Yeah.

Yeah,

mm 

Alcoholism in the 70's with 

Charles E.

Becker MD.

Chief of clinical pharmacology.

San Francisco,

General Hospital san Francisco California.

I call your attention to the reference which I've listed for you 

in the third part of the basic discussion.

This was an article that appeared in the annals of internal medicine 

called self destructive habits.

And they're probably many people in your practice 

who have difficulty and would wish their 

tombstone to look like this.

Namely they told you that they were sick and that you didn't help them 

very much during their lifetime.

These are your smokers,

your drinkers,

you're obese patients and dr Barnum had the 

courage to look over his private practice and to 

see what percentage of his patients were in 

fact inflicting illness upon themselves.

And some of this is summarised on this slide.

He reviewed the fact that the medical literature says that we 

have 9-10 million alcoholics.

Although it's not exactly clear where this comes from that 

we consume huge quantities of cigarettes.

That large numbers of people are using marijuana who 

prescribed million of barbiturate tablets are many people 

using amphetamines.

We have heroin addicts and something in the order of a third of the 

population is seriously overweight.

Two standard errors.

And he concluded that in his practice,

one quarter of all of his patients,

whether hospitalized or outpatient,

were trying to kill themselves,

and that he didn't know exactly what to do about it.

This was remarkable because the abuse that came to poor Dr 

Barnum for writing this in the editorials was somewhat unfair.

As you know,

many people have defined alcoholics or somebody 

that people who drink more than their physicians.

And of course,

this has not been an adequate way of diagnosing alcoholism 

and that people argued that he did in his treatment of 

alcoholism,

for instance,

that Dr Barnum did less than the spontaneous remission 

rate that's been reported for this disease.

He did quite well with obesity and moderately well with 

smokers.

And people suggested that he didn't understand that these really aren't 

habits,

but that these are diseases and in fact,

the emphasis of whether alcoholism and narcotic addiction 

of diseases or habits was played out 

very beautifully in the annals of internal medicine.

Well,

you can see what the difficulty is is because many 

people have tried to care for alcoholics or smokers or 

beast patients who don't have the problems themselves 

uh in for well,

why don't you just simply stop eating or just cut down your 

alcohol intake or stop smoking?

Um,

anybody who's ever had the problems of any one of these 

addictions knows that it's much more complicated than that,

and especially if you're a position who doesn't drink or 

smoke or is an obese,

you have a very hard time identifying with these kinds of 

patients Well,

part of the reason is because we've had difficulty with defining 

exactly what addiction is and what the risks are for 

the consumption of cigarettes,

alcohol and narcotic drugs.

And that's part of what I'd like to do for you.

And you'll see that in the final handout in the 

back part I've summarized in 

in overall sense what drugs do to patients 

and when we refer to someone being addicted to a drug,

it usually means three things.

It means a statement about behavior which is sometimes 

referred to as habituation and there are 

physical factors called withdrawal and tolerance.

These are the factors that are best 

understood,

the ones that we know the most about and the things that I'll be 

discussing today,

these are the ones that often call the patient to our attention.

But it's the behavioral factors that were least familiar 

with.

We don't fully understand them.

We don't exactly see how they're applicable on this 

slide.

I summarize for you when it comes to talking about addictions 

and drug dependencies that there are many people in our 

society who use drugs and some who 

abuse them to a state of physical dependency where we 

see withdrawal and tolerance,

but the drug only makes up part of that,

the personality makes up part of it and the social environment 

makes up part of it.

So as an example,

using the drug,

alcohol is our marker drug for this discussion.

The average American citizen based on tax 

dollars consumes the equivalent of 

3.93 gallons of 100 

proof booze per person per year.

This works out to be three cocktails for every person of 

drinking age every day.

Now you're saying to yourself,

well,

how come not everyone drinks this quantity,

that's because 80 of that total quantity 

that's used in our society is consumed by only 10 of the 

people.

And it's that 10 of the people who are the 

alcoholics.

And it's equally clear that most of us who use alcohol in a 

way,

which doesn't seem to get us into difficulty,

don't fully appreciate the magnitude of this 

problem.

Nowhere is this problem more obvious than in 

industry and in the military 

service.

So you will note that that not only is their use 

of problem,

but for some reason,

only a small percentage of people who abused drugs 

arrive in a medical diagnosis of the abuse of the 

problem.

Now,

part of it has to do with the drug itself and I've noted on 

the your handout,

but I've seen people have used virtually every drug known to man,

except one in 1000.

There has never been an addict of matthias scenes.

In fact,

you have to be crazy to take those medicines.

Yeah,

as uh as an internist who sees this problem all the 

time.

One of the best ways to diagnose crazy 

craziness in your private practice is to give 

someone Matthias means anyone who says that they're feeling 

better.

Taking those medicines are crazy.

It has something,

it has something to do with the drug.

Uh,

we know that nicotine and narcotics,

if given to laboratory animals are the most preferred 

drugs.

Alcohol,

marijuana LSD are less preferred.

It has something to do with the dose and a lot to do with the 

toxicity based on dose.

That's something to do with the root.

As an example,

cocaine is very much different in its addiction,

whether it's snorted or uh injected,

it has to do with the psychological setting in which the drug is 

administered.

It has to do with the previous psychological state.

And we'll have a lot to say this afternoon.

It may have to do with the set of receptors that you 

have in your brain now 

part of this and some of the new information.

Since this is an update has to do with the 

genetic predisposition to not only the 

medical complications but to the abuse of the drug 

and in the alcohol area.

This is some of the hottest information that we have,

namely that if you look to see whether it could be a 

psychological factor that's involved as 

something that was inherited.

We have called people who abuse alcohol all 

of these things neurotic,

over reactive protective and every one of these things.

And no matter how you slice it as an internist,

looking at all the studies when people who are 

addicts are looked at,

they turn out to be essentially normal.

This has not born a lot of fruits in terms of the 

basic personality part,

in terms of giving us an idea about the 

predisposition of people,

we can give some patterns to be sure,

and there are some common traits,

but the usual overall pattern has not 

been remarkable for any of us taking care of this 

kind of patient.

What has been remarkable is the potential for an inherited 

part to this whole area and in 

the field of alcoholism.

And I've listed for you some of the references,

but I'd like to tell you that this brand new book that was just published by 

Donald Goodwin called Heredity and 

alcoholism,

which summarizes all of this.

And there are six lines of evidence that suggests that 

there is genetic predisposition to 

alcoholism.

There's a family history,

there are striking racial and religious preferences 

as an example of their oriental people in san Francisco who don't 

drink at all because every time they drink they flush 

and feel terrible.

There's a whole area of research that suggests that 

maybe alcoholism is not only just consumption and 

toxicity,

but predisposition based on the pharmacological effects.

We have some dramatic twin studies which suggest that if 

identical twins are raised in 

a different environment um 

at birth and separated at birth,

that they have a higher incidence of alcoholism and identical twins 

and non identical twins.

There have been associations for color blindness,

and there have been uh animal studies that have 

shown that you can actually inbred animals to prefer 

alcohol and make them again and make them again and 

create species of animals that are that are 

alcoholic.

In addition to that,

if you give genetic blocking material,

you can block this preference.

This is an important,

uh by the way way of us discovering new 

drugs,

because in fact,

lithium,

as I will mention in a minute,

has been placed in the drinking water of the inherent 

bread preferenced animals for alcoholism and 

they dramatically decrease their alcohol intake.

Then when the lithium is removed,

they start drinking again.

And this has led us to do clinical trials,

which I'll discuss in a minute,

suggesting the potential value of lithium in the treatment 

of alcoholism.

Well,

all of this I think people have appreciated before.

But the hottest area in the field of alcoholism 

today is called the fetal alcohol 

syndrome and raises another question about 

how genetics might relate to the 

consumption of alcohol.

This was totally unrecognized because in the 

1950s people began 

to look at what drugs were affecting the fetus 

and a complete surprise to everyone 

was as depicted on this slide,

the performance,

growth and development I.

And other changes that occurred in mothers 

who did not drink during pregnancy.

By comparison to those mothers who consume large amounts of 

the drug alcohol during pregnancy and the drug 

that was most commonly associated with performance,

growth and development.

I and other changes was the chronic consumption of the drug 

alcohol.

This is extremely important because now it's 

recognized that the fetus may be intimately 

affected by the alcohol that's consumed by the mother 

and that there may be alterations in receptors,

which I will discuss this afternoon,

particularly opiate receptor.

Or there may be structural or enzymatic 

changes which occur in the fetus when when the mother is 

exposed.

This is now called the fetal alcohol syndrome and was 

initially felt to be a structural abnormality.

We now appreciate the fact that infants born of 

mothers who are drinking heavily.

And I might add,

recent evidence suggests who are smoking heavily 

and often they go together.

Uh,

in fact,

in the 12,000 alcoholics that I've taken care of,

there's only been five non smokers 

drinking and smoking go together.

And in fact,

in these studies,

it's been hard to separate the risk of alcohol 

during pregnancy and smoking during pregnancy.

The result of all of this was to suggest that 

infants may be born in a withdrawal state 

or in a tolerant state to alcohol,

and the early life experiences which the infant 

undergoes may be occurring in the presence of drug 

withdrawal and may be associated with later life 

experiences that we call addictive 

behavior,

if you will.

Now,

all of this is very preliminary,

but you can expect to see a whole host of articles coming out 

about investigating the effect of common things such as 

smoking and drinking upon fetal performance.

Well,

once you have a patient in front of you who's an 

alcoholic,

the typical patient that I thought alcoholism was all about is 

the kind of patient at the san Francisco General Hospital.

Recent studies in our hospital have suggested that something in 

the order of 60-70 of all of our patients 

have alcohol or drug abuse problems at our hospital.

Unfortunately,

this kind of patient Is the minority 

of patients in large surveys.

This kind of alcohol drug abusing patient 

makes up less than two of all the people who really 

have alcohol problems.

This is perhaps the most important thing,

which I'll say today,

because if you start using drug 

treatment for this kind of patient,

you'll conclude that it's a failure every time 

it would be analogous to trying to have a 

discussion today of cancer and use leukemia and 

acute plastic crisis and talk about the treatment of 

cancer because you'd be seeing the same kind of 

results.

And this is why many of us have felt that it's it's a dismal 

failure to ever intervene in anyone smoking drinking 

or obesity problem,

because addictions have only been diagnosed 

and clearly faced by the medical community at this 

stage.

In fact,

the vast majority of people who are alcoholics are like all the 

people here,

and in fact,

I've listed for you on your handout 

the key issues that usually present for 

middle class people who have alcohol related problems.

A recent survey suggests that the best person to 

ask about somebody's drinking habits is not the patient 

himself.

A better person is to ask the spouse,

the employer or a significant other is the key 

term today when you find someone who's 

drug overdose,

you should suspect that the person has an alcohol 

problem in the background.

Every there's a linear relationship between the total amount of 

alcohol consumed and the uric acid.

In fact,

there are many,

many more people in society who have alcoholism to 

account for their elevated uric acid than the disease 

gout.

It's much more common to have people have a mild 

elevation of uric acid and have this related to alcohol.

The cholesterol is often elevated an alcoholic 

patients and there may be a predisposition to elevate the 

the cholesterol and people with Type two hyper baited 

life of protein anemia,

diabetic problems,

seizure disorders,

the whole host of gastrointestinal diseases which all of you are 

familiar with,

especially peptic ulcer and gastric ulcer diseases.

Dermatologists are now for the first time recognizing that 

chronic skin conditions,

which don't appropriately hell under the 

usual medical therapy should be suspected.

The person having heavy alcohol intake,

an M.

C.

V.

Greater than 100 occurs in almost all the patients in 

our hospital.

And we recognize that mild folate deficiency is extremely 

common uh in alcoholic patients for 

practical purposes.

Whenever you have a heavy smoker,

you should immediately suspect that he's an alcoholic 

because these two processes are intimately linked 

abnormal liver functions,

the psychological difficulties.

I stress all of this for you only to tell you that the 

kind of alcoholic who's most likely to benefit from 

treatment is not someone who appears as a skid row public 

inebriate.

He's never going to come to you saying I'm an alcoholic.

Help me instead.

Your diagnostic acumen for this problem has got to be great.

I've listed for you two ways in which we're very concerned about 

alcoholism in our society,

namely,

the fact that there are only two diseases in modern 

medicine that are dramatically increasing in frequency.

Uh,

well actually,

there are three venereal diseases certainly wanted to increasing in 

frequency.

But the two major ones that concern us are 

cirrhosis of the liver and death and violence.

Both of these have been intimately related to the total alcohol 

consumption in our society.

I'm not going to specifically discuss the liver disease process 

today,

although I have listed the key references for you,

but I'd like to spend a moment and tell you how violence has 

been associated perhaps how this alcohol.

For instance,

recently in the newspaper has been called the violent connection.

You'll see how it's been difficult to draw this 

conclusion,

That the incidence of deaths and violence 

has gone up 100 from 1960 to 

74,

whereas cancer has decreased one and 

cardiovascular diseases have decreased 7%.

There are country leads the way with the 

greatest risk of dying and murder.

And in fact in traffic accidents today,

70 of all the fatal accidents in California 

occur with the driver,

the person dying having the equivalent of three 

cocktails in his blood.

Much of this has been related to television because in fact,

I put this in specifically because of the hearings which are 

going on now and where this is being widely discussed.

The average high school senior by the time he 

graduates has seen 15,000 hours of 

television and only 11,000 hours of class.

Our he's seen 18,000 murders.

Um,

and that there are,

there are six times more violence in the child hours than an 

adult hours.

And the recent information,

which is the most disturbing is that ads related to 

alcohol and cigarettes are intimately tied into 

this.

Keep peak time of young 

viewers.

Now,

obviously you can see how loose this is.

We're not certain about this,

we're not sure which comes first.

But in fact,

this kind of behavior is often one of the physician is 

asked to deal with and you should suspect alcohol 

use.

Well,

this all sets in motion the uniqueness of the alcohol problem 

for us,

namely that alcohol is the most common sedative hypnotic 

drug that patients take.

It's a food,

it's a legal drug,

90 of us use it and fortunately 

relatively few,

namely 10 abuse it.

I'll be discussing with you briefly the kinetics of alcohol,

which are also unique.

There are clear health hazards,

especially related to liver gastrointestinal disease,

perhaps neurological disease,

and alcohol is a singer most common drug interacts with 

all other drugs.

On the other hand,

we have a $32 billion $10 billion 

dollars a year in taxes and that alcohol is the 

single drug Which has not increased in 

cost over the past 20 years.

In fact,

alcohol costs less today,

considering inflation than any other substance in modern 

economy,

Less than one of all the tax dollars that are 

collected or return to us to assist us to care 

for people that have these problems or to do research about it.

There's tremendous advertising for it.

We have virtually no medical insurance which will allow us 

to deliver health care to these people.

And we currently have zero population growth,

which more and more people at younger and younger ages are consuming 

more and more alcohol.

And result is that that we are expecting 

and some have already said we are seeing more and more 

medical complications of alcoholism at younger and younger 

ages.

The incidents of cirrhosis is perhaps the best marker of this 

and there is debate what the incidents of cirrhosis is really 

decreasing is actually occurring at a younger 

age.

I should stress for you that it's never a threat for us to treat that 

most visible alcoholic.

It never has been a threat.

But in terms of the overall approach for our patients,

if we actually did something about altering the 

smoking and drinking behavior of our patients,

there would be tremendous economic problems.

Well,

based on all of this,

how do you diagnose an alcoholic?

What's an alcoholic,

1972,

the National Council and Alcoholism got together and said,

this is what an alcoholic is.

These criteria are re evaluated in this week's 

journal the American Medical Association,

in which the members of the american Society and alcoholism have 

agreed that these criteria clearly tell us the 

people who are alcoholics,

people are alcoholics and you can remember them by W.

A.

S.

P.

You are an alcoholic if you drink enough alcohol 

so that when the drug is stopped,

you have severe tremor hallucinations,

seizures of the DTs.

You are also an alcoholic if you have a high 

blood levels of the drug alcohol and are not affected 

by it or have a high level at any time.

As an example,

The average blood alcohol level in an average 

sized person goes up 30 mg per cent 

with a single drink on an empty stomach.

So as an example if I had five gin and 

tonics in front of me And I consumed them.

Now in one half hour I would have a blood level of 

alcohol of 150 mg per cent.

And at that time if I were able to stand up here and 

be on one ft unassisted or touch my nose with my 

eyes closed or walk a straight line.

If I could do those things I would be tolerant to the drug 

alcohol,

I would be addicted to the drug alcohol and I would clearly be 

an alcoholic.

If I had 300 mg per cent anytime 

anywhere I would be an alcoholic.

It's of note that some hospitals are removing some of the worthless 

tests they have on there S.

N.

A.

Panels and including a blood alcohol level.

They have found huge numbers of people entering their 

hospital with elevated levels of alcohol.

The p criteria is the pathology of 

alcoholism which I'm sure most people are familiar with.

And the s criteria is the psychological one the one 

that's most difficult,

which says that you're an alcoholic if you drink in 

spite or despite strong medical or strong 

social contraindications.

What this means for practical purposes is that a patient 

has recurrent pancreatitis,

has epilepsy or diabetes or hypercholesterolemia.

The physician recognizes that the alcohol contributes 

to this.

In some way.

He says that alcohol contributes you should 

not be drinking.

And despite the knowledge that these are related to 

the patient continues to consume the drug,

alcohol he drinks in spite of strong 

medical contraindications in the military,

there often social contra indications he's in trouble 

in the military service for somewhere,

another.

He's warned about this and the problem continues.

Now.

Some of the greatest progress in the field of alcoholism has been 

that all of these criteria have been relatively 

subjective and we've been very anxious to come up with 

objective medical criteria of blood 

level.

Something that would clearly give us indices 

for alcoholism and acid AL to 

hide.

And amino acids in the plasma have been this 

uh this slide comes from the reference by 

labor,

which is on your liver slide on the ah 

liber liver reference.

And in in this circumstance,

it just illustrates the metabolism of 

alcohol.

Alcohol is metabolized in the body to acid alga 

hide and acid Alga hide 

is the newest metabolic concern of 

people in the field of alcoholism.

In fact,

one,

well,

in fact,

some people have suggested,

we've called alcoholism the wrong disease all these 

years.

Instead,

we should call alcoholism acid alcoholism 

because it looks as though the toxic effects of 

ethanol are clearly related to 

acid Aldo hide,

especially in the liver process.

So that many physicians have felt that maybe we could 

measure acid Aldo hide in in the in the 

blood and in the reference in the acid 

alga Hide section,

uh,

labor,

did this and showed that in people who were given an 

alcohol infusion over several 

hours,

that their level of acid Aldo hide was at this 

point,

and 14 patients who were after the 

DTs,

who were clearly alcoholics,

um,

would have a much higher blood level.

And this has been related to factors that cause heart disease and 

liver disease.

That acid alga hide itself acts back 

to destroy the mitochondria,

which which are responsible for its own 

metabolism and a vicious cycle is set up so that the 

acid Aldo high levels rise.

They damage the liver and other essential organs.

And this accounts for the pathology in the field of 

alcoholism.

Well,

the problem is that you're not about to readily measure 

acid alga hide.

It's been remarkably difficult.

There's been controversy about it for years.

Instead,

simpler techniques have been developed in an attempt to arrive at a 

metabolic diagnosis of alcoholism And they are 

summarized in the December seven issue of science this 

year,

which was not I sent in 

this outline before that time.

But dr Charles,

Lieber and others have attempted to 

identify specifically alcohol induced liver 

disease.

And there seems to be a specific enzyme which is 

located in the liver,

in the peri uh in the 

paddock vein area,

which is called gluten meal trans Pep.

Today's this enzyme seems to be elevated 

in alcohol related liver disease.

And if you initially measure that enzyme 

and then related to a unique amino acid 

called alpha amino n.

Butyric acid,

which accounts for the A.

Here and related to another amino acid 

loosen in the plasma.

And you take this two step approach of measuring 

glutamine trans Pep today's,

which is a simple test and the relatively simple test of 

measuring this unique amino acid that's 

increased in the plasma.

There is a dramatic association for the 

diagnosis and for the medical complications of 

alcoholism.

We don't exactly know how early this comes on.

It doesn't go away immediately,

but we do know that this is probably a 

metabolic marker for the diagnosis 

of alcoholism.

Whether the typical alcoholic that we've discussed will 

have this or not,

it seems quite likely in the in the early studies 

by labor.

Now,

one of the things that we've attempted to do,

which I just thought I'd mention in passing is that one thing 

certain about alcoholics is they drink too much 

and then if you ask someone how much they drink,

patients often don't tell you,

so that we've set up a method to measure how 

much people are drinking.

Um,

and it turns out to be something and I'd be happy to discuss this with you.

As simple as a waterproof pad 

that's connected and placed on the skin and worn 

by the patient for eight days.

Uh You'll see this published shortly 

and what actually happens is easier placed on the lower 

extremity.

The patient drinks whatever they wish.

Um It looks something like this.

They wear it down here.

I'm a long distance runner and I've worn these for 

several weeks.

They don't seem to cause difficulty.

Uh,

alcohol is freely def usable into water,

and since we're collecting sweat,

you can spend it in a centrifuge injected without 

going into it in great detail.

There's a very definite relationship between the amount of alcohol 

consumed in very low doses and the amount 

that's consumed by alcoholic people drinking on our metabolic 

ward.

Uh if you just measure the square root of 

the amounts of alcohol that you detect,

this is very helpful to us because in fact,

we will now know exactly how much somebody's drinking over 

time and more importantly,

will be able to design therapeutic a 

therapeutic endpoint,

which will allow us hopefully to look at whether 

certain drugs are really useful in the treatment 

of alcoholism.

Well,

what is the treatment of alcoholism?

Well,

the first thing that you do in the treatment of all addictions,

and I'll be discussing this for this afternoon was it relates to 

narcotics,

is that the first treatment is called 

detoxification.

And detoxification means ridding the body of the drug 

alcohol so that there are no medical complications 

of withdrawal When it comes to sedative hypnotic 

drugs.

The fear of detoxification is seizures and 

hallucinations,

and any sedative hypnotic drug,

Valium,

Librium barbs will cause 

seizures and hallucinations if they have been taken 

in high enough doses for long enough periods of time.

This is the most difficult thing that we attempt to do because 

we used to think that detoxification periods 

lasted only a few days that people sobered up in a couple 

of days.

We now recognize a detoxification from 

drugs as a whole.

It takes much longer than we previously recognized 

that people who are smokers and the people who are drinkers 

require many months before their sleeping patterns are 

normal and before they feel normal.

And during the time in which we detoxify them,

we looked for medical complications,

psychiatric problems and multiple drug abuse.

And then we set up a system of modifying their 

behavior about the drug over a long period of time.

I've listed for you some of the specifics without going 

into it in great detail as the time is short in 

the area of addictions,

the group experience is by far the best 

that the one on one 

psychodynamic psychoanalytical 

processes have not been useful in the area of 

addictions.

The psychotherapeutic approach has not been as useful 

as the group experience.

And no matter how you go about modifying behaviour,

it's essential to recognize that there is often a person 

involved with the alcohol smoking or eating 

behavior in addictions and that that person has to be brought 

into the treatment as well.

Now,

what is from a practical point of view,

the clear areas where drug treatments are useful 

in the one area,

for sure,

is that we can alter the withdrawal syndrome from 

alcohol and we can alter the withdrawal syndrome 

from any sedative hypnotic drug by the basic 

principle of substituting a longer acting medicine for 

the short acting medicine that the patient is abusing and 

tapering this over time and just to refresh 

your memory.

This is from our textbook in the field of alcoholism that 

They're.

The typical alcohol withdrawal occurs 

8-10 hours after the alcohol is 

stopped.

There's tremor increase in blood pressure,

increase in pulse respiration and temperature.

Some people will hallucinate during this early period,

Some will have fits,

insomnia,

mild disorientation.

In mildest form.

The alcohol withdrawal is a hangover and in most 

severe form it's a rum fit.

This is part of the pharmacology of the sedative hypnotic 

drug,

alcohol,

it occurs with other drugs as well.

The only difference would be the time course over which it 

occurs.

So as an example,

you often give a patient Valium the drug would be abruptly 

stopped and the patient will feel shaky,

not 8 to 10 hours later,

but 2 to 3 days later,

then the patient will start drinking or taking more drugs and you'll be 

in the vicious cycle of treating them over and over 

again with medications,

A more severe type of withdrawal that's familiar to all of you.

It's called the DTs.

This is delirium tremens.

This is not specific for alcohol.

We have it in our barbiturate addicts and in our placid ill 

addicts and and all of our other addicts as well 

who use sedative hypnotic drugs and I'm sure you're familiar 

with this syndrome.

I've never seen the hallucinations be pleasant.

Um They're just not 

pleasant.

The idea of pink elephants is just not accurate.

Well,

how do you treat the DTs?

And how do you treat alcohol withdraw?

This is the drug and the family of drugs that we use.

These are clearly the drugs of choice.

These are benzodiazepine drugs.

This is the basic benzodiazepine nucleus.

There is diazePAM,

Valium claudia's up oxide,

Librium downing,

LORazepam,

cyrix oxes,

apam and trans seen Cloris a pet.

There are five benzodiazepines on the market and they are 

characterized more by their similarities than by their 

differences.

Despite what many have discussed.

And we know conclusively from 

the national cooperative study that was done in the 

DTs,

that the benzodiazepine drugs are far 

superior in terms of the likelihood of decreasing 

convulsions and preventing uh 

DTs than are the final matthias scenes 

Thora zine here,

which actually lowers the seizure threshold and make 

seizures more likely to occur as compared to 

placebo,

fireman and visceral hydroxy scene in 

the annals of internal medicine.

Was this classic review by Thompson,

which took patients and compared diazePAM versus 

peralta hide.

We've done a relatively similar studies and elegant study.

They even put Peralta hide swabs 

under all the patient's bed so they would smell the same.

And it concluded that with 

intravenous diazePAM uh five or 

10 mg stack and five every five 

minutes until the patient is calm,

calm,

not comatose.

Uh There's a big difference there uh and 

we stand at the bedside and administer 

diazePAM and we treat 

DTs readily with a lot fewer 

complications than any of the other medications.

Now there are a few problems with benzodiazepines,

one of which is outlined on this slide and that is you should not 

give them into muscularly.

The benzodiazepine drugs,

all of them are poorly absorbed from inter muscular sites.

You can see that the plasma levels of 

the clear days up oxide in this case are much 

lower than the oral,

the same dose of the oral drug.

So avoid these particular drugs.

Uh Inter muscularly.

The usual story Is that you give 50 of Librium and 

50 more and 50 more in the patient sleeps for a week and has 

aspiration pneumonia.

You don't want to be treating acute withdrawal in that 

fashion.

One of your biggest problems,

of course,

is you create this kind of issue,

namely that you an attempt to treat withdrawal.

You wind up getting valley aholic or a liberal 

aholic instead of an alcoholic.

And you want to attempt to use benzodiazepine 

drugs in the largest dose at the least frequent 

interval if you're going to use them at all.

And in general,

it's better not to use these medications chronically and 

people who are already abusing alcohol 

or other medications.

Now,

this is the drug that for practical purposes should be given 

to almost all alcoholics.

I give myself Iran to virtually 

every alcoholic that comes my 

way.

Why?

Because it's virtually impossible to work with a person who's 

drinking.

They will not keep their appointments.

They will not work with you in any way.

You have no hope for practical purposes.

This medication must be given in order 

to achieve a more prolonged period of 

detoxification.

High sulphur in itself is a drug which blocks alcohols 

metabolism and causes patients to become 

ill if they consume alcohol along with the dye 

sulfur and the reaction is proportional to the 

amount of myself or am and the amount of alcohol 

so that I rarely give more than 250 

mg.

Instead,

I usually give 100 and 25 mg and we 

usually give the medication at bedtime because there's slight 

sleepiness associated with it.

Some countries France and Canada have mandated 

this treatment via the court system,

have been implanted it in people's rear ends uh in their 

attempt to treat alcoholics.

This medication does three things for you.

That is a value in the treatment of alcoholism.

Number one.

This medic medication is only useful in the 

treatment of alcoholism so that it's called 

anti abuse and it can't be confused with 

depression or anxiety or anything else.

So you get very clear with the patient that they can't 

deny this problem,

namely that you're an alcoholic and you're different.

The second thing is you can't possibly take this drug and 

drink so that you achieve a more prolonged 

period of detoxification.

And finally,

and perhaps most importantly,

that without some motivation on the part of the patient to 

modify their addiction,

you don't have any chance at all in this process and that the 

sulfur and becomes the best way to check the 

motivation for the patient to take the medication 

and what we've done now we've published is to set up a 

method,

a simple method of measuring compliance.

We're able to measure this drug and blood,

breath and urine.

This happens to be one of our clinic patients.

We just have a given amount of C.

02 that's breathed uh through this female 

failing.

And we collect carbon di sulfide which is one of the metabolites of 

diesel from the patient blows into it 

until the color turns clear.

And then you'll note that this patient was taking his Antabuse.

There's a definite yellow color.

This costs very little to run this test 

and you find out that many people who claim to be taking interviews 

are in fact not taking it.

You also find out that many people that complain of the side 

effects of this medication in fact aren't taking it 

so that when they say that there is impotence,

yes,

I'm impotent taking Antabuse which must be extremely 

rare in my experience.

They never were taking the medication in the first place and 

impotence is very high frequency amongst 

alcoholic patients in general.

Well,

a prospective study,

I wanted to also mention to you that there are many sources of 

alcohol and I want to remind you 

that we had some physicians prescribing Alex 

offline and Antabuse together and wondering why the patients were 

having Antabuse reactions when they weren't drinking.

I've had the opportunity to prepare a booklet for the 

patients and um this is free to anyone who 

wishes to get this from your sales 

representative.

Um It's my personal feeling that our patients should know as much 

about any medication that they're taking.

And I give this book prior to giving the patient a 

prescription so that they will know everything that they need to 

know about deciding to take this medication.

It is written for the patient,

not for the doctor.

I recommend that if you use and abuse that you can have these in your 

office and you give them to the patient.

Finally,

I wanted to mention to you that we now have a prospective study 

underway using our patches as an endpoint for the 

alcohol consumption and using the drug lithium,

which was shown in this one study to be a 

great value in the skid row public and every 

population in preventing hospitalization 

in chronic alcoholics.

Well,

to conclude this this part,

I just wanted to relate to you that we've 

reviewed the issues about alcohol from 

psychological and physical point of view and all of this.

I had the opportunity to write in in Time magazine.

I was very happy to do this because um I think you can 

appreciate that in addition to a medical issues 

involved with alcoholism,

you obviously appreciate the social and psychological 

implications of this.

I might also add that I'm not an alcoholic and 

that no one in my family's ever been an alcoholic,

but I've certainly felt the pressure on 

myself treating these kinds of patients and their sort of 

Laos um if you will.

So I was kind of happy to prepare this.

And unfortunately when the article was published,

um there were everything 

that I had said had been removed And they were 

14 ads extolling the virtue of alcohol,

including this one suggesting that what mother needs for 

mother's day is Harvey's Bristol cream.

Um it's,

if you will,

it's the problem and that sort of summarizes 

it for me exactly what many 

people have felt all along,

that we paid a great deal of lip service to this 

in some way.

I can say that this final slide sort 

of lists where I am today,

just when I knew all of life's answers about this problem,

namely how to treat cirrhosis and various is they 

changed all the questions.

And so we hope today to change some of the questions.

And I think you'll see that in your practice are a great 

many people who suffer from addictive problems,

and that early diagnosis and appropriate treatment 

will show you that these problems are readily 

reversible.