly chair the session on "Alcoholism
and its effects".
A line in confirmation will be highly appreciated.
Yours sincerely,

Dr. 6.M, Francis,
Director, St.Martha's Hospital,
Bangalore.

International news and views

lArch
1987

JutinvdMoixlial
■DinikMutYlial

I’W

ALCOHOL AND TOBACCO

p The poisonous charm
of drinks and cigarettes
hasn’t lost its appeal.
108 Businesslndia March 9-22, 1987

But, medically and practically,
drugs are what they are and how
they must be viewed. The
necessary change in mindset
which this presupposes,
unfortunately, is slow in coming.
All over the world, alcohol
production is growing faster than
the population; consumption is
increasing in total—and in per
capita terms.
And tobacco. A recent study
released by the Worldwatch
Institute in Washington notes
that ‘ ‘The leading cause of
premature death among adults in
1985 was not Africa’s famine,
warfare, or the attacks of
international terrorists:
It was cigarette smoking.”
Alcohol and tobacco affect
rich and poor, young and old,
and men and women differently.
But, with all of these groups,
alcohol and tobacco are
equally seductive and morbid.

WorldPapcr

ALCOHOL Ah!!? TOBACCO

’aks 2,iic. cigarettes
i strong opposition
'.fights a ‘brutal process of deterioration’
By Pedro Ontoso
in Bilbao, Spain

L AND TOBACCO are the
iging drugs in the world today.
use problems are particularly
Europe. In countries such as
lany, England and the Nordic
>hol, the preferred drug of socion, is part of the daily routine
.•ctors of the population, parie you nr
*
is so u^^rsally accepted it is
part of the great popular festiiberfest in Munich, for example
he cult of alcohol is the link
>articipants, and where wine
are regarded as the elixir of

>iness fades, leaving behind adI pathology. In East Germany,
0 youths are drug addicts; and
3 is a staff writer with El Como
aily published in Bilbao.

one of the most commonly used drugs is
alcohol. Social analysts use these figures
to explain the fact that one-fourth of all
convicted criminals are below 21 years of
age.
In Spain, where there are over 100,000
bars, there are over 2,300,000 alcoholics.
According to a recent study published by
the Spanish Ministry of Labor, in the
Basque region alone over 400,000 people
consume excessive amounts of alcohol,
with those between 21 and 24 consuming
the most. For the experts who have
repeatedly voiced their concern, this is
something without precedent in Europe.
1 ‘For years,’ ’ points out Dr. Javier Aizpiri, a neuropsychiatrist and social an­
thropologist in Bilbao, Spain, "the dete­
rioration in this area (excessive alcohol
consumption) has been taking place at an
alarming speed. The young, those be­
tween 14 and 30, decided to destroy
themselves. These groups get together
to consume massive amounts of alcohol.
There is no communication: they are
PHOTO BY JIM ANDERSON/STOCK BOSTON

The phenomenon of tobacco
becomes the problem of tobacco.

happy being nothing, just drinking sav­
agely. It reminds me of the mass suicide
of the whales. It is a brutal process of
deterioration.”
Doctors and sociologists have urged the
implementation of preventive measures to
slow this juvenile annihilation. They have
warned of the high social cost to be paid
by a society whose maturing process has
been disturbed, severely limiting its pos­
sibilities of development and adaptation.
These measures should include the pro­
motion of healthier alternatives for the
use of free time.
According to a study of Madrid's youth,
30 percent of this population spends its
money in bars, pubs and cafes, the fa­
vored places for social interaction. In East
Germany, to take another European ex­
ample, a study conducted by the Youth
Research Institute in Hanover, revealed
that the most favored meeting places
were fast food restaurants and cafes.
Once used to dull the harsh conditions
of the industrial revolution, alcohol is now
used to flee post-revolution malaise.
Smoking is the other widely accepted,
and dangerous, addiction.'Even though
smokers are the only drug addicts with­
out a negative social image, tobacco is a
main cause of disease. Recently, however,
awareness campaigns conducted by sev­
eral European governments, as well as
legislation limiting advertisement of
tobacco, are starting to change the image
of the smoker. In some countries, such as
France, the level of addiction was kept
stable.
In Spain, 50 percent of the population
smokes, and over 40 percent do it daily.
Last year alone, almost 4'billion packets
of cigarettes, 823 million cigars and six
million bags of pipe tobacco were sold.
These figures show just a small increase
over those of previous years, maybe a
consequence of higher prices.
In less.than 20 years, Spain has quadru­
pled its tobacco consumption. The tobac­
co industry—a government monopoly—
has over 235,000 outlets generating over
123 billion pesetas (almost one billion US
dollars), for the state treasury. At the
same time, the Ministry of Public Health
has revealed that 300,000 Spaniards died
last year as a result of tobacco-related
illnesses.
The solution for the medical problems
of our era—as pointed out by the World
Health Conference—is not to be found in
research laboratories, but in legislatures.
The Spanish House of Representatives
has already presented a bill promoting the

Businesslndia.March 9-22, 1987: 109

World Paper

WOaUJPAPER

ALCOHOL ARP TOBACCO
filtering of tobacco products and limiting
advertisements directed at those below
sixteen years of age. The EEC, as part of
its fight against cancer, is proposing,
among other things, that European tobac­
co plantations, which produce about 50
percent of Europe’s total consumption,
should be replanted with other crops. It
has also requested that higher taxes be
levied on tobacco products.
In Norway, the National Health Coun­
cil Against Tobacco developed an ambi­
tious program to eradicate tobacco con­
sumption by 2000. It includes the prohibi­
tion of smoking in all public places, in­
cluding restaurants, hotels and nightclubs
by 1990; as well as the proscription of
tobacco sales in kiosks and supermar­
kets, the creation of a government mono­
poly for importing and retailing, anti-tobacco campaigns financed by a 20-peseta
surcharge on cigarettes, and an increase
in scientific and epidemiologic studies.
France became aware of the tobacco
problem ten years ago when it passed the
Veil Law that regulated tobacco advertis­
ing and smoking in public places, and
demanded that information about levels of
tar and nicotine be printed on cigarette
packages. Since then cigarette sales have

Our $ew Look
Cleaner, more contemporary

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With this issue of WorldPaper
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In the words of every
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_____ Hong Kong (English)
BiisihesftAforkl
Bangkok, Thailand (English)

OBSERVER
Ken Boostrom

As if people didn’t know
Correlation between cigarette consumption
and lung cancer deaths after 20 years of smoking ■

United Kingdom

New Zealand
Finland

Japan

France
Chile
Philippines
Spain
• Sweden
Egypt
Thailand

110

Businesslndia March 9-22, 1987

Xinltua (New China
News Agency)

3
I
§

I

s

I

ThenewS

ASSOCIATE EDITORS

Anthony VcsteD, Ottawa

Hilary Ng’weno, Nairobi
Jacqueline Grapin, (E™

Bogota, Colombia (Spanish)
Dally
>JOSrnaL^ln
*
<U

ELDlAKiO
Cameos, Vmauda (Spanish)

Middle Earn
David Toufic Mizrahi, New tork
South Asia
Anin C tucks, New Delhi
Southeast Asia
Mochtar Lubis. Jakarta
Central Asia
Rui Yuanru, Beijing
Northeast Asia
Ysshiko Sakurai, Tbkyo

BOARD OF DIRECTORS
Chairman
• Martin Stone
‘ Vice Chairman
William L. Dusley

United States
Canada

Bombay, India (English)

Spanish Translation

Hoddmg Carter, Patnda Derian,

Lung Cancer Rate
(per 100,000 io 1980,
ages 45-54)
30

Australia
Switzerland
Poland

Singapore (English)
Katnichi Daily (Saw:

1 lanAet Paotetti

stabilized and the positive image of nonsmokers is making great strides.
Today, in Europe, even though three
out of four smokers agree that smoking
is a pleasure, a still higher percentage
feels that smoking is bad. And 72 percent
of all smokers believe that smoking over
a pack a day is harmful. More important
yet, 40 percent have attempted to quit.
Europe, like the rest of the world, is
becoming aware of the inherent danger
posed by both alcohol and tobacco, habits
that end up by costing us dearly.
*

Cigarette Consumption
(per person over 14
years old in 1960)

ASSOCIATE
pupucztnots

Featurbu) frvuh
penspectivcg Jrvnt around
the world an mailers of
global concern.

DEBATE
______ Lima, Peru (Spanish)

*<l
il

____ Quito. Ecuador (Spanish)
COMPET'ENCIA

CZ3Santiago, Chile (Spanish)
vTIjeJtruaalrmsta?
Amman, Jordan (English)

' Cain. Egypt (Erghsh)

feuuuit-k-iriiiire
Kuwait (English)

,
Francis Hatch
Board Membera: Arturo BriDembourg, John Cole, Thomas Cong­
don, Jerome I. Davis, Patricia J.
Edgerton, Antonio Garcia, Marcel
Granier, Harry B. HoOms, Jonathan
Larsen, Timothy Light, Hans Neu­
mann. Bernard Rapoport. Ellis
Ring. James W. Rouse, Patricia
Ewra, G. Harold With.' Wilferd H.
WHch, Frederic G. Ubrden.

New York Ad Director
Carta Wright

INTERNATIONAL BOARD
Argentina: Christian Zimmer­
mann. Canada: Conrad Black. US Wfeat Coast: George Mackin,
Colombia: Mauricio Obregdn. Tel: (213) 850-3339. Switzerland:
France: Daniel Jouvc. Hong Carl Famer, Tel: (01) 720-7373.
Kong: Cyril Fung. Japan: Yuichi Netherlands: Alfons Crim. Tel:
(020) 263615. Japan: lid Koizumi,
Tbdni. Malaysia: Datuk Syed Yu^ Takeda. Nikkei International.
Kechik. Netherlands: John Acda. TH: ZiV-0251.
Norway: Steinar Opstad. Philip­ New York Office: 274 Madison
pines: Sixto Roos. UK: Michael Awnoe, Suite DOS. New ferk. NY
Hook. Karl Jaeger. USA: Amb. 10016, TH: (212) 532-4932.
Miami Office: P.O Box 560963.
Miami, FL 33256-0963, Tel: (305)
251-2056.
Wxidftper
’ Volume IX,
■ 424 Vibrtd Ttade Center
Number 3
Boston, MA 02210 USA
Telephone: (617) 439-5400
° Copyright Wirid
•Times, Inc.

n dec 1333

BHARAT EARTH MOVERS LIMITED
K.G.F. COMPLEX

COUNSELLING, TREATMENT

AND

REHABILITATION OF ALCOHOLIC
ADDICTED EMPLOYEES.

by

WELFARE DEPARTMENT

KW/^

BHARAT EARTH MOVERS LIMITED
KOLAR GOLD FIELDS - 563 115
TREATMENT AND REHABILITATION OF EMPLOYEES
WHO ARE ALCOHOLIC ADDICTS
In recent years there has been great concern about the
excessive use of Alcohol by some of our employees.
Alcoholism, is now considered to be a disease and not
merely a malady. Excessive use of Alcohol is known
to be very harmful not only to the individual, but
also to the family, industry and.society at large.

We find many workers are the victims of circumstances
and environment and thus fall prey to Alcoholism.
It also happens due to personality make-up, heredity
traits, family problems, work and social environment.
The unhappy individuals are unable to carryout their
work in the industry and family rcles effectively
because of their prolonged abuse of Alcohol.
With a view to rehabilitate employees who are Alcoholic
addicts in order to make them more productive workers
and responsible family members, a two day seminar was
arranged by the Welfare Department with the help of
Psychiatrists of NIMHANS. Bangalore during September
1984. The main objective of the seminar was to make
the employees addicted to Alcohol, to realise the
evil effects of Alcoholism on their personal lives and
their poor performance in industry.

Since then, we have successfully counselled 39 herd-coreAlcoholics, who having realised their mistakes, during
the counselling, volunteered to undergo treatment to
overcome Alcoholism. Accordingly., their treatment was
arranged at NIMHANS through ESI. Out of the 39 addicts,
we have successfully weaned away 24 employees and now,
they are productive workers and face their family and
social life with more responsibility. A regular follow-up
is maintained through the concerned Department Heads, to
know their mental/physical health and their work perfor­
mance as a further step in their rehabilitation.
Employees who have unfortunately reverted bad: to their
former habits are not abandoned. They are further
counselled regularly and if necessary, are sent for
another course of treatment. Employees who have
successfully come out of the habit are also counselled
so that, they do not slide back. They are invited to
meet the concerned Officers at Welfare Department
in groups once a week in order to exchange their
views and share, experience and give sunrestions if
any, that may help other unfortunate victims.

Our efforts are continued to identify other employees
who are victims of Alcoholism so that they may receive
similar benefits of counselling and treatment to make
them productive workers again.

BHARAT EARTH MOVERS LIMITED
KOLAR GOLD FIELDS - 563 115
REHABILITATION OF ALCOHOLIC ADDICTS.

CASE STUDY NO; 1 :
Mr. 'A1 aged 48 years has been working in our Company
as Watch & Ward Guard since- 22.05.1980. He was very
irregular in his duties and subsequently he became a
Shronic absentee. The employee had availed of, all the
available loan facilities from the company and outside
and was in the clutches of indebtedness. He has a
family with wife and four'children. Since the
.employee absented himself from duties, he was without
salary and his family was neglected and was on the
verge of starvation.

His wife and brother came and reported that the
employee indulges in heavy drinking and refuses to
come for work and his health is in a very poor
condition. When the Welfare Officer visited his
house, the employee was found to be in a' very badstate of health and his family members were in poverty
sticken condition. The Welfare Officer counselled
the employees on the evil effects of Alcohol and the
damages it has caused on his health and familv life
and the poor performance at his job..
The employee has responded to the counselling in a
positive manner and volunteered himself for treatment
and expressed his desire to give-up Alcohol. The
Welfare Department has arranged for his treatment at
NIMHANS, Bangalore through ESI. He underwent inpatient
treatment at NIMHANS for a period of 12 weeks
(from 13.9.85 to 15.12.85). During the period of
treatment, he has co-operated with the Doctors and
shown good improvement in his health condition. After
his discharge from the Hospital, the employee was in
good health and regular in his duties.
The Welfare‘Department monitors his case by meeting him
once in a fortnight and also by obtaining the monthly
report from his Department Head. The monthly report
clearly shows that the employee is now very good in
his performance, attendance and conduct.

During the post-treatment period, the employee was
extended all moral support and guidance to solve his
problem of indebetedness. During our latest counselling
the employee has expressed his happiness and informs
us that he and his family are well settled in a spacious
house with all comforts like TV Set, furniture etc.,
and the children are attending to schools regularly.
He looks after his wife and children very well.

BHARAT EARTH MOVERS LIMITED
KOLAR GOLD FIELDS - 563 115
REHABILITATION OF ALCOHOLIC ADDICTS

CASE STUDY-NO ;■ 3- ; - Mr. 'C' aged 43 years has been working-’our-organisation
as Turner since 2.11.1974. He is havinc
wife and
four children.

His Department Head has informed Welfare Department
that the employee is very irregular in his duties and
he is a hard-core Alcoholic. Subsequently, the
Welfare Department called the employee along with his
family for counselling. During the counseliina, it
was revealed' that the employee is residing in a Mining
area where there is a social menace of manufacturing
and supplying of -illicit liquor and there he had ample
supply of Alcohol and he was attracted to Alcohol' and
became an addict through regular drinking. Sincethen,
he has been very irregular to his duties and absent
himself for days together under the influence o£
Alcohol.

The employee was counselled during which he has
realised the futility of Alcoholism and volunteered
himself for treatment to give-up Alcohol. Meanwhile,
the Welfare Department has arranged for his treatment
at NIMHANS where he underwent inpatient treatment for
5 weeks (from 18.1.85 to 26.2.85). After discharge
from the Hospital, the employee has resumed duty
during February 1985. Sincethen, he is very good in
his attendance, conduct and performance as reported
by the Department Head. Welfare -Department is
simultaneously monitoring his case and meeting him
once in a week. In order to give him a change of
environment, the employee has been allotted a Company
quarter on out-of-turn basis in the BEML Township.
Now, the employee is very hale and healthy and leads
a happy family life and also a productive worker in
the factory.

B.E.M.L.

KGF COMPLEX

STATEMENT SHOWING THE TREATMENT AND
REHABILITATION OF EMPLOYEES ADDICTED
TO ALCOHOL

SI.
NO.

Year

No. of employees
treated for
Alcoholism

No. of employees
given-up
Alcoholism

No. of employees
gone back to
Alcoholism

1.

1984

1

-

1

2.

1985

20

12

8

3.

1986

4

1

3

4.

1987

3

2

1

5.

1988

11

9

2

STATISTICS

Total No. of employees
treated for Alcoholism

39

No. of employees No. of employees
completely given- gone back to
up Alcoholism
Alcoholism
with %
with %
24 -

62%

15 -

38%

B-E.M.L.

KGF COMPLEX

COUNSELLING, TREATMENT & REHABILITATION
OF ALCOHOLIC ADDICTED EMPLOYEES

FAMILY STRENGTH-WISE DETAILS

Total No. of
employees
treated for
Alcoholism

Family Size

Total No. of
To,. .i.L ‘No. of
employees who
employees who
have completely slided back to
givenup Alcoho- Alcoholism.
lism and
continuing so

Employees having
3 children

Employees having
4 children and
more

15

QUALIFICATION-WISE DETAILS

Qualification

Total No. of
employees
treated for
Alcoholism

No. of employees No. of employees
completely given- slided back to
up Alcoholism and Alcoholism
continuing so

1. PUC & Above

2

1

2, SSLC/NAC/NTC

23

16

3. Below SSLC

14

7

7

AGE-WISE DETAILS

Age Group

Total No. of
employees
treated for
Alcoholism

No. of employees
completely given- No. of employees
up Alcoholism and slided back to
Alee.hoi ism
continuing so

1. 30 to 40
Years

14

5

9

2. 41 to 50
Years

22

17

5

3. 51 years
and above

3

2

1

B.E.M.L.

KGF COMPLEX

COUNSELLING, TREATMENT & REHABILITATION
OF ALCOHOLIC ADDICTED EMPLOYEES
TRADE-WISE DETAILS

No. of employees No. of
given-up
employees
Alcoholism
slided back
to Alcoholism______

No. of employees
treated for
Alcoholism

Trade

1. Turner/Fitter/
Grinder/DBM
Operator/Miller

14

10

2. Welder

6

3. Watch & Ward

3
2

4
2

4
2

2

1
-

5. Driver-cum'Mechanic

2

1

1

6. Sanitary Helper
7. Clerk
8. Messenger-cumcopying machine
operator/Helper

3
4

-

2

3
2

5

3 -

2

No. of employees
?iven-up
Alcoholism

No. of
employees
slided back
to Alcoholism

4. Crane Operator

SHOP-WISE DETAILS

Department/Shop

1. Machine Shop
2. Fabrication
Shop
3. Security Dept
4. Plate Shop
5. Electrical
Maintenance
6. Tool Room
7. Transportation
8. House Keeping
9. LW Assembly
10. Mechanical
Maintenance
11. Stores
12. CT Assembly
13. Progress Dept
14. Gear Shop
15. Accounts Dept
16. R & D
17. Hydraulic Shop
18. Heat Treatment

No. of empldyees
treated for
Alcoholism

7
•11

3
6

•

5

2

1
2
4

1
2

1
2
3
3
2
•11

—
2
2
—
1

3
1
.1
1
1
• 1 '
1
1

2
1
1
—
1
—
1
1

39

24

1
1
3
1
1
1

—
1
—
1
—
••

15

PAN ALCOHOLISM BE ERADICATED ?
-DR. V.A.P. GHORPADE, B.Sc.,MBBS., DPM. , MD.,
Assistant Professor of Psychiatry,
Department of Psychiatry,
M.S. Ramaiah Medical College and Teaching
Hospital, Gokula Extension, Bangalore-560 054

Pathological was of alcohol resulting in social
and occupational impairment with development of tolerenee
and withdrawal symptoms is designated as Alcohol depen­
dence.
When a clinician is confronted with the question
" Can alcoholism he cured?" by a relative of an alco­
holic or alcoholic himself, varied responses ranging
from optimistic to pessimistic is obtained which surprises
the kith and kin of an alcoholic, leaves an enquiring mind
bewildered. What is the truth then?

For the cure or management of an alcoholic it is
very necessary to have a brief idea about the cause of
alcoholism which enables us to plan the treatment well,
upon which success depends.

Alcoholism is considered as an genetic disease,
learnt habit, a disorder with lack of control. Alcoho­
lism could be secondary to many other mental illness
(Depression, mania etc.) or no obvious cause could be
detected which can be termed as primary alcoholism. In
both the type faulty personality is the common factor.
Ideal approach to manage any illness are to remove
the cause, treat the effects of the illness and environ­
mental manipulation. Till recently alcoholics have been
managed in different ways depending upon the school of
thought to which one belongs to, hence the various reactions.
It is not uncommon to come across, an alcoholic undergoing
various kinds of treatment with temperary/permanent improve­
ment, or alcoholics discarding this havit for ever on
their own, or alcoholics showing marginal or no Improvement
.2

- 2 -

with the heat treatment available to them. The real cause
for thia is the patients faulty personality aggravated by
environmental factors. Various methods of treatment are
not to be blamed completely, as different methods are not
suitable to all alcoholics, including the Alcoholic Anonymus approach which is claimed to be the only answer to this
problem.

Ideal treatment approach should be one of the humaine
approach with merits of behavious therapy, individual and
gr cup psychotherapy, marital councilling, regular follow up
fcr 2-3 years along with drugs. This will enable us to
achieve better results than any single approach. The aim
of this approach is to make an unhealthy mind into a
healthy one as much as possible, so that faulty habit dies.
Everyone knows how difficult it is to get rid of a bad
habit and how much time it takes for one to develop a good
habit. Similarly it is not easy to convert an alcoholic
into a teetotaler. As follow up studies have clearly
shown 80-90$ relapses occur during the first 6 months 1 year after discharge.

For our convenience we can devide alcoholics into
motivated and poorly or un-motivated group. The former
group, shows good results with or without any kind of
treatment. Latter group form the major bulk of alcoholics
in whom high failure rate is met with. In this group
motivation can be increased with measures which increase
the fear in their mind about their health, job etc., which
has to be done in a scientific way. This needs good co­
operation of the employer, with the clinician. Added to
this government authorities (police, Temperence Board etc)
should have a tough altitude regarding availability of
’ liquor, driving under alcoholic intoxication etc. To
maintain what we have achieved it is necessary to have a
continuous support from family members, society, employer,
patients friend circle, and regular follow up with the
Clinician.
.3

- 3 It is quite clear now that it is not a single citizen’s
battle with an alcoholic but of the whole societies against
alcoholism. Last but not the least, let us not forget that
all alcoholics are not oriminals/animals but human beings
with a bit of love, affection, in their heart, like any
one of us, which needs to be kindled with love and warmth
so that the lamp of knowledge, discipline, responsibility
and fear glows brightly in his mind making him a respon­
sible citizen of our country and not a burden.

INDUSTRIAL ALCOHOLISM AND LOSS OF PRODUCTIVITY:

A STRATEGY FOR INTERVENTION

DRo M.J. THOMAS. ,. M.B.BoS. ,D.P.M.’,M.D.,

M.NoAoMoS.(Psych).

PAPER PRESENTED AT THE WORKSHOP ON ’ALCOHOLISM AND

ITS

EFFECTS’ ORGANISED BY•BHARAT ELECTRONICS

ON 17th DECEMBER 1988

INDUSTRIAL ALCOHOLISM AND LOSS OF BRODUCTIVITY:
A STRATEGY FOR INTERVENTION.

Problem drinking in industries varies_between five to 15 per, cent,
according:to-various'- surveys—conducted ’ in India,,

In recent

years, prof ession-al'-a-ttention "has‘increasingly been directed to1

the wprkspot as a potential■locus for identifying the problem

l<

drinker. Most problem drivers have jobs.- They can be identified

relatively early by the evidence of impaired work, performance.
Occupationally oriented programmes,, offering help rather than
dismissal, yield the highest reported rates of successful

recovery from probleihmes related to alcohol.

Such intervention

prevents the advance of the problem drinking to more serious

stages.

.

In developed countries, the Employee Assistance Program for

Alcoholism (EAPA) has been introduced, based on recognition of
the adverse effects of problem drinking on productivity, social
consciousness on the part of the- management and specific

awareness of the drinking problem within the industry.

It has

been very successful in organisations of large or medium size,

employing more than 1000 workers.

The workplace is viewed not

merely as an agency of referral but -also as an active force in

the rehabilitation process.

PROJECT DESIGN:
Most programs directed towards helping problem drinkers make use

of the available community resources.

The more successful ones

have a wider approach, including, counselling for the employee and

his .family and identifying the possible environmental or intrafamilial stressors that may maintain the problem.

c

. . .2...

Establishment of a central'consulting service:
Merging of the EAPA with health and safety programs may present a'

logical starting point in developing an intervention strategy.

In

organisations where medical facilities exist, it would be desirable

to establish a consulting service as an additional component.

The

central consulting service can preferably be situated at the
industrial medical centre. A consultant psychiatrist from the
department of psychiatry of a general hospital may be appointed

as the programme director and coordinator.

The physician in- charge •

of the industrial medical centre, the personnel manager of the

.

organisation, the industrial social worker and a clinical psycholo­

gist would form the rest of the team.

The central consulting service would specify the procedures for

identifying the problem drinking individuals and referring them to
the program.

It would ensure the co-operatipn of the management

and labour unions, educate the entire work force along with their

families and carry out the training of the various supervisory
personnel in the identification and follow-up of the problem.

Apart

from these, it would maintain the administrative liaison between

other community facilities (e.g., the Halfway Home) and the general
hospital, and conduct a p'eriodic evaluation of the cost effective­

ness of the program.
Identification of the problem drinker:
Many of the earlier industrial programs relied on the signs and

symptoms of alcoholism for the identification of the problem drinke:.

However, training the work supervisors to detect such signs and
symptoms have been found to be impractical.

Moreover, the super­

visors are usually reluctant to label and employee as an alcoholic,
and often do not report their findings.

3

In most instances, problem drinking by an employee will manliest
itself in impaired work performance and absenteeism, two paramotj^rs which are easily identifiable and more objective than signs

and symptoms.

The supervisors would not require extensive trainin

with regard to these param^t^rs and would find them easier to use.
In addition, self referral, peer referral and referral through
increased awareness of the

program would be encouraged.

Offering assistance to the problem drinker:
In the developed industrial nations, two methods of referral
are adopted - Firstly, there is the method of "constructive

coercion", using a series of corrective interviews with the
problem drinker where confrontation is the main stance.

The

second method is to provide assistance to motivated problem
drinkers who seek help <bn their own.

Such a program, though more

acceptable, would involve major attitudinal changes in the family

of the problem drinker, the labour union, and the drinker himself.
Bringing about such changes on a large scale will require well

planned strategies.
Stage of referral and documentation:
Once the offer is accepted by the problem drinker, he may be

evaluated by the clinical psychologist at the central consulting

service, to assess his motivation and to identify possible
precipitating and maintaining factors for his drinking problem.

He and his family would be informed about the method of treatment
and their co-operation sought.

Ther personnel manager would be

approached for necessary assistance regarding leave from the job

for detoxification.

After the initial documentation, the employee

would be referred to the general hospital for detoxification and
introduction of disulfiram if necessarv.

4

Management in the general hospital:
Detoxification, treatment of complications if any and introduction of

disulfiram would be the goals of management in the hospital, which

will be the most expensive phase of the program.

Three weeks of

admission on an average would be necessary for this stage.

This

may be carried out as an ongoing program, hiring a fixed number

of beds in the hospital, with additional staff for the same to
be arranged by the industry.

The additional staff required would
I

include a medical officer, nursing staff exclusively for the project,
and the clinical psychologist from the central consulting serviceW

who would also spend fifty percent of the time in the hospital.

The consultant psychiatrist, in addition to being the program
director, would also have the responsibility for the treatment of

those admitted in the hospital.

Initiation of counselling for the

.individuals and their families, identification and treatment of

major psychiatric disorders and medical complications will be the

other responsibilities of this team.

The presence of the clinicial

psychologist at both the central consulting service as well as the

hospital to provide counselling and support for the individuals a^

their families would assure the continuity of the treatment and

bolster the confidence of those being treated.

At the .end of the

hospital stay, the individual is either returned to the factory for

resuming active duty immediately, or sent to the half-way home if
prolonged care is required.

5

• Follow up and maintenance of abstinence;
It is known that frequent follow ups results in a higher probability
of success in abstinence of alcohol.

Since the most efficient follow

up may be conducted at the workplace and since objective assessment
parameters are available in this location, it could be carried out

to advantage by the clinical psychologist at the central consulting

service.

Those who drop out from follow up may quickly 'be identi­

fied and their families contacted by the social worker.

Regular

follow up, assessment of performance parameters and contact with

‘

the families would be beneficial, because the cases with relapse wou]
be spotted early and dealt with as necessary.

It would also ensure

accurate documentation of the data available for follow up.

The

problem drinkers are to be regularly followed up for a period of

at .least one. year, since the maximum relapses are seen to occur in
this time.

Training of personnel involved in the program;
The various personnel who would require training are the section

supervisors, in identifying and reporting impaired work performance;
and the medical team of the industry, in managing alcohol induced

disulfiram reactions.

In the course of time, the medical team may.

be given the technology and training to maintain the project on

their own.
The half - way home;

A proportion of the problem drinkers would have deteriorated suffi­
ciently to warrant additional, more technical arid graded care for
rehabilitation.

Such individuals are to be referred to the half-wa

home after discharge from the hospital, where they may have to stay
for three to six months.

.. 6 .
ROLES OF THE DIFFERENT MEMBERS OF THE TEAM;

'

-

’

The clinical psychologist provides the important therapeutic manage- ’

ment and gives the continuity to the program at its various stages,

and at the different locations of treatment.

His time is to be

divided between the hospital and the industrial medical centre.

Once

the project is started and the problem drinkers are identified, the
emphasis of the educational and motivational programs shift to the'
families of the drinkers.

psychologist.

This is the primary responsibility of the

In addition, development of documentation systems,

counselling the individuals and their families, helping them to co{^^
with the intrafamilial and adaptive stessors, and carrying out

subsequent followups of cases would be the responsibilities of the
psychologist.

Once an individual reaches the central consulting

service, he is taken over by the clinical psychologist until he

eventually leaves the program after successful follow up.

Apart from

these^evaluation of the current problems faced by the project and
information to the rest of the team regarding the same are to be

dealt with by the psychologist.
•

The social worker's

primary role is to bring about attidudinal

changes at the beginning of the program, through meetings of labour

unions and the management, and meetings of family groups.
essentially a program of health education.

This is

-Apart from this the

social worker-can facilitate the liaison with the section supervisors

in the identification of casas.

He would maintain the liaison with

other treatment agencies like the half-way home.

He would also take

part in the follow up by conducting home visits in order to detect and
motivate dropouts. He would also keep track of public opinion and

acceptance of the program among the different categories of workers
and tneir families.

7

The medical officer of the industrial medical centre would pri­

marily assist in the integration of the program in the exitd^ing
medical service of the industry, and provide supportive medical

management that may be required du'ring follow up.

He would en­

sure the availability of different personnel for the training
and health education programs which are integral parts of the

project.

'

The additional staff are recruited as and when required according

to the necessity of the moment and facilities available in the

general hospital and industry.
CONCLUSION;

Alcoholism manifests itself in the work place in the form of
deteriorating

job performance, usually far in advance of any

physical symptom of the disease.

Employee Assistance Programs

for Alcoholism have been able to successfully control alcohol

related loss of productivity among the industrial workers.

This

method also has an inherent advantage in that the population

catered for is immobile and thus available for easy identification
and follow up.

Finally the cost effectiveness is

considerable

in terms of productivity to the industry, relief of problems to
the family; reduced expense related .to consumption of alcohol and
management of alcoho'l related medical problems.

However, in most

programs the referral rates tend to be high in the early phase of

the EAPA operation when it is easy to identify the most troubleso:

and chronic problem drinkers, but decline once these employees ha
been treated.

It is expected that the industrial medical centre

will be able to adopt the project technology in time and continue

the program at a lower cost, at the stage when referral rates are
low.

TTK HOSPITAL
Treatment Centre for Alcoholism
and Drug Addiction

TTK HOSPITAL

TTK Hospital/T.T. Ranganathan Clinical ,
Research Foundation is a secular, non-profit,
voluntary welfare organisation dedicated to the
treatment and rehabilitation of persons addicted
to alcohol and drugs.
Established in the year T980, this institution is
the first of its kind in India.

The 55 bed hospital offers the services of a
team of competent professionals, skilled in their
areas of specialisation and deeply committed to
the mission. A comprehensive treatment facility
covering both medical and psychological help is
provided by the hospital in the treatment of
alcoholism and drug addiction.
The facilities offered at TTK Hospital include:
— detoxification centre
— emergency ward
— general wards
— special rooms
— family ward
— therapy centre
— counselling units
— family therapy centre
— recreation centre
— dining hall

ADDICTION:

A DISEASE
REQUIRING
TREATMENT

Alcoholism or drug addiction is not a moral
weakness, sin or crime.

It is a DISEASE.
A chronic and progressive disease that leads to
severe physical, emotional and social problems.

As a serious health problem that cannot be
neglected, the disease of addiction requires
intervention and treatment.

Our authentic experience in having treated over
3000 patients during the last 8 years, has
strengthened our belief that "addicts when
provided with timely treatment and support,
can lead better lives free of alcohol and drugs".
This deep-rooted conviction supported by
experience, forms the underlying philosophy
of treatment provided at the hospital.

OBJECTIVES

Treatment at TTK Hospital aims at:

*

*

total abstinence from alcohol and drugs for
life and
effecting positive changes in the behaviour
and attitudes of the individual to enhance
the quality of his life.

The treatment programme has been drawn up
to offer the patient medical help and
psychological support that will enable him to
recover from the disease of addiction.

Family members are also educated about the
disease and are provided with guidelines to
improve their quality of life.

IN-PATIENT
TREATMENT

The in-patient treatment programme at TTK

hospital is a residential, multi-disciplinary
therapeutic programme, conducted by a
professional team of psychiatrists, physicians,
psychologists, social workers, counsellors and
nursing staff. The duration of the treatment
programme is 4 to 6. weeks.

Incoming patients are directly admitted to the
detoxification centre where the required
medical treatment is given. Withdrawal
symptoms due to sudden stoppage of drug
usage, instances of acute intoxication and
chronic health problems associated with
addiction are dealt with during detoxification.

When the physical condition of the patient
stabilises, he is transferred to the psychological
therapy wing.
The psychological therapy comprises individual
counselling, lectures, group therapy, relaxation
techniques, recreational activities and educative
films. Individual care and attention are given to
each patient during therapy.

FOLLOW-UP

Follow-up forms an important part of the
treatment at TTK Hospital and is maintained
for a period of five years.. Patients are asked to
participate in an after-care programme held
every week at the hospital. They are
encouraged to meet the doctor and their
counsellors every fifteen days in the initial stages
to seek medical advice and report on their
progress. After three months, monthly follow-up
visits are recommended.

AA AND AL-ANON Patients and family members are encouraged to
attend Alcoholics Anonymous (AA) and
AL-ANON meetings regularly. Meetings are
also held at the hospital premises.

PROGRAMME
Addiction is a 'Family illness' that affects not
FOR THE FAMiLY only the addicted individual, but also his
family members. TTK hospital offers a family
programme providing information about the
disease of addiction and its impact on each
member of the family.
The family is given emotional help tp cope with
the stress caused by the behaviour of the addict.
The duration of the programme is two weeks.
The programme includes lecture sessions, group
discussions, assignments, relaxation techniques
and AL-Anon.

PROGRAMME
FOR THE
CHILDREN OF
ALCOHOLICS

Children form an integral part of the family.

Addiction destroys feelings of love, security and
warmth which are necessary for the normal
development of children. These children need a
lot of help and understanding.
The programme for the children of alcoholics
consists of story-telling, exercises, drawings, etc.
These are aimed at educating them about
alcoholism, relapse and recovery.

SOCIAL SUPPORT The Social Support Programme aims at
exploring the possible support the recovering
PROGRAMME
patients can receive from the society in which
they live and utilising it towards their recovery.
The support persons are usually family members
— other than the spouse or co-workers or
friends. Contact with the support person helps in
stabilising recovery and ensuring regular follow­
up.

©IMCOPS Hospital
LATTICE BRIDG

For additional information, contact:

TTK HOSPITAL
Treatment Centre for Alcoholism
and Drug Addiction
©TTK HOSPITAL

IV Main Road, Indira .Nagar,
Madras 600 020. Phone: 418361

alcoholism and its effects

- what can you do?

(DR. MOHAN ISAAC MBBS , MD, DPM)
associate professor of psychiatry nimhans

INTRODUCTION :Alcoholism has been a growing problem in our country

during the past one to two decades.

Similarly, this has

been a difficult problem to deal ■with in many other countries

of the world too.

Several surveys carried out in different

parts of our country have pointed to the growing prevalence
of abuse of alcohol and various types of drugs.

There have

been other indicators of the increased prevalence of alcohol
it has been shown that the number of

abuse too, for eg.

alcoholics being treated in our psychiatric wards have been
steeply increasing.

Persons admitted with various physical

complications of alcohol like cirrhosis of liver has been

on the increase too.

A fairly high percentage of road

accidents and fatalities related to such accidents has been
alcohol related.

One estimate has shown that a third of the

drivers on our highways are under the influence of alcohol.

Large number of crimes committed by individuals, Like
burglaries, assaults, rapes etc. are also committed after

consumption of alcohol.

Many of the growing number of

suicides have been reported to be alcohol related.

It is

roughly estimated that there are more than 3 million
alcoholics in our country.

Yet another pointer to the

problem of alcohol in our country is the amount of alcohol

produced.

In 1985, 331 million litres of pure alcohol was

used, for production of various brands of alcoholic 'b’evSr§ges. •

Today, we have more than 200 brands of whisky, 50 brands of
rum, 30 brands of brandy, 50 brands of beer, 10 to 15 brands
gin and wine, and over 100 varieties of country liquor

being marketed all over the country.

In addition,

illicit

distilling is also a growing industry.

...Contd...

- 2 -

WI1AT_]S _ADDICtiON/aBUSE/DEPENDENCE ?
There are several substances like alcohol and different
varieties of other drugs, which when consumed in certain

quantities, influence people’s thoughts, emotions, sleep,
apetite, sexual functioning, social interation and various

other aspects of behaviour.

These substances also give'a

sense of well-being' (euphoria) when people are under their

influence.

Because of these effects, people who have used

these substances several times, have a tendency to continuously
use them.

When such constant abuse occurs people can get

addicted to or dependent on such substances.

For a person

to be called an addict or drug dependent, he should have an

uncontrollable and strong desire (craving) to procure the

drug, constantly and coiiaurtieit.

He would not be able to

stop the drug taking without help and when stopped, would

develop various kinds of physical and psychological with­
drawal symptoms.

A tendency to increase the dose of the

drug abused (tolerance)

is another indication of the person

becoming dependent on the drug.

The common psychological

withdrawal symptoms are an irres is table craving for the drug,

irritability, restlessnes , feeling bored and disinterested,
difficulty in concentration and work.

The common physical

withdrawal symptoms to various drugs are muscular aches and
pains abdominal cramps, vomiting, diarrhoe^ sweating,

sleeplessness, running nose, tears, chills and fever and at

times unfounded fears, confusion, violent behaviour and fits.

WHAT ARE THE CONSEQUENCE _OF_ALCOHOL_ABUSE_?

The consequences would be primarily dependent on 3

factors, namely, the type, amount and period of alcohol
abuse, the pers onality of the user and the social situation

...Contd...

.

- 3 -

of the user.

However, the various consequences can be

considered under the following heads t

- health
- behaviour

- family
- work or occupation

- financial
- police and law

enforcing

author ities

The abuser initially shows varying types of altered

behaviour as a consequence of regular alcohol taking.

Many of these may ultimately result in psychiatric
complications like Hallucinosis (perceiving things without

any stimuli, continuously), Paranoia (abnormal and unfounded
suspiciousPsychosis (complete loss of touch with reality)
Dementia (various forms of memory losses).

A person who

chronically abuses alcohol can also devrelop various

physical problems.

The common physical problems are frequent

infections, under-nourishment, degeneration of the liver
etc.

In addition such people are also prone for different

types of accidents leading to injuries of head and other
parts of body.

The consequence of drug abuse on the family

are constant tensions, frequent quarrels, violence between
spoujes, child abuse etc. and it may also lead to divorce

and seperatiota.

Alcoholics and drug addicts also have

problems in retaining regular jobs and satisfactorily
performing in their work situation.

Constant decline in

the efficiency may ultimately result in '.Ipsing of employment.

Yet another problem which addicts have to constantly face
is financial problem.

They slowly los'd’:■ their ability to

support their families and ultimately have also difficulty

in finding sufficient money to procure their ^‘lcofiol.

is

leads to their getting involved in stealing, burglary etc.
Stealing initially starts in their own household, but later
extends tn other households too.

Many addicts get into

problems with the police and the law enforcing authorities.

...Ccntd...

all AT CAlhli ADDICTION ?

The various factoro which interact to ultimately
produce addiction in a person is not clearly understood.

Many factors have been implicated which include genetic
(hereditory) other biological, psychological and socio­

cultural factors.

It is currently believed that addiction

occurs du2 to a complex interaction of the several factors.

WHO IS AT RISK OF MIS-US ING ALCOHOL ?

It is widely known that men out-number women in
problem of addiction all over the world.

It is, young and

middle-aged men who are at the highest risk of becoming
addicts.

Amongst them, it is the unemployed, bored and

disinterested people as well as people going through various

life-stresses who are at higher risk.
economic

As far as socio­

factors are concerned there are no specific factors

which consistently correlate with addition.

Rich, poor and

belonging to all economic classes as well as the educated,

illiterate and with various types of educational background
are equally prone to addiction.

There are certain

occupations which might aggravate the proneness for
developing addiction, (eg. doctors, nurses, pharmacists,

medical students, druggists , chemists etc. are much more prone
for different types of drug addiction than the general

population).

Similarly, bartenders.., wa iters , excise personnel

and dealers have a higher proness of becoming alcoholics.

TREATMENT FOR ADDICTION s

Most treatment strategies ware developed 30/^0 years
back, and these strategies have been used with varying

success.

The first step in the management of an addict is

to motivate him and his family for accepting treatment.

...Contd...

5
Once this is achieved, a period of one to two week is

taken for 'detoxification' which is generally done under
an institutional setting with medical supervision.

This

is to take care of the withdrawal symptoms which the
person may develop during the initial period of abstinence.

Following this, the person undergoes a treatment programme
consisting primarily of counselling, esssI individual and

group therapy in a residential setting.

Special techniques

like aversive conditioning may also be incorporated into

the treatment programme during this stage.

Ultimately,

the person is put on a drug-deterr ent agent like antabuse
in alcoholism and discharged from the institutional setting.
Subsequently, regular follow-up and entry into an after­

care programme is encouraged.

Persons are also encouraged

to join self-help groups like alcoholics fetibnymbus .

during

the therapy for the addicts, some kind of therapy is

also

taken up for the family members, like wives of alcoholic,
or children from alcoholic families.

Relapses are more the

norm than exception in the management of alcoholism and

drug addiction.

The best of the treatment programme have

only about 25 to 30 percent of success rates if success is

considered as 3 to 5 years of abstinence continuously
since discharge from the treatment programme.
WHAT can you do for solving the problem of alcoholism in

THE COMMUNITY ?
The following twelve steps are mentioned for any
community leader who is interested in the problem of
alcoholism and drug abuse in this community.

Perish priests

village leaders, school and college teachers, community
health workers, panchayat and zilla parisad members are

all included under the term community leaders t

. ..Contd...

6
- learn about basic aspects of alcoholism and
drug abuse.

This can be achieved by being aware of the
problem through various kinds of simple

booklets and other publication available on

this matter, regular scanning of the media

etc.

Learn also about the existing resources

in your own area/d istr ict/state for the
management of alcoholism and drug addiction.

- detection and appropriate assessment of
alcohol and drug-related problem in the

community.
Detection is not likely to pose much problem

once, one is sensitised to the evils of
alcoholism and drug addiction.

However, a

way of detecting person with this problem
is by asking people routinely about drug

use.

Of course, the questions will have to

be asked non-judgementaly and non-critically
and people should be re-assured of

confidentiality and your concern for their
problems. Once detection has occurred, the

next step is a detailed assessment

of the

problem. Enquire into the nature, severity,

type, amount, frequency, duration, pattern
of the drug taking habit.

Enquiry should

also be made into heald problems,

family

problems and other related social problems.

This sort of an assessment will facilitate
better understanding by the addict as well
as his family of the problems.

Assessment

should lead to search for solutions and

appropriate action accordingly.

Contd

7
learn and develop simple counselling skills:

To work cont inous ly with addicts and their
families one has to develop skills of

establishing a relationship of trust and

confidence with the addict and his family
(rapport).

refer to a resource centre :
If the addict who is detected and assessed

requires institutional treatment through
professionals, refer them to such a centre.
Referral does not mean only naming the

facility but it should also include clear

information about the centre as well as
what the addict and his family can expect
from such a treatment centre.

Provide continuous re-assurance about your
own interest and involvement in the Welfare

of the addict and his family.
help the addict and his family with the

associated medical, social and legal

problems which may have arisen as a result
of the drug abuse.

do not get discouraged with relapses,

Relapse is the norm rather than the
exception in the management of drug
abuse.

Some people may recover

completely only after l5/20th attempts.
Continue your supportive visit to the

families of the addicts.
failures

Even if there are

of the Management of the addicts,

the other family members of addict will
benefit from your continued visits.

.. . ’’Oontd

- accept limitations.

There are few

causes which nobody can help.

Repeated

treatment failures should not discourage
you.

Discuss with more experienced

pers ons.

- develop new and innovative resources for

tho help of addicts and their families.
You may think of starting voluntary

associations, self-help groups for former

patients or an alcoholic annonymous branch
in your parish.
- enlist/mobilise community support.

Take up

measures to increase awareness of the

community about drug and alcoholic related
problems.

This can be done by organising

talks, exhibition, essay competitions etc.

Once people understood the various problems
related to alcohol and drugs, they will be

more willing to help prevent various problems

as well as detect cases early and help
addicts to recover.

- Remember - CONFIDENCE WILL COME WITH KNOWLEDGE

AND PRACTICE.

COMMITTEE OF CONCERN IN BHARAT ELECTRONICS

A

REPORT

ON

CORRECTION AND REHABILITATION OF ALCOHOLIC EMPLOYEES

IN
BHARAT

Bangalore-13

ELECTRONICS

17th December 1988.

A Report on Correction and Rehabilitation of Alcoholic
Employees in Bharat Electronics.
INTRODUCTION :

Absenteeism is one of the illness
Organisations.

of Industrial

Research studies have identified its

nature and causes.

The causes for absenteeism may

be grouped into two categories (a) sickness, indebted­
ness , laziness , lack of awareness , lack of interest

towards widening the scope of life, mal-adjustment
to a given situation, inclination to other business,

job dissatisfaction, habit of easy earning without'
labour, and like other causes may be grouped as the
first category.

These may, no doubt affect the

organisation in terms of production and productivity.

But an organisation itself can tackle them appropriatly by adopting systematic counselling, motivation,

guidance, and other corrective

measures, (b) The

second group of character of absenteeism

are Mal-

adoptive behaviour like addiction to alcohol and
drugs.. Besides loss of production and productivity,
the latter generates other multifarious human relations

problems to the Management, as the addicted employees

are controlled not by themselves but by the chemical
they consume.

So it is beyond the limits of the

Management to bring them back within the socially

accepted norms and rightly fit them into the

organisational setting.

Yet many organisations are

groping for solution to the second category of
absenteeism, wherein majority, of the chronic absentees

fall under this group.

...Contd...

- 02

t

Problem of Absenteeism in Bharat Electronics

Bharat Electronics, Bangalore Complex, is engaged in
manufacturing Electronic equipments and components.

We have engaged about

13,000 employees, about 10% are

habitual absentees.

Indeed the observation and

experience of the Management shows that 50?o of the

absenteeism

is caused only by those who have history

of Maladoptive behaviour of Alcoholism.

Alcoholism, therefore, is the major contributory
factor for absenteeism in Bharat Electronics.

Eventually the Management was facing not only loss
of production and productivity but also other problems

of human relations.
It is in this backgr ound ,that an' organisation

running a Half-way Home, CaIM got in touch with us.

CAIM defended the theory of alcoholism putforth by
the Alcoholic Anonymous and belived that it alone

could take the alcoholics to sobriety.

They further

pointed out that 1. Alcoholics are not delinquents.

They are suffering

from the disease of alcoholism.

So they should be

considered as really sick person.
2.

Neither the members of the families of alcoholics

nor the general public have no/less knowledge about

alcoholism and they a-r-e simply believe that the •
behaviour of alcoholics was intentional.

Hence,

hardly they could get out from the vicious circle.

3.

While taking steps to treat alcoholics, first, one
should accept the alcoholics as they are and should

. consider them as patients.

...Contd...

03

4.

They should be kept away from the members of their
family, ntleast for a period of 3 months and put

them in half-way home to unlearn their behaviour of
alcoholism and support them to

re-learn to live

happily without alcohol.

5.

For the first 10 days of the 3 months treatment,

they should be detoxified in one of the nursing home

under the observation of psychiatrist and treat them

for their withdrawal syndrome and other physical
ailments if any.

6.

During their stay in the half-way home, they should

be provided nurished food and should engage them
with 24 hours tight programme.
7.

They should be taught physical exersice and yoga to
relax and react ivise their physical function.

8.

The attitude of the alcoholics towards drinking

should be changed through group therapy and one-toone therapy in order to bring out their hidden feelings

9.

Since the denial is -’G&S one of the character of the

alcoholics, confront them appropriately with
documents and help them to accept that they are really

suffering from the dis-'ease of alcoholism.
10.

Teach them the 12 steps envisaged by the Alcoholic

Anonymous (aa) and motivate them to attend AA meeting

every day.
11.

With a strong confirmation and commitment to the AA

concept ,-thej sa id, the alcoholics are powerless.
lost control over drinks.
them from drinking.

They

No human beings could , stop

So they should depend on only

God or Super power as one's own belief to maintain

s obr iety .

...Contd...

- O'l

12.

Meeting the members of the family of alcoholics and

the shop floor supervisors as and when the situation
arises and help the family members to make aware of

alcoholism and the way of dealing with them.

They suggested, the Management to start Employee Assistance
Programme and identify the poor job performers and their

causes for it, pick up the poor job performers whose
causes jure come under the group of Alcoholism.

Since

denial is part of the disease of alcoholics confront

them with necessary documents and refer them for alcoholic
treatment at half-way home.
CAIM also made it clear that Alcoholic Anonymous does not

believe in pharmacholgical approach in resolving the
problem of alcoholics, as there would be chances for

causality or adverse effect while administring drugs.
Instead of depending on alcohol the patient may depend

on drugs.

Taking the suggestion of CAIM and analysing the condition

in the factory,
alcoholic

it was

in principle agreed to send our

employees to the correctional institution

for treatment and rehabilitation.

Further to make the

scheme more effective, it was also decided to involve
the Trade Unions, Labour Welfare Fund, and the

-

Departmental/^ ect ion Heads of various departments,

particularly where there was more concentration of
alcoholic employees.

Subsequently many meetings were

held with the representatives of the trade unions to

make an awarness among them about alcoholism and its

effect on the individuals as well as on the organisation.
The Negotiating Trade Unions responded positively and

appreciated the stand of the Management.

They also assured

that their co-operation, support and participation, would

always be there for the good cause of rehabil iat ing the

alcoholic employees and their family.

...Contd...

- f>6

cl) Employee

who expr est
5h
*

is

inability to control his

drinks and voluntarily approach the Management for
help will also be sent for treatment after varifiention.
5» The Offer of assistance to help to resolve such problems
shall be in an confidential manner.
6.

Consideration would be given for the use of annual
leave or leave without pay for those who

are sent for

treatment as is granted for ordinary health problems.

7.

The programme aims at rehabilitation and not at
elimination of an employee.
Management

8.

ror pro-union.

It is neither

pro­

It is just pro-patient.

Employees referred by the committee for treatment
through the programme will be secured adequate medical,

rehabilitative counselling, food, accon|&dat ion, or

other services as may be necessary to resolve their
pr oblems.

9.

The employee will be referred by the supervisor to a
designated resource person who is professionally trained

to diagnose
10.

problem and secure help.

Necessary counselling service also will be extended to

the members of the family of alcoholic employees.

11.

If the employees accepts the offer of help and the job
performance or attendance problems improve

to

satisfactory level, no further action will be taken.
12.

If the employee refuse the offer of help and job

performance or attendance problems continue, the regular

disc:-iplinary procedure will apply.
SELECTION OF TREATMENT CENTREt
Initially we desired to admit our alcoholic employees in

St.Johns Hospital as it was the only hospital with the facility
for treatment of alcoholics.

But the condition put-forth

by them was not acceptable to our organisation.

...Contd...

- OS COMMH'IEE OF

CONCERN

i

Aft<;j getting positive response from the Trade Unions, the
Manpgemcnt decided to constitute a committee, exclusively

for correcting alcoholics and helping other personal Mal­

adjusted employees.

The body was named as "the Commit tee

of Concern in Bharat Electronics", with the Chief
Administrative Manager ns the Chairman, pur representatives
from departments with hifjier alcohol proneness, and the

Trade Unions.
THE POLICY OF COMMITTEE OF CONCERN IN BEL t
1.

The Company recogOnized that alcoholism is a disease.

2. Those employees of BEL who are affected by th is disease

will be identified and referred to an appropriate

modality of care.
3.

SOURCES OF IDENTIFICATION AND REFERRALt
a)

Wien an employee’s Job performance or attendance is

unsatisfactory and unable to change by himself with
normal supervis ioy^ will be referred, if the findings
proves through him SXX that such of his behaviour

only on account of alcoholism.

b)

When an employee - is

observed by the Trade Unions

as problem dr inker, asset they can also recomfend him to I
referred for treatment after confirming it through

counselling.
c)

Based on the complaints of the dependants of the
employee that his spouse/parent addicted to alcohol/

drug, such employee/s will be referred for treatment
after confirming it through counselling.

.. .Contd. . .

07
However we selected Varalakshmi Nursing Home, Raja jinagar

for detoxification and treatment under psychiatrists for
withdrawal panic of the alcoholics.

Then after 10 days,

admitted them to half-way home, Koramangala, which was

run by CAIM.

IDENTIFICATION AND PROCEDURE FOR ADMITTING EMPLOYEES FOR

treatment.
As per the policy of the committee of concern, the procedure
of identifying, motivation and referring the alcoholic

employees is given in the form of diagram -

...Contd,..

08

Once the Welfare Department receives information either
from the respective department or trade unions or dependants

about one's poor job performance, chronic absenteeism or

chronic alcoholism,

the concerned employee

and interacted

by a professional social worker of the

is

called

Welfare Department or counsellors of the various personnel

divisions to identify the reason for such behaviour.
the reason

is

If

alcoholism , help him to be aware about

the illness of alcoholism and how it ruins the individual

and his family.

Further he would be explained the programme

of Committee of Concern and motivated to free himself from
the disease of alcoholism.

In case, the employee denies

or is reluctant to go for treatment, he would be confronted

with necessary documents.

The social worker would also

meet the dependents of the alcoholic employee and keep them

aware of the disease of alcoholism and its effects and
persuade them to admit him to.the treatment centre.

Once

the employee/family agrees for Alcoholic treatment, he

would be sent for medical examination at our medical
department to confirm whether he is fit for alcoholic
treatment or not.

After confirmation, the employee would

be sent to the treatment centre.

The first batch of our alcoholic employees were admitted
to Varalakshmi Nursing Home on 5-9-1985 and later taken to
half-way home.

From 5th September,

1985 to 25th January,

1987, 150 poor job performers and habitual absentees were
interviewed and about 9O were identified as alcoholic
employees.

Out of 90, 67 were 2>ent for alcoholic treatment

at half-way home, Koramangala, Bangalore.

. . . C ont d. . .

09
STA'J EMEM ollOWlNG THE ADM1SS ION AND DROP 01 ns

Total no.
of estimated
poor job
perf orm a n c e ft.
habitual
a bs ent ces

1200

No. of suspectcd alc oh ol ic
empl oyees

600 ,

No. of
No. of
empl oyees empl oyees
c ouns elled ident ifr om
f i ed a1 5.9.85 to c oh ol ics
25.1.87

160

90

No. of
ein pl oyees
s ent f or
trea t men t

67

pos n ion

No. of
empl oy­
ees
were
d is charged
on
med ical
gr ounds

No. of
empl oy­
ees not
w il1ing
to
cont int

3

14

Over a span of one year and five months, we admitted 67

employees to half-way home.

Out of which 50 employees had

completed the full course of treatment and three of them were

discharged on Medical Grounds.

The rest of the fourteen

employees discontinued their treatment as they could not cope

up with the given situation, as the treatment procedure of

the half-way home was more discipline oriented.

The severe

disciplinary standard led to increase of dropouts.

Hence,

we felt little difficult to motivate next batches of employees

to go to the half-way home for treatment.
An alternative way was located at Ramaiah Medical College

Hospital (RMCH), where Psycho-pharma ch ol og ica 1 therapy was
being practised.

The whole concept of alcoholism and the

treatment of RMCH is quite different from the theory of
Alcoholic Anonymous.

Over a period of one year we have

admitted 48 employees to RMCH for treatment and rehabilitation.
At present option is given to alcoholic employees for treatment

either at CAIM or T. T. K. Ranganathan Hospital at Madras.

...Contd...

t

JO ,

THE STATEMENT SHOWING THE F60T10N OF ADMISSION, DISCHARGE,
DROPOUTS, PERIOD OF TREATMENT ANU COST OF TREATMENT PER
EMPLOYEE:

Name of No. of No. of No. of No. of
T/Centre Employ-employ- employ- dropees ad-ees com-ees dis- outs.
mitted.pettd
charged
treaton mediment.
cal
gr ounds

HALF­
WAY
HOME

67

50

3

RMCH

48

48

__

caim

17

11

1

5

3

__

137

112

4

TTKH

14

No. of
empl oye es un dergoing
treat­
ment .

Per i od
of
treat­
ment
in
days.

0 os t of
treat­
ment per
empl oye e
in Rs .

--

9°

8,200-00

—

60

90

6,000-00
( exclud i)^
food
charges )
7,500-00

2

30

3,500-00

7

--

madras

Total

14

A third alternative was found in the T.T.K Research Foundation
Madras.

EVALUATION OF THE ALCOHOLIC EMPLOYES REHABILITATION PROGRAMME}
From our experience we concluded that a single agency could

not attend to the physical, mental, psychological and moral
problems of alcoholics.
They required the attention of phy- "
sician, psychiatrists, psychologists, social worker, and re­
covered alcoholics.

We, therefore, felt that a team of pro­

fessionals of different disciplines could help the alcoholic

employees more effectively rather than single counsellor.
Further, after experiencing with the procedure of Half-Way

Home treatment, we have introduced two more hospitals (i.e.,
Rama iah ,Medical College Hospital and T.T.K.Hospital) having
the facilities of treating alcoholic patients and kept them
open to select the treatment centre at their choice.

Contd

Ov'-r a

period of 3 years the organisation gained rich

experience in the field of helping, supporting and

motivating the alcoholic employees.

We also sent 10

employees including Personnel Officers, Welfare Officer
and employees, Trade Union representatives to TTK

hospital to attend a one-wcek alcoholic counselling

c ours e.
AS

on to-day we have admitted 137 alcoholic employees

to various treatment centres.

The following table shows

the position of admission, recovery and relapse rate of
the emp]Loyees who were admitted to Half-way II ome.
No. of
per s ons
sent t o
HWH.

67

No. of
pers ons
d is c ont inued

17

No. of
pers ons
comple­
ted tre a tment

50

The above table shows,

No. of
pers ons
left the
service
after
treatment

10

No. of
pers ons
d ied
aft er
tr eat
*
ment

03

No. of
pers ons
s ob-

25

No. of Total
per- Resons
lapse
redu­
ced
freq.
off
drinks

08

23

out of 50 persons who completed full

course of behaviour ial training in the Half-way home, 25
(5O?o) continue to be totally sober for a period of minimum
2

years to 3 years.

frequency of drinking.
3

The other 8 persons have reduced their

However, even among 17 dropouts,

persons have become sober.

Apart from this, we could see

a lot of qualitative change in their life style.

Some of

them are engaged spreading the mesaage of the Alcoholic

Anonymous and voluntarily assembling every day and sharing

their feeling among their Alcoholic Anonymous Group.

...Contd...

Since many- of the alcoholic employees feJ t that the

procedure of Half-way home treatment was vry strict
and dis.ciplirie oriented, we found some sort of reluctence

from pur employees

to go for treatment at Half-way home.

RAMAIAH MEDICAL COLLEGE HOSPITAL «
In one year two months, we have admitted
RMCH.

h8 persons to

Here the psychiatrist and the psychologist, would

conduct individual counselling, group therapy, relaxation
therapy, and aversion therapy.

Though it is a general

hospital, a ward exclusively meant for treatment and
rehabilitation of alcoholics had been set up.

The following table shows the position of admission, rate
of recovery and relapse at RMCH :
No, of
pers ons
sent

No. of
pers ons
completed
the
treatment

No. of
pers ons
left the
service

48

48

2

No. of
pers ons
bee ome
sober

17

No. of
pers ons
r educed
dr inking

No. of
pers ons
t otally
r ela ps ed

8

21

Out of 48 persons, 17 recovered from the disease and continue
to be sober for the last one year.

It is

important to note

that none of them discontinued their treatment as the

"

patients are allowed freedom, as in the case of other patients
and the concept of their treatment itself does not believe
in enforcing or brain washing the alcoholic patients to stop

dr ink ing.

Contd,

13

Cain «t ttk.jigspitai-:
Though recently we admitted 22 persons to CaTM

TTK Hospital

and 17 of them have completed the treatment from the last two
However, the

months, we could not assess their sobriety.

following tables show the admission and discharge position as
on to-day•

Treatment
Centre

No. of
No. of
pers ons
pers ons
admitted. discont inued.

Number of
pers ons
c omplted
treatment.

Number of pers ons
undergoing treat­
ment .

calm

17

1

13

3

T T K H

5

-

3

2

PROFILE OF alcoholic EMPLOYEES ;

Alcoholic employees are distributed regardless of age, quali­
fication, nature of work, marital status.

The study of 137
Along with the

alcoholics brings out the following profile.

profile, the number of recovered alcoholics are also shown;

AGE group
26-30 31-35 3^-40 41-45 46-50
________________ ___________ above

GROUP

20-25

NUMBER

-

8

16

37

42

26

8

137

IMPROVED
SOB ER TTY
Percentage -

1

5

11

13

9

3

42/86

37.5%

48.8%

12.5%

31.2% 29.7% 30.9% 34.6%

51 &

total

education

Illite­ Pri­
*
rate. mary

Middle SSLC
School

SSLC+
HI

DEGREE

TOTAL

NUMBER

29

23

35

9

40

-

137

IMPROVED
SOBERITY

08

07

14

02

11

-

42/86

30.4%

40%

22. 2% 27.5%

-

48.3%

Percentage 27
5%
*

C o nt d ,

1i»

Highly Sk ill-Non-Tcchskilled ed.
nical

Nature superof
visor
work

34

09

Impr oved
S Ober Ity 04

10
*
29.^1

*
44.44

Year of
service 0-5 6-10
4

15

Impr oved
S ober ity
*
25

Q_

HABIT AL
STATUS

Improved
Sober ity

*
40

.
Married

23

07.

06

02

*
26.09

Vn-skllled Sanitary
Helper

Semiskilled
operator

uo

11

*
28.57

Total

13

137

42
"“48.8
*
86

04

13

03

*
36.36

*
32.5

*
23.00

11-15

16-20

21-25

26-30

31-35

26

58

19

15

-

137

-

42
----- 48.8
*
86

09

17

07

06

*
34.62

29.31
*

*
38.84

*
40

Un-marr ied

36 A above

Total

------------------------------------ --- ----------------------------

------------- ------------

Widower

Broken family

Total

137

135

02

01

18

_

00

00

03

04 2

*
16.67

*
V

*
28.89

®The total sobriety is considered only

among gg- persons who completed *
he

full

course of treatment at half-way home and
B.M.C.H.

>Contd.

8,8*

The study reveals the social, environmental and inter and

intra conflicts are the contributory factors to alcoholism.

Out of 137 persons, 60 come from lower strata of the Society.
Most of them are living in bad housing condition.

Recovery

rate among them is also poor.

Among the group of broken family, the recovery rate is very

poor.

Sven after treatment, 8^% of them resume drinking.

AFTER CARE PROGRAMME ;

The persons who recovered from the disease of alcoholism
themselves conduct Alcoholic Anonymous meeting every day in

BEL colony.

They themselves meet the members of the family

of employees who resume drinking after treatment.

We are

also getting feed back from the recovered alcoholics regarding

progress and relapse cases.

CONCLUSION;

Yet efforts are being made

Alcoholism is a complex illness.

to evolve a systematic therapy to cure it totally.

As such

our organisation has taken up the venture of helping/supporting

both alcoholic employees and therapists by hoping for early

cure from the illness of alcoholism.

Though this venture is

expensive in terms of money, its aims and objective to help

our employees and their family to accomplish qualitative life,
is humane, realistic and un-meaaurable.
Having high commitment and confidence, our Committee of Concern
gave rebirth to many employees.

Eventually their family

members too got greqt relief from the world of tension,

anxiety and stress etc.
Among the employees who underwent treatment through our scheme,
60$ have shown improved sobriety, and good performance of

attendance.

We do receive the report of good job performance

from their respective supervisors.

...Contd...

- 16 Cases

of drunkness while on duty, have reduced considerably.

Many employees who were at the early stage of alcoholism have

become more alert and cautious and changed their attitude to­
wards drinks.

Increasing awareness programme on alcoholism

through, pqjnphlets, brochure leads to falling alcoholic number

A group of recovered alcoholics have already started spreading
the message of alcoholic anonymous and sharing their feeling
among themselves through AA meeting.

We hope a time may

come that the recovered alcoholic employees of BEL themselves

will render a remarkable human service to the other alcoholic
employees.

Despite 40% of relapse cases, the committee of concern of

BEL has determined to march ahead till the eradication of
the disease of alcoholism in Bharat Electronics without
frustration and disappointment.

I

<+>-

TTK HOSPITAL
T T RANGANATHAN CLINICAL RESEARCH FOUNDATION
IV MAIN ROAD, INDIRA NAGAR, MADRAS - 600 020.

EMPLOYEE ASSISTANCE PROGRAMME
(EAp)
Facts about Employee Assistance Programme:
The first alcoholism assistance programme was
started by E.I.Du Pont and Company in 1942. Dr.George
Gehnman, the company's Medical Director set up the
programme as an alternative to terminating employees
with alcohol problem. The supervisors were trained to
identify the alcoholics on the basis of certain symptoms
like red eyes, trembling hands, frequent intake of cold
water and use of breath sweetners. But this method was
not very effective since the above mentioned symptoms
were indicative of wide variety of illnesses. Further
more the principal treatment modality employed to help
the employees was through 'Alcoholics Anonymous'.

It was in 1950 that a new approach for providing
help to employees with drinking problem was devised by
Lewis Persnell. ,He employed a number of methods of case
finding through observations of deteriorating job per­
formance. From the results of these methods it was found
that supervisors can only be given the responsibility of
evaluating the job performance of an employee and not
that of identifying alcoholics. If an employee's job
performance has been deteriorating, then the supervisors
can offer two choices to the employee - he can accept
help on a confidential basis for whatever has been causing
a decline, in his work capacity - he can face disciplinary
action for his performance.
In 1971, the National Institute of Alcohol Abuse and
alcoholism was formed to promote the Employee Assistance
Programme in the American Industrial set up.

Employee Assistance Programme is neither pro-company
not pro-union, but rather pro-patient. Both Union and
Management share equal responsibility in evolving poli­
cies and in promoting this programme.

Objectives of the EAP Programme:
1. Early identification of alcoholic employees.

2.

Effective motivation to help them accept
treatment.

3.

Prevention of alcoholism.
.......... contd.2

- 2-

Installinq the programme:

a.

Policies and procedures.

b.

Procedures for case-handling.

c.

Referral system

d.

Supervisory training.

e.

Need for line management involvement in
programme implementation.

f.

Employee Education component.

g.

Record keeping system.

h.

Insurance coverage for treatment of
alcoholism.

i.

Evaluation.

a. Policies and Procedures:
There is an unwritten policy regarding alcoholism
in every company. This unwritten policy put in words reads
like this. 'Any employee (including executives and members
of top management) who can successfully conceal the disease
of alcoholism from superiors will be entitled to full use
of sickleave and payment of hospitalisation costs and will
receive all pay and benefits including promotions and re­
gular raises. When the employee can no longer conceal
the disease, termination will result'. This unwritten
policy leads to denial and concealment of the problem by all
concerned.
A written policy on alcoholism provides a frame
of reference for uniform administration throughout the
organisation. The programme's acceptance and credibility
depends on how well the policy provides clear cut answers
to questions which are uppermost in the minds of the
affected employees.

Some of the crucial questions that must be answered

are:
1. Does the organisation really accept alcoholism
as a disease?
2. How is alcoholism defined for programme
purpo se s?
3.

Will alcoholism be handled the same as
any other disease?

4.

Will request for an acceptance of treatment
affect job security or promotional opportunities?

5.

Will records be kept in strict confidence?

6.

Will group health insurance benefits cover
treatment for alcoholism?

7.

What are the consequences of refusing to
accept referrals or failing to respond to
treatment?

- 3 -

8.

will there be an opportunity for self­
referral on a confidential basis?

9.

Is the primary purpose of the programme
to encourage employee to seek diagnosis and
treatment as early as possible?

b) Procedure for case handling:

Once the policy has been adopted by the management,
a simple set of procedures for case handling should be
set up.
Individuals who seek help voluntarily, will not
come under this section. Our concern is with those who
will be referred to the programme because of poor job
performance. The following are NCA
*
s (National Council
on Alcoholism) recommended procedures.

1. The supervisor should prepare a detailed
documentation of the employee's job performance
deficiencies - specific dates absent or tardy,
specific deadlines missed, serious errors in
work and incidents of unacceptable behavious.

2. The focus of the initial interview should be
on job performance. No opinions or judgements
as to the cause should enter the discussion.
3.

The employee should have the right to have
union representation at the interview.

4.

After the job performance has been reviewed
and the employee told what sort of standards
must be met in the future, the employee should
be informed of the professional services including diagnosis and counselling - which are
available on an absolutely confidential basis.

5.

At this point, the employee may accept or
reject the offer without prejudice. Neither
the supervisor nor the union representative
need know whether or not the employee has
contacted the programme. No disciplinary action
is involved.

6.

If the employee's job performance improves to
an acceptable level, there is no longer a
problem.

7.

If the initial interview involves discipline
or if the job performance problem recur, the
employee should be offered a firm, fair choice
between accepting the offer of confidential
help or accepting the disciplinary consequences
of the poor performance.

8.

In the overwhelming majority of cases, the
...4.

- 4 -

.employee when confronted with this sort of
choice will ultimately agree to accept
referral to the programme.

C.

9.

If the employee chooses termination, there
is little that can be done to help.

10.

If the employee accepts help, there should be
clear understanding that this means following
whatever course of treatment is prescribed.

Referral System:

Since an employee assistance programme is, in
effect, a job performance action programme, those indi­
viduals who need professional assistance, regardless of the
nature of their problems, will have to be referred to the
resources in the community which are best qualified to
help them. The treatment resources will range from de­
toxification facilities to out-patient treatment, including
alcoholics Anonymous. Referral to programme is a major
responsibility of the supervisors.
d)

Supervisory Training:

For the success of any FAP, supervisors at all
levels should be trained. Prior to the introduction of
EAP, there should be an orientation programme for senior
executives and union leaders. Training for supervisors
should include reviewing the organisation's policy on
alcoholism and explanation of procedures with which the
policy will be implemented.

e)

Employee Education Component:

An educational component designed to inform
employees and management regarding the modern approaches
to alcoholism, should be a part of all EAPs. The employees
should be educated on the disease concept of alcoholism,
and the treatment aspect of the disease emphasising the
fact that alcoholism is treatable. Self assessing sings
and symptoms of the disease should be made clear to them,
as also the organisation's policy regarding the disease.

f)

Record Keeping:

A record keeping system which assured confi­
dentiality to the employee and maintains the progress of
the programme should be included. Data to be recorded will
include the name of the individual, department, various
demographic details, education, job description, rate of
pay, years of service, marital status and lastly his
progress in the programmes.
g)

Insurance coverage:

If the organisation's policy states that
alcoholism is a disease, and that employees suffering from
that diseases are entitled to the same consideration and

- 5 -

treatment as those who suffer from any other disease,
then the establishments group health insurance coverage
should reflect that policy.

h)

Evaluation.

The employee assistance programme should be
periodically reviewed and evaluated. There should be
an annual evaluation review of the EAP staff performance
....oOo....

e

COVER STORY ADi)!CTiO^3

The devil in
Dr Bhide

Consultant Psychiatrist
“Candy is dandy but for liquor is
quicker."

The irrepressible Ogden Nash said
this in a very different context but
nothing can summarise lethal
effects of consumed substances
more pithily. The present article will
concern itself only with the “quicker"
substance and leave candy aside.
Alcohol in its many consumable
forms has been widely used all over
the world over millenia. Even some of
the most respected medical men
have acknowledged its efficacy as a
®reat social lubricant and many
cultures set store by it as a symbol
of well being, prosperity and
hospitality.
And yet the "bottle" is the
harbinger of great disasters and
misery to an untold number of the
world’s citizens at any given time.
It is impossible to ascertain how
many people consume liquor in a vast
country like ours, but at best it could
not be less than 40°/o of the adult
males in towns and cities. Even more
difficult to establish is the number of
people who have a drinking problem,
but on any day in a city like Bangalore
atleast 3 new alcoholics are being
brought for treatment to the medical
Specialists! And this does not take
into account the large number who
"ave a problem but are yet to
acknowledge it
>
In India, the economic improve­
ment in many families, the lifting of
prohibition in many 'dry' states, the
expense account culture, increased
promiscuity among the youth and
their poorer ability to tolerate
frustration would all appear to have
increased the magnitude of the
problems. Also, increasingly, younger
people seem to be becoming more
prone to the habit.
Alcohol produces several physio­
logical alterations which cause it to
be used repeatedly. These include its
effects on the mood; a moderate
dosage often allays anxiety, and a
slightly strong one causes a sense of

euphoria. Alcohol seems to also dim­
inish the inhibitory activity in the cen­
tral nervous system. This loss of
inhibition facilitates the ability to
show hitherto suppressed aggres­
sion.
When one learns to use alcohol for
these reasons, one gradually opens
the lock of self control that keeps
dependence in check. Most alcohol­
ics indeed are individuals who have at
some time been mere 'Social
drinkers'. The slide from this state to
that of. an alcoholic is often so insi­
dious that everyone is taken by alarm
when it becomes obvious: the family,
peers, even the family doctor and not
the least, even the patients them­
selves!
The prolonged use of alcohol, as of
many other abused substances,
directly damages different parts of
the nervous.system and also causes
grave injury to the mind of the individ­
ual. The effects include a state of
trembling and unsteadiness even
when the person is not drunk, a
marked inability to coordinate the
muscles, leading to clumsiness, a
deterioration in memory and intelli­
gence and burning sensations or tin­
gling or numbness in many parts of
the body. Unrealistic thoughts,
especially of being persecuted by col­
leagues or of the spouse being
unfaithful and vivid and disturbing
visions and voices that nobody else
experiences (hallucinations) can also
result from chronic abuse of alcohol.
Alcohol adds insult to the brain
injury it causes, by impairing the
functioning of the liver where most of
it is metabolised in the body. ’ In the
long run the liver can only totally
breakdown if the load of alcohol
becomes too much. This leads to the

accumulation of substances that
can no longer be detoxified, and are
potentially poisonous. This causes
further brain dysferection and such a
doubly insulted brain is often in a fatal
condition.
Alcohol has also been implicated in
disorders of the gastrointestinal
system (gastritis, peptic ulcer). A
devastating effect is the fetal alcohol
syndrome that results from a preg­
nant mother's drinking and can
cause the child to die or be bom with
severe handicaps.
Apart from these tangible physical
maladies, alcohol drains the individu­
al’s sense of self esteem and having
earned the label of being an alcoholic
he becomes a social derelict, a poorly
respected family head or member, an
incapable worker or bread winner
and a social hazard, e.g.. if he is at the
steering wheel of a vehicle.
A significant number of road acci­
dents is directly the result of drunken
driving. Research also seems to indi­
cate that the more serious the acci­
dent, the greater the chance that it
has been caused by an inebriated
driver. Alcohol seems to impair driv­
ing skills by interfering with one’s
judgement, attention to stimuli from
the environment and also motor
coordination. In Manchester, bus
drivers who had received awards for
safedriving were studied in one
researchprojectanditwas reported
that even for these experienced pro­
fessionals there was no "safe" blood
alcohol level below which their
judgement could be guaranteed to be
sure. Even in the period of the
so-called 'hangover', perhaps due to
irritability and fatigue, the driver who
had a drinking bout, can be prone to
cause accident. Equally important is
the risk caused by intoxicated
pedestrians!
The havoc that liquor can wage in
family life is truly devastating. An
obvious effect is the drain it makes
on the family budget, and the well
known fact that it takes more and
more liquor to get a person drunk as
his habit progresses CtolerancpD
aggravates the problem. Debts tend
to accumulate rather than be paid of.
The quality of accomodation which
HEAtTH AqriON NOVEMBER 1968 • 7

COVER STORY .ADDICTIONS

Getting an alcoholic treated, is
The ideal management of addiction
therefore of paramount importance. of course is in its prevention, which
This is easier said than done, not the means effectively restricting the
smallest reason being that very availability of alcohol and educating
many alcoholics are unwilling to the public, especially the vulnerable
acknowledge that they have a prob- groups such as students on the ill
a lem at all! Even those that do, often effects of the drinking habit. For per­
r-i fantasize that in some way they can sons who have sustained physical
rfcontrol the problem but have chosen dependence, the best advice is life­
Sea not to because they dont "yet” need time group such as Alcoholics Ano­
''to.
nymous and encouragement ’to
The treatment of alcoholism resume a creative life are aspects of
needs to pay sufficient attention to treatment that can never be over­
, the alcoholic can sustain declines, the physical and emotional aspects. emphasized.
leading to family disruption or even This is best achieved by admission to
homelessness.
a hospital/faculty geared for de­
Sexual dysfunction is almost inva­ addiction and with the aid of selfhelp
WANTED
riably a long term outcome of chronic groups that can be run by reformed Adoctor urgentlyneededforal2
alcohol abuse. This is ironic in the addicts under the surveillance of qual­ bedded hospital with scope for further
face of the popular notion that ified personnel. Involving the family, expansion.
‘drinks’ are aphrodisiacs (Sex stimu­ the peers or employers when war­ Contact:
lants). Perhaps there is some grain of ranted, becomes important from the
Holy Gross Hospital
truth underlying this notion, in that. point of view of rehabilitation,
Gandhi Nagar
alcohol being an inhibitor of inhibi­ because these individuals can be
Nidadavole, W.G. Dt.
tions, helps remove some inhibitions understandably embittered, scepti­
A.P. 634 301
even about sex; but even in people cal anti even unforgiving. Many alco­
who use liquor frequently without holics benefit from the use of a drug
being dependent on it, there is that by itself is largely harmless and Pertly Precise:
unequivocal evidence that alcohol non-addicting but in combination Psychiatrist: A person who deals with
causes a somewhat rapid degrada­ with liquor is a potential poison. Such people who have the same problems
tion of hormones responsible for a drug, (disulfiram) however, must we all have, but have more money.
healthy sexual functioning leading to a'ways be administered under medi­ Commuter: A man who shaves and
impotence. This is one important cal supervision with the patient’s takes a train, and then rides back to
factor that contributes to the mari­ foreknowledge of the potential shave again.
tal breakdown so common among hazards. In some de-addiction units Conscience: The thing that hurts
alcoholics.
patients are made to experience the when everything else feels so good!
Even in the absence of such a sex­ danger of the combination under a Contented: A man who enjoys the
ual problem alcohol causes disturbed doctors’ supervision, making sure scenery on a detour.
marital relations. In England and that ho life threatening situation
Wales, alcohol abuse contributes to arises. Some patients are exposed Patience: A minor form ofdespair dis­
as many as one third of divorces! The to these adverse reactions in guised as virtue.
children of alcoholics are far more another patient in the ward or to a Happiness: The interval between
vulnerable to emotional and/or phys­ video film demonstrating the same. periods of unhappiness.
ical abuse and also to developing The general principle is to form an
behavioral problems themselves. aversion in the patients to allowing a Punted
A magician working on a cruise ship
There is no doubt that in India as in very unpleasant situation arising
had a pet parrot who was ruining his
many Western countries, alcohol from the consumption of liquor.
has become a major scourge among
Apart from such chemical aver­ act. The bird would say to the
the poor families already caught in sion, other forms of aversion to drink­ audience, "He has the card in his
the vice-grip of penury.
ing can also be administered. These pocket, "or "The card's up his sleeve, “
are procedures administered over a or "It went through a hole in his top
While drinking problems are course of time by trained clinical psy­ hat."
Oqe day there was an explosion
extremely common among criminals chologists. Many de-addiction units
an aspect of this phenomenon that is lay emphasis on group therapy whe­ and the ship sank. Theparrot and the
too often ignored is that crime can rein freshly admitted patients can magician found themselves together
often be the consequence of this gain confidence from alcoholics who on a piece of wreckage. The parrot
habit gripping a hitherto law abiding have progressed through the difficult stared at the magician. Finally, the
citizen. This is of course true for all initial phase of being weaned from parrot said, "Okay, Igive up. What did
the bottle.
you do with the ship?"
forms of addictions.
8 • HEALTH ACTION NOVEMBER 1988

COVER STORY ADDICTIONS

^Llcoholism is the third largest
killer disease of the world, next to
heart attack and cancer. Such a
dreadful disease is found to have
affected a number of rural women
belonging to Chakkiliyar caste, one of
the schedule caste communities
(^iidravida) of the Tirunelveli District
cWTamil Nadu. Alcoholism is being
fostered by this community as a
social custom. Husbands bringing
the inebriating drink to their spouses,
mothers filling the feeding bottle with
toddy and children drinking alcohol in
the company of their parents is quite
common in this community. On
occasions like festivals, funeral func­
tions etc., the entire family along with
their kith and kin intoxicate them­
selves with alcoholic beverages.
Moreover, drinking habit is tradi­
tional in this caste. Ontogeny of
alcoholism in this caste is traced
back to their traditional occupation
of collecting dirt, garbage, faeces and
wastes. Once they drank to earn, but
now they earn to drink.

^Because of the alcoholic 'infection'
entire Chakkiliyar Community
could not make any progress in life.
Socio-economic backwardness still
prevails in them. Hence, an attempt
has been made to probe into the var­
ious facts behind this contagion in
this community. For the study, three
villages viz., Reddiarpatty, Kadanganeri and Llthumalai of Tirunelveli
District of Tamil Nadu were chosen,
where more than 750 families of
Chakkiliyars are living. From these vil­
lages a random selection was made
comprising 200 females of Chikkiliyar caste in the age group of 15 to
65 years. Details of their alcoholic
habits and work pattern were col­
lected using a questionnaire and the
data analysed on the basis of the
information received. This data were

collected before the promulgation of
prohibition in Tamil Nadu.
Socio-economic status of the Chakkityar community.
Chakkiliyars are one of the sche­
duled caste communities of Tamil
Nadu. Their population exceeds 5
lakhs in the Tirunelveli District of
Tamil Nadu. They are traditionally
cobblers and scavengers. They
speak a scriptless language which is
a mixture of Telugu and Kannada.
They are believed to have originated
from Naikkar community. They speak
Tamil fluently. Certain menial jobs
viz., lavoratory cleaning, drainage
cleaning, sweeping, garbage collec­
tion are exclusively done by the men
and women of this caste in the
human habitat. In many places they
have to carry human excreta in a
bucket as a part of latrine cleaning.
Such undesirable jobs thrust on
them in the name of social custom,
has resulted in branding them
"untouchables". They are also called
THOTTIS or SCAVENGERS. In addi­
tion to performing this menial work,
they are good agricultural labourers
and beedi rollers. Each high caste
family has atleast one Chakkiliyar
family as their labourer to do menial
jobs in their houses.

Alcohol abuse
among the
wofflosi
of
©smmimifey an
£h@TiiW@h@li
dfefiHet ©f
TamMadw
Prof AJA Ranjitsingh
Dr Padmalatha Ranjitsingh
Prof LM Warayanan

Divorce is common in this caste. A
woman without much hesitation or
The socio-economic status of this fear, joins another man who is
society is very poor. Their chief already married and has his own
source of income is from their tradi­ children. The new man accepts her
tional occupation and agricultural with her children without any hesi­
labour. Now-a-days the women have tancy. Once a husband humourously
learnt to earn money by rolling bee­ said to his wife, "My children and your
dies. More than 9O°/o of the women children are playing with our child­
folk of this community discharge one ren". This saying is popular among
or more than one of these duties. the villagers even now. Extramarital
Their average family size is 5—8. relationship with their landlords and
■Except 9.1°/o of the families, all the others is quite common in this caste.
other members earn below Rs. Pre-marital sex was found in 76.1 °lo
1200/- month. About 4O.3°/o of of the girls in this caste. More than
families earn Rs. 500-1000/- 8O°/o of the women of this caste
month. 50.6 percent families earn were illiterates. The maximum edu­
less than Rs. 500/- month. The cation they had received was till VIII
income is not steady and it is high Std. Their working environment is
during paddy farming and harvesting exclusively dirty, filled with foul smell
seasons. Only 4% of the families and it is extremely unbearable.
could live in comfortable houses,
In spite of all these adverse socio­
while the others dwell in huts, small economic conditions, alcoholic bev­
tiled houses or rented houses. The erages are consumed to a great
average age of marriage in women is - extent, perhaps to forget their occu­
16.7 years. In this caste, women pational hardships. 79.5°/o of the
change their husband quite easily. women of this community were
HEALTH ACTION NOVEMBER 1388 • 9

COVEASTOHY ADDICTIONS

found to be alcohol users. But the
percentage was only 4.6°/o among
the women in the other communities
of the study area.

Fig. 1 Drinking pattern of Alcohol in the different age groups of Chakkihyar community
[percentage)

Drinking Pattern

4

Drinking pattern among the wom­
enfolk of this community has been
determined by categorising them
into three age groups viz., 15—25
years, 25—45 years and 45—65
years. (Fig.l) In the age group 15—25
years, 63.1 °lo of them were alcohol
users. Among them 51.1°/o were
heavy drinkers. In the age group 25—
45 years, 9O.8°/o were alcohol con­
sumers. Of them 12.95 were light
drinkers. 9.4°/o among them con­
sumed alcohol more than once in a
day. In the age group of 45—65
years 83.3°/o women were drinkers.
jAmong them, the ratio of the light
drinkers and heavy drinkers was
15.5°/o:68.7°/o.

From the results it is clear that they indulge in extramarital affairs
womenfolk in all the age-groups of with each other, so as to maximise
this community freely used alcohol. their enthusiasm.
The alcoholic drink popular among
The intensity of drinking is little less
in the age group of 15—25 years and them is toddy. It is a palmyra pro­
it is perhaps because of their initial duct. About 80% of the women
'drinkers use this liquor. ,69.6°/o
hesitation in drinking liquor.
Drinking pattern varies with women use arrack in addition to
income. In the months of December toddy. Only 16°/o of them use other
— February, that is during the harv­ varieties of IMFL (Indian Made For­
esting period, the women earn more eign Liquor) alcoholic beverages.
money in the form of paddy and Alcohol is a family drink:
Women drink only with the knowl­
spend more than 33.6°/o of their
eamings on drinking. During that sea­ edge of their husbands, parents and
son about 60 percent of women in all children. It is a family-accepted habit.
the age-groups consume alcohol 56.5°/o of husbands bring liquor for
- once or more than once in a day. Dur- their spouses. 29.5°/o of woman get
I ’ ing week ends, the women beedi the drink with the help of their family
rollers get their salary and they members. 14.5°/o of women even
freely spend a part of their income on visit the liquor shops either alone or
alcoholic drinks.
Also, on occasions like festivals,
funeral functions and other celebra­ Easy
tions there is heavy consumption of
A woman Hon tamer had the cats
liquor. During funeral functions it has under such control they took a lump
become customary in this commun­ of sugar from her Ups on command.
ity to supply liquor to all the When a skeptic yelled "Anyone can
mourners. Hence, the entire com­ do that!" the ringmaster came over
munity seems to encourage this and asked him. "Would you like to try
habit.
it?"
In the study area, about 60°/o of
"Certainly," said the man. "But
these people usually take drinks in first get those crazy Hons out of
the evening. Other use alcohol at any there."
time they like. 28°/o use alcohol while
working. 2O°/o consume alcohol when

----- o

with their husbands. During harvest
season 80°/o of the women diredtly
get alcoholic drinks from toddy
sellers in the field itself. 79.5°/o
women who consume alcohol have
extra-marital relationships either
with their land-lords or with others.
Extra-marital sexual relationship is
even tolerated by some of their hus­
bands. Thus alcoholism becomes a
family-disease.
Ontogeny of Alcohol abuse:

Alcoholic usage has crept into the
society of Chakkiliyars in the begin­
ning as an occupational drink. To
forget their hardship in the filthy
working environment, they started
drinking, under intoxication, they
believe that they can discharge their
menial labour more effectively. Also,
after finishing their work they want
to relax with a peg of alcoholic drinks
to get relief from the tension. The
people of this community used to eat
the beef of the diseased and dead
cattle which their landlords offer
them freely. On such occasions
every Chakkiliyar family in a village
gets a free supply of beef. They con­
sume the beef even though it is in a
rotton condition. On such occasions
also, they use alcoholic drinks. During
harvest season their land-lords
supply them free toddy. From drink­
ing toddy slowly the people have
HEALTH ACTION NOVEMBER 1988* 11

COVES STOBY ADDICTIONS

fallen into the hands of more toxic
arrack and other liquor. Once they
drank to work but now it has reached
the stage of working to drink. Today Checking out
non-menial servants are also habit­ whether your
uated to alcoholic drinks. With the
patronage of the elders of the com­ drinking is a problem
munity, alcoholism, has gradually
affected every one of the members — Do you feel the need to have a
of this community including the
' drink everytime you are exhaus­
women. Illiteracy is another factor to
ted, tense, depressed or lonely?
consider when dealing with alcohol — Do you drink alone or early in the
abuse. Immoral sexual contact has
morning or more than thrice a
also encouraged the continuation of
week?. '
alcoholic habit in 16°/o of the women — Are you consuming more than 3
studied. Lack of willingness to
"larges" on any single occasion?
reserve their income for better living
encourages them to waste a portion — Under the effect of liquor do you
tend to become irritable, garru­
of their income on drinking liquor.
lous, silly, abusive or violent?
Among the alcohol using women
—
Does stopping drinking cause you
6O°/o use snuff which is deposited on
to become anxious/morose or
teeth and 9O°/o are betel chewers.
have trembling hands/blackouts/
The prevalence of other unhealthy
unsteadiness/sleeplessness/
habits also indicates their negligence
lack of appetite?
with regard to their health. It is no
doubt that alcoholism will become an — Has there been a parent/brouncontrollable disease among the
ther/sister/son or daughter who
had a serious drinking problem?
women folk of this community in the
days to come. It is the right time for If the answer is yes to any one of the
the Government agencies and volun­ these, please check with a doctor
tary organisations to act and to about your drinking habit.
rehabilitate the women folk of this
Chakkiliyar community.
a
HEART 1

BRAIN 7

Unstable Blood
pressure,
Irregular Pulse, ■
Enlarged Heart
PANCREAS 2

Cell damage
resulting in loss of
memory, confusion,
halluci­
nations

Painful
inflammation

LUNGS 8

LIVER 3

Severe swelling,
Hepatitis
Cirrhosis
MUSCLES 4

Weakness, Loss
of muscle tissue
STOMACH 5

Greater chance
of infections
including T B
GENITALS 9

Temporary
impotence
SKIN 10

INTESTINES
Lining becomes
inflammed, Ulcers

Flushing.
sweating,
bruising

NERVOUS SYSTEM 6

BLOOD 11

Tingling and loss
of sensation in
hands and feet

Changes in Red
blood cells

__ — from Alcohol and Alcoholism. TT Ranganathan Clinical Research Foundation, Madras. —

12 • HEALTH ACTION N0VEMBEH1988

The new lotus eaters
The classics refer to a band of sold­
iers under Ulysses who lost them­
selves to the problems of the world
by eating lotus stems which causedthem to reach rapidly a state of bliss
that was reinforced with fresh doses
of the repast.
Young people today are alarmingly
taking to chemical means of over­
coming the problems in life, thus
becoming the new lotus eaters.
While experimental abuse of drugs is
common among youth everywhere
(more than 5O°/o in urban Indian
boys) if this occurs on the back­
ground of an unstable personality, a
large number of stresses in the
individual's life at that time or in the
face of an emotional disturbance, a
likelihood of drug dependence
developing is considerably increased.

Not all Drug Addicts, however,
come from disrupted or unhappy
families — sometimes a drug prob­
lem in a* previously healthy person
can cause the family to become dis­
turbed.
Not pattern of drug abuse fre­
quently observed among youth is
that initially legal drugs (such as
tranquillisers) are abused, then alco­
hol and/or tobacco, progressing to
cannabis or marijuana and finally to
illicit substances like heroin.
Peer pressure or persuasion by
friends (the so called 'bad company"]
is not the most important factor in
making a person an addict though
some ruthless antisocial elements
undoubtedly make a bad situation
worse by taking advantage ofan indi­
vidual's weakness.

After the malady develops the
best outcome arises in children of
parents who do not allow their alarm
over the habit to get the better of
them, do not submit to their child­
ren's demands for more drugs/
money and yet keep channels of
communication open. Parents who
delay their children's treatment or
are highly secretive about the habit,
often do their children harm — which
can prove lethal.

helped and Priya is beginning to pick up
the broken pieces of her life. She is now
reunited with her two children and is try­
ing to make her marriage work.
In urban India, alcoholism has for
■long been regarded as a male affliction.
Not any more, as psychiatrists in the
country's metropolises report. What be­
gan as a trickle <5f female patients com­
ORE than anything else, this ing in for treatment is now a widening
letter from her 11-year-old stream. An estimated three out of 10 al­
daughter put Priya Singh, a coholics in many established clinics
Delhi housewife, back on the across the country are now women.
Unfortunately, only now is the prob­
road to sobriety. "That was my rock-bot­
tom. I decided that I had to do something lem being taken seriously. At the Na­
■ about my alcoholism." But after drinking tional Institute of Mental Health and
. heavily for almost two years—something Neurosciences (nimhans) in Bangalore.
that pushed her marriage to the brink— the country's premier neurosciences re' she knew getting back to normal wasn’t • search institute, around 10 female pa­
going to-be easy. She.visitcd afehabilita-, tients used to report for treatment every
jion cepjrc. and after several relapses-fi- month Just five years ago. Now. there are
:n'aUy%Ccecded ingiying up alcohol alto- 30 to 35 every month and the institute
I gether. Frequent attendance at the. has been forced to open a separate outL^Jqoholics Anonymous(-aaJI meetings : patient department for women alcoByARCHANA JAHAG1RDAR

Dear Mom. missing you tons. Aniland [don't
. get to see Daddy much as he is always travel■ ■ ling. It ‘snofun here. Mom, please stop drink­
ing. Ifyou do that, we will oil be able to live to­
gether again. It will be so much fun. I hate
- school here. Write soon. Loveyoulots, Anjali.

M

j Nowadays, three out of 10 alcoholics reporting
INDIA TODAY ♦ -APRIL 15, IW5

holies. Explains Dr I.A. Shariff. head of
the Department of Psychiatric Social
Welfare at nimhas'S: “Nobody speaks or
makes public this problem because, in
the Indian situation, for a woman to be
alcoholic is considered worse than being
a prostitute ora criminal. There is social
ostracism. So. the way most women cope
with it is by hiding their problem."
In Bombay, as the problem escalated.
the Kripa Foundation, which has seven
centres across the country for treating al­
coholics and drug addicts, had to open a
separate section for women. Part of the
reason, according to Ossie Pereira, co­
founder of the foundation, was that "most
alcoholics, men and women, haven't been
ab to handle sex normally. So if I had a
mixed centre. I would have to start a ma­
ternit}’ ward instead." And Dr D. Mohan.
head of the Department of Psychiatry. All
Indialnstituteof Medical Sciences (arms), '
predicts that by the year 2000, overall In­
dia is likely to see one female alcoholic for
every three male alcoholics—a ratio
prevalent in the West today.
So. why exactly are women in India
hitting the bottle in such alarming num­
bers? There is no clear answer. Research
worldwide points a finger at a gene
which could make alcoholism heredi­
tary. Others talk of a certain pgt—-plage
of people who c' c exposed to alcb_ol au­
tomatically becoming chemically de­
pendent on it For instance, the’ who esti­
mates that one out of 25 people who
drink will turn alcoholic as a result.
Part of the reason for the dramatic
rise in women's dependency on alcohol is
simple—they are now more exposed to
alcohol socially than at any timein therecent past. It is no longer taboo for women .
to drink in public, and in parties it is the
done thing. Confirms Rakesh Ghildiyal,’
associateprofessorofpsychiatryatKEM,-- Bombay: "Alcohol is a bigger problem
amdnpwChien than any other drug be­
cause it now has social sanction.”
Others, like Delhi-based psychiatrist
Dr Avdesh Sharma, feel that it could be
modern-day problems which are driving
women to alcoholism. The most cited
reason is stress. The balancing act re­
quired to keep ahomeanda career going
has been known'to take its toll. Con.versely, a workaholic husband could^'"
lead to a depressed and lonely wire’s.-’'-.-:-?
home. RaChna '-Sharma, 381 would
agree. Three grown-up children meant
more time in her hands and a loving but" .
hopelessly busy husband had no time to
fill that.The bottle provided the initial so- .
lace and then the addiction took oyer.
If lonelinessiscreepingsteallhilySito. •

treatment in established clinics in

Indian lives as joint families—and even
nuclear ones—break up. it is com­
pounded by an increasing identity crisis
faced by urbanised Indians. Are we as cool
and hip as our western counterparts?
Hot-shot marketing executive Sonia Ma­
lik. 40. wanted to be all that and more. “I
started drinking to deal wi th stress and to
be in with the crowd." The only problem
was thatherdrinkingcontinued well after

alcoholic faces are very different from
what a man goes through—this needs to
be addressed. Her drinking is even more
hidden than his. thus making it all the
more difficult to detect. Says Sonia: “I
used to stay late in the office and drink se­
cretly. but I was always very controlled in
public—a woman has to be. I would fall
apart the minute I reached home.”
Home, unfortunately, is not where

WHY TREATMENT IS TOUGH
□ Indian women are usually closet drinkers, so identification and treatment is
often delayed or even denied.
H Alcohol is often abused, with prescription pills making it a deadly cocktail.
■ Complete lack of rehabilitationcentresandsupportgroups.
B Families are rarely supportive..

proved as short-lived as the fizz in a glass
of beer. Atruncatedcareerandseveral vi­
olent fights later, the Khannas realised
the severity of the problem.
Career and family life are not the
only things at risk. Studies conducted in
the US show that spontaneous abortions
and early miscarriages are more likely to
occur among alcoholic women. Preg­
nant women in their first trimester are at
a risk factor of 12 per cent even if they
are modest drinkers. And the risk of con­
genital abnormalities is estimated to be
ashigh as 3 2 percent for women who are
heavy drinkers. Worse, children are
found to be more seriously affected by a Icoholic mothers than fathers.
HE problem also persists because
there are no stereotypes, no target
groups. And unfortunately, no safe
groups either. Atoneend of thespectrum
are groups like tribals and plantation
workers, from whom come 48 per cent of
women alcohol users. Women in the
weaker economic strata have always con­
sumed alcohol. Now, there is the new ad­
dition of the middle classes, which could
include anyone from a collegestudent to a
bored housewife. Says Karl Sequeria.
joint director of the Bangalore-based
Freedom Foundation, a rehabilitation
centre: "I find that more and more young
college-going women are drinking heav­
ily. a cause for grave concern."
So. while recognition is often myopic.
treatment runs into a blind alley. Women
face specific guilt trips and problems but
rehabilitation centres and support
groups are dominated by. and are often
for. men. Rape, manipulation and sexual
baiting are all part of a woman alcoholic’s
routine. With such a negative gender
background, a woman with this problem
finds it difficult to enter a predominantly
male group. Even an immensely success­
ful support group like aa faces this prob­
lem. There is now a crying need for sepa­
raterehabilitationcentres for women, like
the one mmhans has begun.
The silver lining to this dark cloud is
that sobriety gives recovering women al­
coholics an unparalleled high. Every ex­
perience is savoured with a new enthusi­
asm and talk of a new life. Sonia, who
was considered dead for all practical and
financial reasons, is today at the centre of
all family decisions. Priya is the emo­
tional anchor for her two teenage chil­
dren. Most of them further the cause of
sobriety by keeping their doors open to
fellow alcoholics. —»uh ARUN katiyar

T

everj’one went home. And often, just as
others were beginning their day—a pat­
tern common among alcoholics.
Denial and lack of empirical data
have led to the problem turning even
more serious. Says Ashwini Aiktwadi. an
addiction counsellor in Delhi: "We have
this neat policy of denial. Indian women
do not have sex. they don't have orgasms
and they don't drink. We simply solve the
problem by denial." The issues a woman

Indian cities are nomen.

the support system is anymore. Hus­
bands could be alcoholics or. at the very
least, the initiating party. At the other
end of thescale could be an alcoholic par­
ent hovering in the background. Rahul
Khanna. 40. became the target of his
wile's criticism about five years ago. Iler
complaint? That he drank too much. In
tvhat she thought was an attempt at get­
tingcloser to him. Deepli. .55. too started
drinking. "We began to share a few
drinks together and things began to look
' more cheerful." she recalls. The cheer

111 Bi'inb.iy 111111 SARtntA RAI In Bangalore
l diangcd to pro-

British Journal of Addiction

Members of the International Advisory Board of the British
Journal of Addiction

Published by the Society for the Study of Addiction

Editor: Griffith Edwards

ProfessorS. W. Acuda, Department of Psychiatry, Kenyetta National Hospital, P.O. Box 30588, Nairobi, Kenya.
DrJ. M. Bertolete. Luis de Camoes. 172. 9000 Porto Alegre - R.S., Brazil.
Dr Sheila Blume, M.D., 284 Greene Avenue, Sayville, New York, N.Y. 11782, U.S.A.
Dr Kettil Bruun, Sociologiska Institutionen, Stockholms Universitet, S 106 91 Stockholm, Sweden.
Dr med. J. Casselman, Psychiater. Leopold 111 Laan 14, 3030 Heverlee, Leuven, Belgium.
DrJohn E. Dobson. Community Mental Health Service, The Arts Centre, P.O. Box 845. Christchurch 1, New Zealand.
ProfessorJ.C.Ebie.HeadofDepartmentofMcntalHeakh.UniversityofBenin.UniversityofBeninTeachingHospital, P.M.B. *

Professor L.S. Gillis. Head ofDepartmentof Psychiatry. UniversityofCape Town. GrooteSchuur Hospital. Observatory. Cape
Town. South Africa.
DrJenyjaffe. 29 Old Army Road. Scarsdale. N.Y. 10583, New York, U.S.A
Dr Lynn T Kozlowski, Ph. D., Smoking Research Programme, Clinical Institute, Addiction Research Foundation, 33 Russell
Street, Toronto. Ontario M5S 2S1, Canada.
Dr E. Lichtenstein, Department of Psychology, University of Oregon, Eugene, Oregon 97403, U.S.A.
Dr Davinder Mohan. Associate Professor. All India Insititutc of Medical Sciences. New Delhi. India.
DrV. Navaratnam.Director.NationalDrugDependenceRescarchProject.UniversitiSains, Minden, PaulauPinang, Penang.
Malaysia.
Dr Vichai, Poshyachinda, Institute of Health Research, 7th Floor, New Science Building, Chulalongkorn University,
Bangkok 5, Thailand.
Dr Alvaro Requena. Centro Medico de Caracas. San Bernardino. Caracas 1011, Venezuela.
Dr John Saunders. Department of Medicine - Drug and Alcohol Services. Royal Prince Alfred Hospital, Missenden Road.
Dr Ole-Jorgen Sltog, National Institute for Alcohol Research. Dannevigsveien 10, Oslo 4, Norway.
Dr R. Smart. Addiction Research Foundation, 33 Russell Street. Toronto. Ontario M5S 2S1, Canada.
DrH. Suwaki, Department ofNeuropsychiatry. Kochi MedicalSchool, Kohasu. Oko-cho, Nankoku-shi, Kochi 781 -51.Japan.
Mr Archer Tongue, Director. International Council on Alcohol and Addictions, Case Postale 140, 1001 Lausanne,
Switzerland.
Professor W. K. VanDyk. Psychiatric Clinic. Oostersinje! 58, Gronigen. Netherlands.
Dr I. Wald, Psychoneurological Institute. Sobieskiego 1/9,02-957 Warszawa, Poland.
Dr Dermot Walsh, The Medico-Social Research Bbard. 73 Lower Baggot Street, Dublin 2. Northern Ireland.
Dr Rolf Wille, Aentlicher Leiter, Jugend-und Drogenberatung, Stadtjugendamt Munchen, Augustenstr. 47/Rgb., 8000
Munchen 2, West Germany.

Information for Contributors:
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dependence on alcohol and other drugs. Papers arc accepted on the understanding that they are
subject to editorial revision, and that their contents have not been published in whole or in part

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Unit, Institute of Psychiatry, 101 Denmark Hill, London SE5 8AF, U.K.

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e

SMOKING IS A HEALTH HAZARD

TOBACCO smoking is injurious to health because of nicotine and

carbon monoxide contained in the smoke.

These particles are

drawn into the nose and throat during smoking and into the lungs

by inhalation.
It is generally accepted that nicotine raises the blood
pressure, heart beat, heart work and blood cholesterol.
Nicotine action eventually makes a person prone to heart attacks

and strokes.

Researchers say nicotine reaches a smoker’s brain in

six seconds as opposed to 14 seconds when injected intravenously.

Carbon monoxide is equally harmful.
It reduces the free
oxygen available in the blood which is very essential for the
proper functioning of not only the heart muscles but the entire
body.
It makes attacks, such as, the ischaemic heart diseases more
common amongst the smokers.
Smoking leads to diseases:

Smoking is the single most preventable cause of lung
cancer, emphysema (serious lung disease), chronic bronchitis,
ischaemic heart diseases and peptic (stomach) ulcer. The trend

of scientific evidence has been consistant to indicate that
tobacco smoking particularly cigarette smoking shortens life.

many a people, it is opined, needlessly become sick, disabled or
die before their ’time' due to their smoking habit.

Lung Cancer
Cigarette smoke paralyses the tiny hair (cilia) which
line the bronchial tubes, that sweep foreign particles out of lungs.

Without this protective action, healthy lung tissues can be injured,
even destroyed by particles which remain in the lung.

Statistics from various countries including India reveal
that cigarette smoking leads to cancer of the lung. In fact, the
larger the number of cigarettes smoked and the longer they are

smoked, the greater are the risks to the smokers. On the other
hand, studies show that in those who stop smoking, the risk of

lung cancer decreases directly in proportion to the length of time
they have stopped smoking.
It has also been found that pipe,
cigar and bidi smokers run a lesser risk of lung cancer.
But they
are more prone to cancers of the lips,
non-smokers.

tongue and mouth than

Bronchitis and emphysema
Bronchitis is inflammation of the air tubes. In chronic
bronchitis, there is a continuous inflammation of the air tubes
because of irrigation by the smoke. The lining membranes of the
air passage get thickened and abnormal.
.. .2

2

Surface’ of the bronchial tubes is lined with hair like
cilia (fine hair).

These fine hair help the lungs expel irritating

or poisonous particles.

Smoking paralyses and then destroyes the

cilia which play a very important protective function for the

lungs.

It is commonly agreed that cancerous lesions are most

frequently found along the bronchial tube lines, particularly in

places where the exposure of smoke is intense.
Emphysema is another respiratory disease which mostly
affects the cigarette smokers.

Damage to lungs is caused because the

cilia (fine hair) tend to diappear leading to hyper-inflation of
lung tissues.

working.

The patient has to struggle to keep the lungs

He or she requires big effort at each breath.

Smoking also affects the larynx or voice box. The
changes at the voice box are similar to those that occur in the

air passages and in the lungs. These irriations cause swellings

and result in ’smoker's cough'.
phelgm.

Cigarette smokers usually pass on

It has been observed that symptoms of cough and expectora­

tion are closely associated with smoking.
side rapidly in those who stop smoking.
Ischaemic heart disease

These symptoms usually sub­

This is condition in which heart muscles receive less
blood supply through coronory arteries.

Smoking is one of the

factors which affects heart and the blood vessels.

It is often

seen that smoking increases the severity of angina pictoris-a

condition which usually precedes heart attacks. Smokers die more often
from coronary heart attacks. Mortality from ischaemic heart

diseases is greater in cigarette smokers than in non-smokers.
It
increases with more cigarettes smoked. It is lower in cigarette
smokers who stop smoking than in these who 'love' smoking.

Among the younger smokers the risk of death is two to three
times more than in non-smokers.
Peptic (stomach) ulcer
Tobacco smoking delays the healing of stomach ulcer,
increases the pain, and the size of the ulcer. Patients who smoke
wh show a poor respons to the treatment.

Smoking in pregnancy
Smoking during pregnancy is harmful. A pregnant mother
who smokes, can endanger the life of her child. She is likely to
have an undersized baby and run a greater risk of death during
child biith. The risk to habits of mothers who had smoked during
pregnancy increases by two times. Babies may be still-born or die soo;
after death or there may be an abortion.
In fact, one in five
babies lost can be saved if their mothers do not smoke.
. . .3

3

Socio-psycho aspects
Smoking for fun or to calm one's nerves is a costly price to
pay.

Young people often take to smoking in imitation of older

people or as an expression of a subconscious wish to be like them.

Older children and youth want to be accepted by their friends and
associates. Often friends dress alike, talk alike and have other
behavious in common.

conform.

Smoking may be part of this attempt to

Non-smoking could also be part of a group pattern.

As a

means of relaxation or fun on individual is responsible for his/her
own decisions. But never forget that in a few.years teenagers will
be fathers and mothers. Then they will have a responsibility to

their own children. They will have to do everything now.to keep
their children healthy and live as long a life as possible.
Let us look at facts :
Smoking is a big health hazard.

The risk of contracting any

one or more of the diseases through smoking increases with the
number of cigarettes smoked.

Evidence has proved that lung cancer

is often fatal, unless found early.

All medical scientists agree

it is ’smarter' never to develop the smoking habit. Doctors
advise that if one does not smoke, things are in his favour,
healthwise.

Moreover, smoking costs money.

To conclude, the hazards of smoking are Many:-

* The greatest single cause of preventable death is
cigarette smoking.

* Cigarette smoking may lead to lung cancer.
* Cigarette smokers are more prone to heart disease.

* Children of women who smoke during pregnancy are likely
to be adversely affected.
* The earlier the people start smoking, the greater the
risk of heart trouble.
to avoid smoking.

Teenage years are very important

* The early effects of smoking may handicap teenagers who
go in for competitive sports.

* Cigarette smoking can lead to the cancer of the lips,
larynx and oesophagus.
Hence, smoking or health, the choice is one’s own. To not to
smoke is, however, a better and a wiser choice, in one's own interest.

Source: Swasth Hind - March/April 1980

Hh

‘*

Globalization and Increasing Trend of Alcoholism *
I.

Introduction
Although alcohol consumption has existed in India for many centuries, the quantity
patterns of use, and resultant problems have undergone substantial changes over
the past two decades. Alcohol consumption produces individual health and social
problems. The global burden of disease from alcohol exceeds that of tobacco and is
on a par with the burden attributable to unsafe sex world wide (Global Status
Report on alcohol, WHO, 1999). Although recorded alcohol consumption per
capita has fallen since 1980 in most developed countries, it has'risen steadily in
developing countries and alarmingly so in India. The per capita consumption of
alcohol by adults of 15 years and above in India increased by 106.67 percent
between 1970-72 and 1994-96!

2.

Alcohol industry
Based on beverage type the Indian alcohol industry has three prominent sectors:
The IMFL (Indian Made Foreign Liquor) and beer sector, the country liquor sector,
and the illicit liquor sector. The IMFL and beer sector is the most visible part of the
alcohol Industry, with a few large companies with multiple production units and
nation wide marketing networks. These companies control much of the market.
They have been present in India for several decades and have established several
brand names regionally or nationally. These companies aggressively advertise and
promote their brands and their corporate identities, and constantly monitor and
protect their products'and market shares. They are also cash rich, since profit
margins are high in this industry.

Beginning in 1992 under liberalized industrial laws, some Indian alcohol
companies developed collaborative tics with international corporations. Joint
ventures have been established to use local production capacity to manufacture
international brands under a technology transfer and licensing system. These joint
ventures have served a dual purpose: they have brought international alcohol
brands to India, and they have utilized the existing production and marketing
strengths of Indian Industry. Hence they have been mutually supportive. Nearly all
of the major transnational alcohol companies now have a presence in India and
many internationally popular brands of whisky and beer have become available.
The upper middle and higher socioeconomic classes now purchase these ‘famous’
brands locally rather than having to carry these back from trips to other countries
or to buy them from illegal importers. The price of these products remains high,
but since they carry high social prestige value, there is good demand in this
premium range.
With liberalization and globalization, foreign liquor has become freely available.
The IMFL and beer industry spends much effort and money to promote and
advertise their brands. Since direct advertisement of liquor was
not permitted in the print and electronic media, the industry has found methods to
advertise indirectly (Saxena, 1994). Alcohol brands are advertised in the form of
same or similarly named other products (e.g. mineral water, soda, and playing
cards) made by the same company. The advertisements
★Compiled by Mr. S D Rajendran, Community Health Cel! for the Asia Social Forum, 2'"1 - 7"‘ January 2003,
Hyderabad. India.

display the alcohol product prominently. In addition, beverage ads have become
common on satellite cable television beamed to India from neighboring countries.
I MFI. and beer producers also financially sponsor major sporting events that attract
sustained media attention, including live television coverage of the event. With its
new international linkages, the Indian alcohol industry has also got into the
entertainment and fashion world. It is now common for a liquor company to
sponsor a fashion show or musical event. Hence the Indian IMFL and beer industry
has initiated a high level of sustained marketing and promotional activities and
these have become especially aggressive in the 1990s.
The Indian alcohol industry produces a large amount of revenue for the
government. It has been estimated that direct collections of excise and sales tax(are
approximately USS 5 billion per year for the country as a whole. In Karnataka, it is
approximately Rs. 2400.00 crores per year. States derive as much as 25% of
money from alcohol sales for their annual budget. Besides the generation of legal
revenues for the government, the alcohol industry is- thought to create an
approximately equal sum in “black money” (hat takes the form of bribes,
protection payments and profits from illicit alcohol. This gives the alcohol industry
enormous political power and clout, which may be used to help influence and
maintain government policies ‘beneficial’ to the industry but harmful to the people.
Studies indicate that the losses borne by household, states and the nation out weigh
financial gains.

Table 1: Annual Distilled Spirits Production in India, by Year (April to March)
Year

1982-83
1983-84
1984—85
1985-86
1986-87
1987-88
J988-89___
1989-90
1990-91
1991-92
1992-93
1993-94
1994-95
1995-96

AMOUNT
OF
ABSOLUTE
ALCOHOL
PRODUCED (IN THOUSANDS HECTOLIRES)
2862.55
3104.75
3310.64
3407.49
3204.80
3432.48
____________ 4190,45
No data available
No data available
4895.00
3467.00
3626.00
6056.00
7888.04
1

Source: Alcohol and Public Health in 8 developing countries, WHO, Geneva, 1999.

3.

Alcohol - Related Problems
It is probable, given equal amounts of drinking, that developing countries like
India experience more problems than developed-countries (Saxena, 1997). Among
the reasons for this may be such things as a highly skewed distribution of drinkers
in the society, the prevalence of nutritional and infectious diseases, economic
deprivation, more hazardous and accident-prone physical environments, and lack
of any organised support system. Although conclusive scientific evidence for
alcohol related health and social problems is lacking for India, (here are enough
2

indications in the available literature to infer that these are substantial. Women’s
sanghas participating in a women health empowerment training in several districts
in Karnataka have consistently said that (he biggest problem they face relate to
alcohol abuse. Community health groups in different parts of the country also
recognize the importance of the problem. The rapid rise in alcohol consumption in
recent years has increased the likelihood of further growth of the following health
problems in the years to come.

3.1

3.2

Health problems include
•

Cirrhosis of the liver and premature death

°

Cardiomyopathy

•
o
»
o
•
•
•

Cancer of the upper gastrointestinal tract
Pancreatitis
Cognitive impairment or neuropsychiatric disorders
Road traffic accidents and injuries
Nutritional deficiencies and infections
HIV infections and STD
Hypertension

SOCIAL PROBLEMS
Excessive drinking produces a variety of closely inter related social problems in
India. For ease of description these have been divided into the following broad
categories.

3.2.1 Violence and Crime
Violence within and outside the home is frequent in India and a substantial
proportion of it is alcohol - related. Wife beating and child abuse under the
influence of alcohol are common, and street brawls and group violence happen
often after drinking

3.2.2 Workplace effects
Heavy drinking affects work performance in a number of negative ways. When
compared to their sober counterparts, drinkers are more frequently absent, are less
efficient, have more accidents at work, and also show maladjustment with other
workers which leads to over all decreased performance.

3.2.3 Economic Effects
While alcoholic beverages are less expensive in India, their purchase may still
require a substantial portion of a poor persons meager income. With one in three
people in India falling below the poverty line, the economic consequences of
expenditures on alcohol attain special significance. Besides money spent on
alcohol, a heavy drinker also suffers other adverse economic effects. These include
reduced wages (because of missed work and lowered efficiency on the job),
increased medical expanses for illness and accidents, legal cost of drink-related
offences, and decreased eligibility of loans. Most individuals with severe alcohol
dependence find it difficult to reduce their expenditure on drink, and hence their
families often must do without essential necessities. Although the overall economic
3

effect of alcohol use at the national level has not been estimated, it is likely that it
represents a substantial proportion of India’s national income.
3.2.4 E(unity Effects

Excessive drinking by one or more family member results in several negative
consequences for others in the family, especially for the wife and children of a
male drinker. These effects arc particularly serious for poor families. As has been
mentioned above, much of the family income may be used to buy alcohol, wages
may decline, and the drinker may eventually lose his job. In such situation the wife
and children arc forced into work, often in low paid, hazardous jobs. Children may
be unable to continue their schooling and may also suffer from nutritional
deficiencies because there is not enough to eat at home. Wife and child battering
are common, which lead to physical and mental trauma. Failure of (he man to use
contraceptive methods often leads to unwanted pregnancies, further increasing
family size. These factors contribute towards greater poverty, often to the point of
destitution.
Strong family ties and social disapproval of divorce save many of these families
from a formal breakdown, but the prevalence of intermittent or prolonged marital
separation, as well as suicide, in heavy drinking families is high. Problems laced
by wives of alcoholic men have been studied scientifically by Ganihat ct al. (1983),
but the many descriptive accounts by the lay press offer more vocal testimony of
these phenomena. Wives of alcoholic men show a high degree of depression
(Dcvar ct al., 1983) and of suicide (Ponnudurai & Jayakar, 1980)

4.

Govt, of India Response
Govt, of India should seriously think about the alarmingly increasing alcohol
related problems and work towards developing a clear-cut and comprehensive
Alcohol Policy.

The Indian Charter on Alcohol should be adopted with the following principles,
which would be agreed upon by all the health ministries of the Slates:
1. All people have (he right to a family, community and working life
protected from accidents, violence and other negative consequences of
alcohol consumption.
2. All people have the right to valid impartial information and education,
starting early in life, on the consequences of alcohol consumption on
health, the family and society.
3.

4.

All the children and adolescents have the right to grow up in an
environment protected from the negative consequences of alcohol
consumption and, to the extent possible, from the promotion of alcoholic
beverages.

All people with hazardous or harmful alcohol consumption and members
of their families have the right to accessible treatment and care.

5.

All people who do not wish to consume alcohol, or who cannot do so for
health or other reasons, have the right to be safeguarded from pressures Io
drink and be supported in their non - drinking behavior.

National Master Plan
The government of India formed an expert committee in 1986 to develop a
comprehensive strategy for reduction of both supply and demand of all substances
of abuse, including alcohol. The details of the master plan and its position on
alcohol - related issues are not yet available. Again Govt, of India should review
the National Master Plan and revise it for up to date condition. This plan should be
implemented through Primary Health Centres and through health workers. It
should contain the following broad areas:

1. Training to PHC doctors and Health Workers
2. Raise awareness of the effects of alcohol in rural areas
3.
Arrange community based de-addiction treatment involving family members
and the community
4.
Proper after care should be provided with the family and community support
5.
Introduce Life Skills programme in high schools to increase the ability of
young people to meet the needs and challenges of every day life and avoid high
risk behaviors
6.
Provide and / or expand meaningful alternatives to alcohol and drug use and
increase education, training and networking among community development
workers ad organisations.

In monitoring and implementing the above plan, the local NGOs and community
action groups should be encouraged to participate fully.

6.

Conclusion
Globalisation is based on commercial interests, which want to increase the
consumption of alcohol. They promote the expansion of drinking into new social
context and situations. Their central perspective is that of the market, seeing
developing countries as 'emerging markets’. Drinking is shown as a symbol of
‘cosmopolitan outlook’. European and North American life styles are presented
glamorously and attractively. We have to counter them. Globalisation has brought
in global methods of manufacture, distribution, advertisements and promotion of
alcohol consumption. We have to adopt or adopt global strategies to reduce alcohol
consumption and its ill effects on the health and social life of our people. While
interventions for primary prevention and community health based approaches are
required along side medical deaddiction approaches, it is imperative that social
movements also address the broader policy aspects and economic underpinnings of
the problem.

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W APP A
Workplace Alcohol Prevention
Programme and Activity

KARNATAKASRATEROADTRANSPORTCORI ’ORATION

BANGALORE

WAPPA to ARMADA

INDIA

Workplace Alcohol Prevention
Programme and Activity

to
Association of Resource Managers
against Alcohol and Drug Abuse

( Statutory Warning!)
None for the Road and NOT one for the road

should be the policy of transporters towards alcohol
consumption notwithstanding their personal predilection

The path from WAPPA to ARMADA is the appropriate path for
Industrial enterprises to follow for ensuring Accident Reduction,
Increased Productivity, Reduced Absenteeism and Worker
reach out programme

CONTENTS

INTRODUCTION

Page

3

INTRODUCTION

4

GOALS AND OBJECTIVES

WAPPA-KSRTC INITIATIVE FOR
WORKER WELFARE & PASSENGER SAFTY
UNIQUE FEATURES OF THE POLICY
OF THE CORPORATION
EVOLUTION OF AN ANTI-ALCOHOL
POLICY IN KSRTC

5

w

In KSRTC the Workplace Alcohol Prevention
Programme and Activity (WAPPA) started on 30lh January 1997
essentially as a Worker reach out programme. In view of the
unsettled industrial relations obtaining at that time and the stand
off between the management and a section of the labour who
chose the path of militancy, the need was felt for a programme
>to reach out to the worker and look after his health and
welfare and that of his family. This unique proactive
vigilance programme was also aimed at curbing indiscipline
at the workplace responsible for losses to the Corporation.

8

9
11

DE-ADDICTION POLICY

KSRTC’S STRATEGY TOWARDS EMPLOYEES
IN DIFFERENT ZONES
COSTING AN ACCIDENT :
THE HASSAN EXPERIENCE
LEGAL PROVISIONS

RESULTS ACHIEVED

CONCLUSION

KSRTC & I L O
ADVANTAGES OF ARMADA

14

18

21

22
24

®

25
26

27

PROGRAMME OF ACTION

RESOURCE PERSONS TO BE CONTACTED
FOR FURTHER INFORMATION

28

Inauguration of the De-Addiction Centre at Jayanagar

[Goals and Objectives

J

Every enterprise is concerned with increased production,
worker welfare, accident prevention in the workplace and
improving its profitability and cutting down losses.
A transport organisation having a statutory mandate to provide
safe, reliable, adequate and economic transport service to the pub­
lic at large is duty bound to ensure that passengers are transported
from one place to another with utmost safety and comfort. The
slogan Driving and Drink Do Not Mix needs to be enforced strictly
in any public transport system.
For the Police and other Enforcement agencies concerned
with Road safety, accident free roads mean better traffic
regulation, less work for themselves and smooth passage for the
road users. For the Industrial enterprises this means reduced
monetary losses and compensation to be paid to the affected.
For the public of course this means reduced suffering and
misery and physical injury.

At Tavaregere in Raichur District on
13-02-1998, 12 persons died and 35 got
injured when a KSRTC bus with POLICE
personnel on election duty had a head on
collusion with a metador van. The KSRTC
driver who also died on the spot, had consumed
alcohol when the police party broke journey
for food a little while before the accident.

WAPPA - KSRTC Initiative for worker welfare
and passenger safety.
Karnataka State Road Transport Corporation (in short KSRTC
or the Corporation) is a state owned public sector
undertaking dedicated to meet the needs of the travelling people of
the South Indian state of Karnataka. Established under the Central
Road Transport Corporation Act, 1950 with the prime objective of
'providing the people of the eighth largest State in
the country with economic, reliable, safe and adequate passenger
transport facility, the Corporation is currently being restructured
into smaller independent corporations for better administrative
control. Together, the original monolith transported 6.5 million
passengers running 11,227 buses over a total of 3.43 million
kilometers every day. The Corporation had a total revenue
collection of about Rs. 12,080 million in a year. With a total strength
of about 70,000 employees on its rolls, the combined Corporation
was one of the biggest employers in the State. For ten years the
Corporation made losses, year after year, accumulating to over
Rs.4,500 Million. Rank indiscipline and militant labour union had
stifled most activities in the Corporation and public demands for
privatizing the nationalized transport services became strident over
pe years. The restructuring process was initiated in 1997 to
set matters right and saw the birth of Bangalore Metropolitan
Transport Corporation for the City of Bangalore and North West
Karnataka Road Transport Corporation for the North West region
of the State. The North East region too is to get its independent
corporation soon. With the restructuring, several new initiatives
were also launched to turn the Corporation round. WAPPA was
one among them.

Indiscipline needed to be put down with an iron hand to

improve the performance in various units of the Corporation
covering one Printing Press, three body building workshops, 23
divisions, 124 bus depots and 300 plus bus stations. Alcohol
consumption was diagnosed as one of the important factors that
caused violent incidents time and again in the depots.
Workplace Alcohol Prevention Programme and Activity
(WAPPA), the unique preventive vigilance programme of the
Karnataka State Road Transport Corporation was designed to
assess the need and implement a programme of Anti Alcohol Policy
in the public transport organisation. Formulated as a worker
welfare policy to reach out to the workers in an atmosphere where
tough measures were being taken to contain the indiscipline, the
Workplace Alcohol Prevention Programme helped to win over the
workers and their family.

the Corporation. With over 400 fatal accidents in a yearly tally of
2500 accidents involving the death of about 500 persons and
injury to over 5000 passengers in a year, the Corporation has claims
of compensation running into Rs.3000 million filed against it. There­
fore, the KSRTC had to urgently formulate a policy that would
venture to arrest all the ill effects of these problems by adopting a
humane and welfare oriented de-addiction programme.

e

Alcohol abuse among Industrial workers is recognised
as a universal phenomenon, which brings down productivity and
makes the life of the employees and their family members miser­
able. In the transport sector, the life of the passengers is made
unsafe and unsecured in their journeys in public transport buses.
Any number of incidents are available to substantiate the huge loss
caused to the Corporation as a result of the employees developing
a liking for the liquor especially while on duty.
"
In a transport organisation like the KSRTC, alcohol abuse
among employees has a serious impact on passenger safety. Acci­
dents due to drunken driving brings about avoidable suffering and
bad name to the employees, exploitation and inferiority complex to
the family members, loss of valuable life, permanent impairment to
the passengers and bad image and loss of hard earned revenue to
6

Several studies and analysis were undertaken in 1996-97 in
the Corporation to understand the full import and magnitude of the
problems. It was seen that on an average one employee died in
harness every day and the average age of the deceased employee
was between 38 - 48 years. Each had a minimum of ten years
service left and the Corporation was losing trained manpower every
day. The principal causes of death were found to be heart attack,
cancer and alcohol related in that order. Stress in the family as well
as the work spot, conditions of the transport sector where peak
efficiency and performance is demanded all through the work hours
with zero tolerance for even a second of relaxation were identified
as the causes of the transport workers seeking the bottle to relieve
their tensions. The transport workers being forced to
be away from their families and homes for long periods soon
developed the habits of drinking and casual sex and brought upon
themselves attendant consequences as well as causing a huge loss
to the Corporation. The consequences of the alcohol habit had
various consequences for the welfare of the workers and their

families.
Implementation of Anti alcohol Policy started in January 1997
in combination with several other measures before the actual
restructuring process to turn the monolith loss making State

Transport Undertaking into profitable public transport
organisation came about. WAPPA has had its share in the resultant
turn around. WAPPA helped reduce road accidents,
curb absenteeism and indiscipline and increase
productivity. Astounding results were obtained with the
implementation of the overall strategy bringing down yearly
losses of the Corporation from Rs.945 Million in 1996-97 to just
Rs.26 Million in 1998-99. This proved that a large work force
could be motivated to find cost-effective solutions to the perennial
problems of absenteeism, indiscipline, low morale, road safety
hazards, low productivity and loss of revenues plaguing the
Corporation.

[ Unique features of the Policy of the Corporation ]
First Time : The Corporation spends Rs 5000 and gives
leave to the employee to join a deaddiction centre of his choice
and give up the habit.
Second Time: In case of relapse as assessed during a follow
up programme, he is referred this time again to a deaddiction
centre at his cost.

Third Time: Relapse yet again entails severe disciplinary
action which may culminate in dismissal in view of the documen- Av.
tation of the case history done in the first two efforts.

Did you know ?
■=>

20% to 25 % of accidents at the workplace are
related to Alcohol and Drug Abuse

■=>

On the job fatalities related to Alcohol and
Drug accounts for 15% to 16% of all accidents
8

[

Evolution of an Anti-Alcohol Policy in KSRTC

]

The De-addiction programme of KSRTC titled WAPPA
(Workplace Alcohol Prevention Programme & Activity) evolved
in 1996-97 necessarily as a worker reach out programme to
motivate the workers and cut down the losses of the Corporation
and bring about better discipline. WAPPA turned out to be a
unique and unparalleled programme of its kind and size. There are
' numerous institutions both in the private and public sector in India
as well as elsewhere in the world with a large labour force.and
Workplace Alcohol Prevention Programmes. Yet few
undertakings have such a wide interaction with the masses and
serious consequences for public safety. In India there are 68 other
public transport Undertakings/Corporations and KSRTC is easily
in the top five for its size of operations. One in thousand in
the world is a KSRTC daily bus traveller. KSRTC’s de-addiction
programme is an example of sustained effort in the transport sector
in India that was implemented with technical assistance from the
International Labour Organisation and other Non-Governmental
Organisations in the State and has proved successful.
Treating alcohol addiction as a health problem of its
Employees, KSRTC decided to spend time and effort to encourage
its employees to give up the bad habit. The Corporation spends
upto Rs.5000 from its coffers on each identified employee who is
deputed for treatment of alcohol abuse. The problem of alcohol
abuse is considered as a disease instead of a self acquired or
inflicted malady. This perspective has a chain effect in reducing
not only the sufferings and miseries of the employee and his imme­
diate family but also has huge cost benefits to the organisation
and ultimately benefits the society at large. Professionally

qualified people are the backbone and strength of this programme in
which addicted employees are coaxed to give up their habits
and borderline cases are stopped from going over the brink and
becoming confirmed alcoholics. The treatment schedule is a
mixture of good points of the medical and other models practised
world-wide. Emphasis is given on identification of the employee
with the Corporation. Employees are categorised into three Zones
- RED (Chronic cases), AMBER (Social drinkers) and GREEN
(Teetotallers). Separate strategies are devised to address the
problem of the workers in each of the three zones.
Employees classifications in zones :

DE-ADDICTION POLICY OF KSRTC APPROVED BY
THE BOARD ON 22-12-1998.
POLICY OBJECTIVES:

a)

To prevent Alcohol abuse among all employees as a part
of the Corporation’s commitment to the health and welfare
of its employees, operational safety and the environment.

b)

To educate the employees on the dangers and
consequences of Alcohol abuse specially in the interest of
commuter safety and Corporation and assist all employees
so desirous to overcome this habit.

AMBER (Social drinkers) : 14,500
GREEN (Teetotallers)

: 48,252

GENERAL:
It has been recognised that Alcohol abuse continues to be
a major health hazard and safety problem. As a prudent and
progressive organisation, the Corporation acknowledges that
employees’ suffering from Alcohol problems may need medical
assistance and it cannot be dealt with by disciplinary measures alone.
The Karnataka State Road Transport Corporation’s policy
therefore is intended to meet the high level of safety requirements
of the organisation to exercise reasonable control over its
employees’ consumption of Alcohol and to provide a positive

approach to employees who seek assistance to overcome

Alcoholism.

ALCOHOUS!
10

PREVENTION, EDUCATION AND TRAINING:

Within the scope of the Total Quality Management
strategies of KSRTC, emphasis will be made on integrated
Alcohol prevention education and training assistance module
covering all the employees, supervisors and officers of the
Corporation.

REGULATIONS AND CONTROLS:
The employees working in the Organisation at Depots,
Workshops and Offices understand that intake of Alcohol can have
detrimental effect on relationships, self control, judgment and
ability, to make effective decisions and to provide the intended
safe transport facility to the travelling public, and being under the
influence of Alcohol is a gross misconduct, as a result of which the
organisation can initiate disciplinary action on account of i) the
consumption of Alcohol or being under its influence within the
office or work premises which is prohibited, ii) No individual can
report for duty under the influence of Alcohol.

SCOPE OF POLICY:
This policy will apply to all the employees of the Corpora­
tion, Supervisors and Officers working at various places like
Depots, Divisional Workshops, Bus Stands, Control points and
Offices etc. It shall be the endeavor of all Corporation servants to W

implement and follow this policy faithfully.

ALCOHOL RELATED MEDICAL PROBLEMSBeing under the influence of alcohol while on duty, would
amount to gross misconduct. The organisation would expect that
any employee who considers that he/she has a problem should seek
help and advise from both the organisation and medical sources.
12

Such employees will be provided the assistance and medical help. As
a policy, the identified employees will be referred for medical treat­
ment and counselling at the cost of the organisation. In the first instance
by extending medical advance and leave to the
credit of the employee. In case of relapse after the treatment, the
employee will be referred for treatment, for a second time at his
cost and leave to his credit. Even after the treatment for second
time if there is a further relapse, severe disciplinary action will be
taken against such employees under the C & D Regulations of the
organisation. The KSRTC believes that the loyalty and commit­
ment of its employees depends upon the quality of the life they are
offered at work and home and the organisation is committed to
creating on alcohol, and drug free environment at the work place.
This would be achieved through the involvement of the employees
from different Departments, Trade Unions and NGOs.

This process would include:
raising awareness, education, training.
assistance, treatment, follow up action.
prevention programmes among the employees and their
families.

As a measure of effective control, it is proposed to provide
modern Breath Analysers to all Depots. Workshops and important
Bus Stations to check the Drivers, Conductors and other Staff for
consumption of alcohol before the resumption of their duties and
also by the Line Checking Staff on line during the line checking
programme extensively.

EXCEPTIONAL CIRCUMSTANCES:
There may be no variation to the above policy except with
written permission of the Board of Directors.

KSRTC Strategies towards employees in
different Zones
The employees in the RED Zone with acute alcohol problem
were hitherto treated with harsh punishments and inhuman
methods, instead of being shown sympathy, they were shown
apathy, teased and shouted at. The presence of an employee in the
work spot in a drunken condition invariably led to unruly scenes of
disturbance at the work spot leading to stoppage of work. The
supervisory staff had problems in preventing the situation from
escalating. Red Zone strategies include identified employees
being sent for detoxication to centres set up by the KSRTC itself at
the state headquarter or other centres run by the NGOs.
Employees are sanctioned upto Rs.5,000 as medical expenses
and leave to the extent of 30-50 days is sanctioned (even if not
to their credit leave not due is sanctioned) to cover the
treatment period.

In the transport sector even social drinking cannot
be encouraged and that is why the slogan driving and drink do
not mix. Given the relaxed regulatory mechanisms at work, it has
always been difficult to ensure that the staff does not drink
while on duty. Presence of employees at the workspot after
consumption of alcohol leads to trading of abuses and counter
abuses, assaults and other violent incidents over petty matters.
Several cases of indiscipline under the influence of alcohol have
been reported in the past. Even Depot Managers have been
seriously assaulted by employees who had consumed alcohol
just before the incidents. At times of strikes, work stoppages and
confrontation with the management and even at the time of
routine gate meetings, it has been observed that several workers
14

consume alcohol and several others are instigated or financed to consume alcohol to increase the shouting brigade.
As part of AMBER zone strategy, KSRTC has now
equippped all the depots with breathanalysers and the supervisory
and security staff conduct surprise checks to detect cases of
alcoholism on duty not only at the depot or office premises, but
also at the places of night halts of the crew and other enroute points
w in case of night services. Security and other Di visional authorities

go in the night to far off places to check out the condition of
their employees armed with the breath analysers.
KSRTC recruited over 10000 employees in the last
three years. It was necessary to address the employees in the
GREEN Zone to stay put in the Green Zone as buses driven under
intoxication have resulted in serious road accidents leading to loss
of human lives. The bus passengers have been inconvenienced and
road safety seriously compromised. The other ill effects of
alcoholism among KSRTC employees has been the worsening
employee-employer, employee-family and passenger-Corporation
relationships. Therefore armed with a formal policy resolution of
the Board of Management making drinking on duty a serious
misconduct, a concerted programme has been run since 1997 to
keep the Greens Green. The results are there for every body
to see.
ALCOHOLISM - Is a progressive disease

Any one who drinks can become an Alcoholic

If your best friend in drugs, choose a better one in 2000

For the benefit of other transport operators facing similar
problems, the three zonal strategies are summarised below.

•

Drama and skits organised by the workers for the workers and
their families

©

Seminar s and workshops at all levels

0

Regular review of WAPPA at all other staff meetings

Red Zone Strategies
•

»

Treatment at employer’s cost

•

Inculcating a feeling of collective responsibility and a sense of
ownership among workmen.

Vocational rehabilitation - a second opportunity to reform

followed by threat of dismissal.

•

Display of WAPPA Policy and printing slogans on tickets and
other publicity material including in house magazine

•

Awareness of the physical, psychological, social and occupa
tional consequences of alcohol, Experts n the area, as well as
recovered addicts.

Rei ntegration into workplace

•

Follow up and relapse prevention

•

Use of sei f help groups

•

Incentives and rewards for positive behaviour

«

Flexibility-changed shift timing, transfer to place of residence,
harnessing support from family, networking with other organi
zations providing support

•

Stress management programme for various levels

•

Information on WAPPA incorporated into all the Orientation/
Induction training programmes organized by the seven in house
training institutes.

Amber Zone Strategies
•

Facilitating self change

•

Early identification

•

Training staff in communication and assistance skills

•

Motivating and encouraging supervisors to understand
their roles

•

Assessing and improving their awareness of early signs of
non-performance

•

Working with the families and medical personnel to identify
early social and medical problems

Green Zone Strategies

•

Awareness programme for all employees

•

Consequences of alcohol ism on the workplace shared in
a simple and understandable manner
16

Recovered employees... ■■

programme.

[ Costing an Accident : The Hassan experience ]
Hassan is one of the 23 divisions of the Corporation, where
WAPPA was implemented with full force and commitment.
Actions taken to implement WAPPA sincerely in the division brought
rich dividends by decreasing the number of road accidents.
As an example of good practice, the Hassan experience is to be
commended for the turn around achieved amidst organisational
changes, protecting the workers from the social evils and assisting
them in performing better. A systematic evaluation was done in
1997 in Hassan to assess the cost of an accident involving a public
bus. All costs incurred by the Corporation concerning each and
every accident that occurred in 1997 in Hassan was compiled and
the average cost of an accident (major, minor or fatal) was worked
out. Hassan division has both hilly regions as well as plains. In this
division out of a total 539 schedules 278 were operated
as urban and semi urban services. The division had 601 buses oper­
ating out of eight depots and there are 3367 employees
consisting of 1284 drivers, 1032 conductors, 630 mechanical staff
and 421 other support staff. In the year 1997 there were 141
accidents involving 36 deaths and 544 injured. One employee and
14 passengers travelling in KSRTC buses died while 15 passengers
of other vehicles and six pedestrians were the other fatalities. Six
of the injured persons were KSRTC employees and 399 were the
bus passengers. 125 passengers of other vehicles involved in the
accidents suffered injuries, as did 14 pedestrian road users. It is
seen that for every three persons killed four other road users were
killed in accidents involving KSRTC buses. In respect of
injuries however the ratio was more favourable—for every three
persons in the bus injured one person outside the bus was injured.
Even so it is evident that in accidents involving the KSRTC buses.
the other road user feels the severity of the accident. Of the 141
18

e

W

accidents during the year 17 were fatal 14majorand HOrecordedas
minor accidents and it was found that in as many as 115 cases KSRTC
driver was found to be at fault. Therefore majority of the accidents and
fatalities associated with it and the pain and
damages caused to the other road users can be minimised if the
KSRTC drivers are made safety conscious and less accident prone.
Though no proof is available about the actual no. of KSRTC
drivers who were drunk at the time of these 141 accidents,
atleast 80 of the drivers involved in these accidents were known to
consume alcohol at one time or the other. As many as 90 had been
involved in some accidents previously.
To arrive at the average cost of an accident to the Corpora­
tion, every item of expenditure incurred in connection with all the
141 accidents of 1997 and their handling was systematically costed
in Hassan division. Wherever possible exact figures were taken into
account and where actual figures were not yet fully available, ap­
proximations were made based on similar cases where such ex­
penses were available. The expenditure involved in an accident
begins with the first telephone call made to inform the authorities
of the occurrence of the accident. Rushing to the accident spot,
arranging to shift the injured to hospitals after first aid and rescue
operations at the spot, locating the next of kin to come to take care
jof the injured or the dead and clearing the traffic jam are priority
actions. Lodging police complaints, helping police investigations
and visits by senior Corporation officials to the spot for assessing
the cause of the accident are next in priority. Arranging for
inspection by the motor vehicle inspector and the photographer,
and towing the vehicle for repairs are also part of the immediate
expenditure. Exgratia payments are made to the next ot kin to meet
their urgent requirements. Time and ef . • pent in repairing the
vehicle, mandays lost due to injured
> being unavailable

for duty, their medical expenses and revenue loss to the Corporation
for the period the vehicle is not available on road cost the
Corporation dearly. Legal expenses in connection with the police
cases and disciplinary proceedings if any launched against
the defaulting employees are no doubt small compared to the
compensation claims to be settled in favour of the accident
victims. The Corporation paid over Rs 150 Million in a year as
compensation and has claims totaling Rs 3000 Million yet to be
settled.Hassan division has estimated that the total cost of the 141
accidents in Hassan division worked out to Rs 37.6 Million and
cost of each accident works out to Rs 2.88 Lakhs to the Corpora­
tion alone.

(Legal Provisions :~J
The Karnataka State Road Transport Corporation Servants
(Conduct and Discipline) Regulations 1971 lays out very clearly the
Corporation’s stand on the use of intoxicants in the work place or
consumption just prior to duty. The rule 7 of the C&D is as
under.
A corporation servant shallStrictly abide by the law relating to intoxicating drinks or

drugs in force in any area in which he may happen to be for the
time being ; not be under the influence of any intoxicating drink

or drug during the course of his duty and shall also take due care

Accidents involve expenditure towards :
0 Accident, Spot IMV inspection, Transportation charges,
Attendance and immediate relief: Rs. 2 Lakh
0 Damages to vehicle and repair costs: Rs. 1.3 Million
0 Loss of vehicle days and resultant revenue: 715 days
Rs 4.4 million
0 Injured on duty and loss of mandays
0 Medical Attendance paid : Rs. 1 Lakh
0 Public Compensation claims: Rs 31 million
0 Workmen Compensation Claims
0 Default case expenses : Rs. 1.59 Lakhs
0 Court case and lawyers expenses : Rs.3 Lakhs.

Hassan Compilation of all accidents of 1997 but the cost
of each accident (Major or Minor) as Rs 2.88 lakhs to KSRTC
alone. Costs incurred by others including the Police, Medical
departments, Courts etc. may take the cost of each accident to
Rs. 4 Lakhs or more. Since there are nearly 20,000 accidents per
year, the notional loss due to accidents is equivalent to the entire
budget of the Police Department in Karnataka. Each accident
prevented is NET SAVING to the State.
20

that the performance of his duties at any time is not affected in
any way by the influence of any intoxicating drink or drug.

A corporation servant shall notAppear in a public place in a state of intoxication;
if he is a Driver or Conductor have taken or used any intoxicat­
ing drink or drug within eight hours of the commencement of
duty or take such drink or drug during the course of duty.

W

The recovered employee sharing his experience
in the followup meeting.

F

J

Results achieved

Accident Reduction : The innovative programme to prevent
alcohol abuse in the workplace launched with full vigor in 1997
embracing about 70,000 employees in the Corporation has in the
last three years resulted in astounding results with accident rates
dropping from 2.2 per Million kilometers to 1.7 per Million
kilometers.

Losses : The overall losses of the Corporation have been brought
down from Rs.94.05 crores in 1996-97 to Rs.2.46 crores in
1998-99 and the details are as under

Year
1994-95
1995-96
1996-97
1997-98
1998-99

Losses
-69.65
-48.01
-94.05
-62.38
-2.46

The Corporation has been awarded the Union Surface Transport
Ministry’s National Safety Award this year, which includes a Cash
Prize of Rs. 5 Lakhs.

The Details of the Accidents/Rate of Accidents before and
after implementing the project are as under :-

SI.
No.

Year

Fatal

Major

Rate of Accident
/lakh kms

1
2
3
4
5
6
7

92-93
93-94
94-95
95-96
96-97
97-98
98-99

459
435
408
421
385
351
374

608
723
679
636
507
409
417

0.29
0.28
0.28
0.25
0.22
0.19
0.18

Improvement in attendance after treatment
Out of the identified employees in the Red zone 840 employ­
ees of KSRTC, BMTC & NWKRTC have been referred for
treatment at various centers and the attendance particulars of 431
employees have been compiled for a period of six months before
and six months after the treatment. The improvement of attend­
ance of these employees are as follows:

Strikes: The employee morale has been improved & productivity has
gone up and the Industrial relation situation has been
improved considerably which can be seen by the strike details
and loss of mandays as indicated below:Year
1989
1990
1991
1992
1993
1994

No of strikes
8
18
15
12
49
21

Year1985
1996
1997
1998
1999

22

No of strikes
29
7
23
8
1

No of days

No of employees

0 to 10

58

11 to 20

35

21 to 30

34

31 to 40

41

41 to 50.

52

51 & above

38

Over 126 employees have remained sober
for more than one year.

Conclusion :

KSRTC & ILO

The introduction of the de-addiction programme in KSRTC
from 1997 emerged as a panacea for the many ill effects. The success
of the programme resulted in tremendous change in
relations in between the employees, passengers and the
Corporation.This programme of the Corporation is a unique
Human Resource Development Programme and the same is being
implemented in all the divisions and depots of the Corporation.
This programme has also resulted in reduction of accident rates. In
a year all the money spent on the programme has been got
back more than adequately in the form of improvement in
productivity and the reduction in number of accidents.

A memorandum of understanding was entered into with
International Labour Organisation on 5-11-1997 for technical
assistance and cooperation in running the Workplace Alcohol
Prevention Programme. The International Labour Organisation has
been associated with the Corporation in assisting implementation
of the total de-addiction project by extending guidance, technical
assistance in the training process, identification of NGO’s,
treatment process, formulation of action plan, formulation of
organisational policy on de-addiction, conducting training
programmes of officers, supervisory category etc.

In a labour intensive organisation worker reach out
programmes such as WAPPA help both the organisation and worker
to improve production, reduce absenteeism, reduction in accident
rates and to improve the operations. Though the programme
initially met with lot of criticism in KSRTC, concerted efforts of
dedicated and committed managers in the project, helped
to sustain the programme in the organisation. Evaluation of cost
benefits results based on documentation helped to remove the doubts
about the sustainability, validity and viability of the programme.

Wholehearted support from affected workers and their families, and the first hand information about the transformation brought
at workspot led to the full acceptance of the programme. Constant
innovation including computerisation of the records available
for independent audit and inspection makes the programme highly
credible. When accolades started coming from outside agencies
the programme got all round support within the organisation.
Seeing the success of programme in KSRTC, the same is now sought
to be replicated in other organisations.
24

National Project Manager ILO inagurating the training
session for the supervisory staff.

Association of Resource Managers against Alcohol and
Drug Abuse:

ILO, UNDCP & Ministry of Social Justice and Empower­
ment, Govt, of India have decided to establish and run projects
all over India to mobilise community based organisations and
enterprises to reduce and prevent drug abuse. ARMADA India is
being formed to take this programme to all parts of India by mutual
co-operation among all enterprises associated with this programme.

ADVANTAGES OF ARMADA

Programme of Action
TO SHARE EXPERIENCES AMONG COMPANIES ON
THE IMPLEMENTATION OF PREVENTION AND EARLY
ASSISTANCE STRATEGIES - BY THE COMPANY
STEERING COMMITTEE MEMBERS THEMSELVES.

An Enterprise adopting WAPPA could follow this programme of action.

Immediate survey, identification and classification of employees
according to their propensity towards alcohol consumption specially
in the workplace

TO MAKE EXPERIENCES IN PREVENTION AND
EARLY ASSISTANCE AVAILABLE TO MEMBER
COMPANIES.

■=>

Compilation of History of each worker including his drinking habits,
medical and family problems and work performance and default
history

TO OFFER ASSISTANCE TO MEMBER COMPANIES
REGARDING :

-

Formulation of firm Policy in the organisation and
creating an awareness among all the employees

POLICY FORMULATION
CAMPAIGNS
PROCEDURES REGARDING REFERRAL OF RED ZONE
PERSONNEL
APPROACH TO MANAGEMENT
EVALUATION OF THE PROGRAMME IN COMPANIES

Forming a Steering Committee under a committed leadership to run
the programme with workers involvement
Networking with Non Governmental Organisations
and other Experts involved in treating alcoholism / ARMADA

Counselling by dedicated team of doctors, Psychologists
and trained counsellors to the workers and their families

TO FOSTER AMONG COMPANIES A LINK
TO THE FAMILIES OF WORKERS (TO ARRANGE JOINT
FAMILY EVENTS AND FAMILY AND FAMILY
SEMINARS)

c■>

Employee Assistance programme for treatment for
RED Zone persons

■=>

Active Intervention and counselling for those in AMBER Zone /
Health care programmes

c'-

Keeping the GREENs green by extended education and greater
awareness

I

TO THE COMMUNITY (EG: ADOPTING A SCHOOL TO
EDUCATE THE WORKERS OF TOMORROW ON THE
WORKPLACE’S NORMS REGARDING ALCOHOL AND
DRUG ABUSE)
TO KEEP THE COST OF PREVENTION PROGRAMMES
LOW AND TO OFFER ONGOING TRAINING TO NEW
COMPANY STEERING COMMITTEE MEMBERS ON
PREVENTION ACTIVITIES.
26

■

Making WAPPA/ARM ADA a part of proactive vigilance
programme and its regular monitoring through usual management
information system

c‘-

Strict follow up of all treated cases and their documentation

'

Spreading the programme to as many oils.
• possible through
audio-visual presentations, street pro
pines. rostersand other
innovative techniques

RESOURCE PERSONS TO BE CONTACTED FOR
_________ FURTHER INFORMATION__________
1. SRI K.R SINGH I.A.S.

PH

: 2221125

*
CM
■ 2. SRI R. SRI KUMAR I.P.S.

PH

: 2227491

DIRECTOR (SECURITY & VIGILANCE),

FAX

: 2235251

VICE CHAIRMAN & MANAGING DIRECTOR.

V

E-mail : r_sri_kumar@holmail.com

3. SRI K.R. SASHIDHAR I.A.S.
DIRECTOR (PERSONNELS ENVIRONMENT)

4. SRI K.M. AURADHKAR

PH

: 2223038

FAX

: 2235251

PH

: 2235075

CHIEF LABOUR WELFARE OFFICER

5. SRI S. MANOHAR

PH

: 6347465

PH

: 6347465

CHIEF MEDICAL OFFICER

6. DR. G.Y. NARAYAN

Sri Sageer Ahmed, Hon’ble Transport Minister
Govt, of Karnataka with ILO Evaluation Team

VIEWS OF THE ILO EVALUATION TEAM:
‘WAPPA is the most courageous and innovative programme initiated
by the dynamic and visionary management conceived and implemented with
total sincerity for the exclusive benefit of the employees who alone can
ensure the productivity, profitability and excellent image of the corporation. It
needs to be extended, expanded and replicated all over India with or without any
support from outside’.

SENIOR MEDICAL OFFICER

SRI MUKHT1AR SINGH I.A.S.,

PH

: 4602101 (NEW DELHI)

NATIONAL PROJECT MANAGER

FAX

: 4602111

INTERNATIONAL LABOURORGANISATION,

E-mail : delhi@ilodel.org.in

NEW DELHI.

NEW DIRECTIONS BEING TAKEN
From bottle addiction to BYTE addiction
All round computerisation effort including followup
Having kicked the bottle habit - let us now root out
corruption

28

Hou’ble Minister of Industries, Govt, of Karnataka,
inaugurating the meeting of Association of Resource M • ?er«
Against Alcohol and Drug Abuse in Bangalore on I'-' .>2-2000

Meeting of ARMADA at KSRTC Central Office on 19/02/2000

KARNATAKA SIATEROADTRANSPORTCORPORAllON

Central Office, Transport Bhavan,
K.H. Road, Shantliinagar, Bangalore-560027.
PH.: 91-80-2221321 FAX: 91-80-2237465
E-mail: r_sri_kumar@hotmail.com

SPECIAL FEATURE
By Naveen Kumar

or thousands of years man has been
using substances that have
p: ’cho-active effects. In some
regionsSnd countries the use of
such substances was closely linked to the
rituals and prevailing socio-cultural
practices. For example, opium, coca-leaf,
khat and alcohol have been regularly used
in different regions of the world in a
variety of ways. The apparent social
acceptance of the use of such substances
stemmed largely from the fact there was no
abuse. There there was, it was severely
ostracized. Society had very clearly drawn
the line and there was no question of
condoning any abuse. Unfortunately, what
we are witnessing today on a global scale
is a virtual epidemic of drug abuse.
According to the United Nations estimate,
there are 15 million drug abusers world­
wide.
About 2.27 lakh drug addicts were
registered with various de-addiction,
counselling and after-care centres during
1990-91.
As no census of drug addicts has
been undertaken, exact number of drug
addicts in the country cannot be

F

Smoking life away!

ascertained. This figure is considered to be
a conservative estimate or just the tip of
the proverbial ice-berg. Adding a new' and
disturbing dimension to the problem is the
fact that more and more young people are
being affected by what can.only be
described as the sinister network of global
drug cartels. In view of the vulnerability of
intravenous drug users to AIDS, drug
abuse has now assumed even more
dangerous proportions.
Besides, for the people seeking a
-|38 Rashtriya Sahara ♦ July 1995

Clutching onto the fatal support

DRUG-DEPENDENCE

The probability of an adolescent succumbing to the
temptation of drug is not necessarily related to his knowledge
about it

SPECIAL FEATURE.
Drug addicts
doing yoga
exercises as
part of their
rehabilitation
programme

euphoric state of existence, away from the
maddening crowd around, the deadly
consequences of substance abuse and
dependence seem to be less important, if
not an illusion. The dark future is washed
away, at least for a moment, by the glaring
“flash". Hence the rush for a “kuck” of a
different life!
The phenomenon of substance abuse
is the product of a complex interaction
among the individual, substance and the
environment.
“Drug-pleasure of a moment, debacle
of a life-time”, so goes a graffiti on the wall
along one of [he main thoroughfare of
Delhi. Another hoarding exhorts, “say no

to drugs the first time, evety time”. Looking precipitous behaviour, a mixture of peer­
at these hoardings one could sense that the modelling, risk-taking and going for
problem of drug-abuse and dependence in challenges. Or, it will simply be an offer
our country is not an illusion but a reality of the opportunity to join with others in
±at takes a heavy toll of human life.
what appears to be the method of
It has been convincingly argued extending pleasurable aspects of a
that people take to drugs because they conventional recreational situation. So,
are offered. It is very rare, at least for in spite of being 'anti-drug' he or she
illicit drugs, that first drug contacts . evaluates the offer not in terms of the
happen on the initiative of the user. The drug-education but in terms of the
offer comes normally in circumstances current situation and the normal rules of
where it is difficult to resist, in a behaviour (sociability, enjoyment,
situation which tends to be described reciprocity, keeping one’s cool, etc)
not very aptly as social pressure or appropriate in such recreational
curiosity. More often, it is in a situation situations. This is true both for early
which is conducive to impetuous or offers of legal drugs (cigarettes, alcohol)
and for later offers of illegal drugs.
Hardly any studies have been
undertaken to elicit the circumstantial and
emotional details of such situations of drug
initiation. It is difficult to see how
programmes of ‘preventive education' can
be effective if so little is known about the
behaviour which is to be prevented. “Just
say no” is certainly not the full answer.
This lack of knowledge on the initiation
into drugs has led to the generalisation of
the medical model of dependence to drug
use in general. We are asking for “cause”
of using drugs. There is an evidence to
suggest that dependence has a certain
medical connotation in that there exists a
genetic predisposition towards it.
Rashtriya Sahara ♦ July 1995 139

SPECIAL FEATURE
However, the behaviour of taking a drug popularly known as Number 4 among the
or accepting the offer of a drug does seem locals. This brand of heroin is called
to resemble a medical condition about as Number 4 because it is fourth stage of
refinement containing as high as 90 to 95
closely as do other behaviours which
imply a definite risk to heakh like skiing per cent heroin. From where do these
or mountaineering. All these behaviours drugs come? Immediately the query leads
are pleasurable. And in all of them risk­ to the fact that National Highway No 39
connects India and Myanmar, a constituent
taking is one component of the pleasure.
The fact that ‘people do things which country of the notorious “Golden Triangle"
they enjoy doing’ does not need further (Myanmar, Laos, Thailand) where opium is
“grown like rice". Besides, Manipur shares
explanation.
However, it is important to keep in a 352-km border with Myanmar which is
mind that the risk-taking can be fun, and sparsely guarded and it plays a crucial role
especially so during adolescence. The in the availability of drugs in these areas.
physiological reactions to fear and fun are Apart from this, people in the districts of
very similar. From merely observing Rajasthan, (Barmer, Jodhpur) sharing its
hormonal and some other physiological border with vicious ‘Golden Crescent'
changes we are normally
not able to say whether a
person is living through a
frightening experience, is
enjoying a good joke or is
experiencing an orgasm.
The smooth and virtually
timeless
undulations
between fright and fun can
well be observed on the
faces of people on a roller
coaster. It is therefore not
surprising
that
the
probability
of
an
adolescent accepting the
offer of a drug is not
correlated
to
his
knowledge about drugs.
A sportman’s ‘weakness’
The component of pleasure
experienced in the process of drug (Afghanistan, Pakistan and Iran) hold
initiation in many instances often opium offering in high esteem. Chippa and
neutralises the unpleasant experience of Sinhhis communities attach a lot of
the drug effect itself. This excitement importance to opium. The high frequency
permits, for example, adolescents to (22 per cent) of opium intake may be
become smokers inspite of the initial attributed to their frequent handling of
unpleasant bitterness and cough opium in their professional life.
provocation by cigarettes. They often have
Famous psychiatrist (AI1.MS). Dr
to literally work themselves into regular Mohan has found in his study of school
use. Like skiers, mountaineers or car boys and girls in Delhi, that they use
drivers, drag users are convinced that they painkillers (49 per cent) followed by
can overcome the risk. The facts, however alcohol (12.7 per cent), tobacco (6.4 per
tell a different story. The situation is so cent), tranquilizers (3.4 per cent) and less
alarming in the N-E states that in Imphal than 5 per cent other drugs like cannabis
there is rarely a home that has not been
amphetamines, barbiturates, LSD and
invaded by the drug menace.
opium.
The most widely used drag in ±ese
School of Social Work reported that
states is the most refined form of heroin, drug users are marked by features like
■j 4Q Rashlriya Sahara ♦ July 1995

insecurity, dependence, frustration and
anxiety. Besides, more than three fourth of
the respondents were dissatisfied with their
family and social situation.
In a study conducted by Malhotra and
Murry at the National Institute of Mental
Health and Neuro-Sciences, Bangalore, it
was found that drug addicts manifest
neurotic traits and anti-social behaviour
patterns.
Drug peddlers befriend before they
offer crag for the first time to their victims,
at the pockets in city slums and, in the face
of gross apathy from administrative,
medical and related agencies, their
business flourishes smoothly.
One may well ask what role
government could play in the
control of drag abuse. Supply
reduction is the job of the
police and narcotics bureau.
Demand reduction is the job
of doctors in their treatment
centres. To the extent that
these administrative agencies
can't stop the availability of
drugs, let the health care
service cure those who
become drag addicts, in spite
of all supply control efforts.
We
have
ample
evidence in India and abroad
that these traditional
strategies alone do not work.
Law enforcement will at times
drastically reduce the
availability of illicit drugs by spectacular
seizures, or a vigilant narcotics police may
prevent the establishment of a criminal
distribution network. But such successes
do not sustain. Clinics and drug de­
addiction centres may cure large numbers
of. them but the rate of relapse of this
vicious cycle has acquired menacing
proportions.
Drug abuse is thus closely linked to
health care, with health services
rendering necessary support. But for
successful prevention and care of the
disabled and chronically ill, community
involvement is necessary. Only people,
friends, teachers, media and above all a
commoner can prevent others to stay
drug free. ■

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