alkoholisme

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Alkoholisme er en vanlig, folkelig betegnelse for det som i medisinen heller omtales som risikopreget alkoholbruk.

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alkoholˈisme

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Kommentarer (5)

skrev Morten Mikalsen

Syns det er noen svakheter med artikkelen. Når det står at AA hjelper mange, ja mange om man teller individer. Men prosentvis svært få tall under > 5% har vært antydet. Det bør også komme frem med slike data at AA selv ikke har gode tall. Videre bør kanskje SMART recovery nevnes.

Det bør også komme klart frem hvilket synspunkt forfatter har. AA har holdt fast ved alkoholisme som en sykdom eller allergi. Men noe som trenger en åndelig løsning.

Maja Slazavitza heller mot at det mer en en læringssykdom at tar til ordet for at kanskje ikke dopamin er en "feel good" substans, men mer "wanting" eller læringshormon.

Mens andre igjen nå gjennom SMART recovery snakker om en mer mistilpasset atferd, og noe man med riktig motivasjon og veiledning på et vis kan "vokse av seg".

Videre bør artikkelen diskutere farmakologi rundt faget. Filmen "One Little Pill" viser godt hvordan en farmakologisk avtjening av trangen kan være hensiktsmessig (Sinclair metoden).

svarte Guri Spilhaug

Hei Morten
Takk for kommentar. Denne artikkelen er svært gammel og det arbeides med å erstatte den med to andre artikler, hvorav en som særskilt beskriver behandlingsmodeller, og dette vil skje i nærmeste fremtid. Det har derfor ikke vært aktuelt å revidere nåværendee tekst.

svarte Morten Mikalsen

Takk for svar og beklager sent tilbakesvar. Har ikke hatt tid før jeg har begynt å jobbe med en relevant oppgave igjen. Men hvilke to andre artikler er det jeg kan forholde meg til?

svarte Guri Spilhaug

Hei igjen
På grunn av forhold i redaksjonen så har det enda ikke blitt ryddet opp i denne artikkelen eller lagt ut den andre jeg refererte til. Jeg har purret på dette og blitt lovet at det skal bli gjort. Så da regner jeg med at det over nyttår legges ut to nye artikler som skal erstattet denne.

skrev Morten Mikalsen

Ikke noe problem. SML imponerer meg stadig, med at man faktisk får gode svar og fagautoriteter. Jeg håper virkelig en dag at vi skal slippe mye pensumbøker fordi SML har blitt så bra og oppdatert og papir litteratur blir unødvendig. Håper heller at jeg ikke fremstår som masete, da jeg har kommentert på en del artikler :)

Legger ved en del av en oppgave tekst som jeg har skrevet om emnet og bruken av Selincro som en del av Sinclair Metoden.

INVERSE AGONIST OF THE m-OPIOD RECEPTOR AS PHARMACEUTICAL AID FOR BEHAVIOURAL CHANGE THROUGH “UPWARD-SPIRAL THERORY OF BEHAVIORAL CHANGE”

Since psychiatric health work is something I found quite challenging, during my time as a ambulance medical technician. I also acknowledge that it is within this field I have the most shortcomings in my theoretical knowledge. During all the other internships during the nursing studies, I have come across patients struggling with alcohol use disorder (AUD). Therefore I decided quite early that I wanted to do this internship in a clinic that have patients with AUD. Realizing that I knew little about this field, but remembering reading about dopamine in «Why Zebras Don´t Get Peptic Ulcers» by Robert Sapolsky. The book does not address a link directly between addiction and dopamine, but describes dopamine’s role in learned helplessness and depression, whereby dopamine plays a role (Øye, 2018; 1994). Actually is quite interesting that the syllabus “Praktisk Psykiatri” does not mention Sapolsky´s work when they actually have no references for the statement that the hippocampus shrink with prolonged exposure to corticosteroids (Aarre, 2018). Further I find it strange that our syllabus on the chapter of “Alkoholproblemer” does not mention the learning model. But the connection between AUD is described to be fourth fold. Skjøtskift, Opheim et al. also mention three pharmaceuticals that can be considered: disulfiram, acamprosate and nalmefen (2018). These three medications work on three quite different pathways, which is useful to understand, and also the pharmacodynamics of these pharmaceuticals reflects the development of the rehabilitation to recovery orientated focus. It will be necessary to use Wikipedia as a reference to some of the pharmacodynamics and history, this because it will take too much time to find all that information on databases that can be academically validated. But as I usually do, I will email the “Store Medisinske Leksikon” about articles that should be in their inventory or changed (Malt, 2018).

Disulfiram (Antabuse):
More commonly called “Antabuse”, works by inhibiting the breakdown of acetaldehyde into carbon dioxide and water. Acetaldehyde is a biproduct from the breakdown of ethanol and is usually not accumulated at dangerous levels in the body after a binge (Slørdal, 2014). But with disulfiram administration even a seasoned drinker can feel ill after just a small bottle of beer. But the drug does not remove the craving for alcohol, and hence its necessary for the patient to have those endogenous resources and a desire to stop drinking (Øye, 2018). Since Antabuse does not alter the level of craving for alcohol, there is a fair chance that the patient will stop taking the drug and could be worse off on their consumption of alcohol than before. Because it´s well known that craving for alcohol will actually increase the longer you stay abstinent (Eskapa, 2009).

Acamprosate (Campral):
How the pharmcodynamics of this drug works, is not fully understood. But it´s thought to influence the chemical signaling in the brain, and hence stabilize the patients during alcohol withdrawal. It is not an effective treatment used on it´s own, and research suggest that the best results are in combination with psychological support (Wikipedia, 2019, 13 oktober).

Nalmefene (Selincro):
The pharmacodynamics of Naltrexone used in USA and Nalmefene (Selincro) that is preferred in Europe, is very similar, they mainly diverse in their pharmacokinetics. Naltrexone is broken down in the liver and Nalmefene is secreted by the kidneys (ref???).
Nalmefene acts mainly upon the m-opiod receptor as an inverse agonist, but is also a weak partial agonist on the k-opiod receptors (Wikipedia, 2019). The mechanism of alcohol and Nalmefene is complicated and not fully understood, but there is strong evidence that alcohol stimulates the endogenous opioid system (Weerts et al., 2008). Naltrexone blocks the euphoria induced by alcohol on these receptors, but still impacts the Glutamate system. So drinkers will still be cognitively impaired, but the euphoria that can lead to excessive intake, will be blocked to a significant degree (Eskapa, 2009).







I started out searching YouTube for good videos about Dopamine´s role in addiction. I then came across «Drug Addiction is a Learning Disorder, says Maia Szalavitz» (Edge, 2016). This lead me to read her book «The Unbroken Brain» witch further addresses addiction as a learning disorder (Szalavitz, 2017). For me this really challenged my previous conceptions about addiction. If I go with my gut feeling, it just don´t seem right that some people are predisposed to addiction, without nature providing any benefits. It´s here that I think I have found a congruence between the role of dopamine as described by Robert Sapolsky (Sapolsky, 1994) and Maia Szalavitz addiction learning model. Maybe the attraction towards reward can be both a blessing and a curse, maybe people with addiction also have a great potential for learning.

Addicts to any kind of harmful behavior is often impulsive and driven by short term goals (Banerjee, 2014). This implies that patients in this group might not be open to therapy that addresses long term planning and assessments. They might even be in denial towards their on situation and where their current path will lead them in the future. Could it be that using the principles of conditioned positive reward on a more rudimentary level can prime them for more long term thinking? “The Upward Spiral Theory of behavioral Change” addresses this approach.
(Figure 1)

Figure 1.

This model implies that instead of confronting individuals with issues around their current habits that can be harmfull for them. A better approach would be to engage in an activity that is fun and by itself gives an immediate reward. This liking can lead to wanting, that is the true role of Dopamine. Such wanting can open up for a more long term and cognitive approach towards more healthy habits (Van Cappellen, Rice, Catalino & Fredrickson, 2018).


Because most literature and research about alcoholism touches base with Alcoholics Anonymous (AA), I felt it wise to read some of the AA original literature and to see what the 12 steps and “The Big Book” is all about (Seeberg & Anonyme, 2000). The 12-step program for me gave an impression of voluntarily indoctrination, and the question I was left with was: “Who does this program work for, and can it be harmful for some individuals”? There is suggestions that AA can actually be harmful, for some people. Dr. Wilson suggest that AA is best suited for individuals with a low maturity level, but directly harmful to individuals with a more self-reflecting perspective (Wilson, 2019). He uses Dr Loevingers “Milestones for Ego Development”, to categorize certain traits that will identify witch people that will fit the “mold”.
(Figure 2)

Figure 2.

Also, a big controversy in the fellowship is the exposure to predators when people are in a vulnerable state in early recovery. To be sober does not alter a persons personality, and it personal sobriety does not make you an expert on what work for other individuals (Szalavitz, 2017). Also AA expects a person to stay absolutely abstinent. But is that really the right way to recover. The jargon often used about AA members is “a dry drunk”. Meaning that the person is sober, but still have not changed. Dr. Roy Eskpa suggest that abstinence actually can be undesirable in rehabilitation. Because the longer a individual (mouse, monkey or human) stays away from alcohol, the higher will the subconscious motivation for drinking be (wanting).
(Figure 3)

Figure 3.

In further investigation of the history of rehabilitation, two very interesting points came up during this research. Bill Wilson the founder of AA, was actually a keen advocate for pharmaceutical treatment of alcoholism. Bill W himself advocated for the use of LSD, after his own experiments with the drug. The idea was that LSD could induce the spiritual awakening needed for an alcoholic to search a new purpose with life. But the AA fellowship opposed to the idea of recovering with a mind-altering drug. His wife Louis Wilson did actually write to the U.S. Food and Drug Administration after Bill W passed and asked them to research Niacine as a potential pharmaceutical treatment for alcoholism. Even to this day both fellowships Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) opposes to the idea of mind altering drugs, and many people in the fellowships go as far as saying you can´t claim «clean or sober time» necessary to receive the tokens handed out on meetings if you are on a pharmaceutical assisted recovery.

Further in my research I came across the video «How I overcame alcoholism» (TEDx, 2016). For me this was a eyeopener in how we look at rehabilitation. The drug Naltrexone was actually first produced in 1964 and approved by FDA in 1981. The theory is: you take a pill, wait 1 hour and you drink. You actually tell a alcoholic that they have to drink, to recover. Is this idea so paradoxically towards everything we thought we knew about alcoholism and addiction, that the research might have been suppressed by more established lobbying around treatment? Then especially 12-step programs that insist that alcoholism is a disease and only 100 % abstinence is a solution to freedom? This was something that to me seemed so controversial that I could not wrap my head around it, so I read “The Cure for Alcoholism” (Eskapa, 2009). If the research in this book is valid, there is a potential for 78% of people suffering from AUD, becoming 100% abstinent or «normal» drinkers. By taking one pill, one hour prior to drinking. I then remembered one of the conversations I had with one of my friends that have struggled with alcohol and ME. He told me that his physician had given him a prescription on Selincro. He never understood how these pills was supposed to help him, so he never took them. He tried the local fellowships in NA and AA, but he chose to end his own life. Maybe if he had stayed compliant to what is known as «The Sinclair Method (TSM)», he would still be alive and well today. Take one pill, one hour prior to drinking.

Dr Eskapa also shows to research that points toward the opioid receptors being hypersensitive when the effect of Naltrexone wears of. Hence a person that stays compliant will get a enhanced endogenous reward for activity conducted the day after drinking while taking Naltrexone (Eskapa, 2009). The existing theoretical accounts point towards the behavior being thought through pleasant situations around consuming the drug (this case alcohol). Also it less likely to endorse in healthy behavior, if the short term discomfort hugely outweigh the positive gain in the long run. By removing, at least partly, the arousal from drinking. Then increasing “the feel-good” by doing something healthy, it´s possible that alcoholics can by pharmaceutical extension get a new life. What do they need to do? What the know best: to drink. But take a pill one hour before consumption. Well I don’t believe it´s that simple. But honestly I believe that just taking some of the edge of the “wanting” for alcohol, a victim to addiction can get some relief to open up new perspectives in their life. Not getting the jugdemental “NOW YOU HAVE TO STOP TO DRINK FOREVER, OR ELSE………….”. They can gradually change their life, in the time their mind have the “wanting” for change, and is not only forced in to change by scare-tactics.












Litteraturliste

Aarre, T. F. (2018). Stemningslidingar. I T. F. Aarre & A. A. Dahl (Red.), Praktisk psykiatri (2. utg., s. 139-163). Bergen: Fagbokforlaget.

Banerjee, N. (2014). Neurotransmitters in alcoholism: A review of neurobiological and genetic studies. Indian journal of human genetics, 20(1), 20-31. https://doi.org/10.4103/0971-6866.132750

Edge, B. T. (2016). Drug Addiction Is a Learning Disorder, says Maia Szalavitz. Hentet 2019, 10 oktober fra https://youtu.be/yf9F3vIEJLQ

Eskapa, R. D. (2009). The cure for alcoholism : drink your way sober without willpower, abstinence or discomfort. Dallas, Tex.; London: BenBella ; Turnaround [distributor].

Malt, U. (2018). Alkoholisme. I G. Spilhaug (Red.), Store Medisinske Leksikon. Hentet fra https://sml.snl.no/alkoholisme

Øye, I. (2018). Disulfiram. I H. Nordeng (Red.), Store Medisinske Leksikon. Hentet fra https://sml.snl.no/disulfiram

Sapolsky, R. M. (1994). Why zebras don´t get ulcers (3. utg.).

Seeberg, A. S. & Anonyme, a. (2000). Anonyme alkoholikere : historien om hvordan tusener menn og kvinner har gjenvunnet helsen etter alkoholmisbruk (3. utg., [i.e. 5. utg.?]. utg.). Oslo: Anonyme alkoholikere i Norge.

Skjøtskift, S., Opheim, A. & Daltveit, J. T. (2018). Alkoholproblemer. I T. F. Aarre & A. A. Dahl (Red.), Praktisk psykiatri (2. utg., s. 307-323). Bergen: Fagbokforlaget.

Slørdal, L. (2014). Misbruk av legemidler og rusmidler. I O. Spigset (Red.), Legemidler og bruken av dem (2. utg. utg., s. 376-384). Oslo: Gyldendal Akademisk.

Szalavitz, M. (2017). Unbroken brain : a revolutionary new way of understanding addiction.

TEDx. (2016). How I overcame alcoholism [Videofil]. Hentet fra https://www.youtube.com/watch?v=6EghiY_s2ts

Van Cappellen, P., Rice, E. L., Catalino, L. I. & Fredrickson, B. L. (2018). Positive affective processes underlie positive health behaviour change. Psychology and Health, 33(1), 77-97. https://doi.org/10.1080/08870446.2017.1320798

Weerts, E. M., Kim, Y. K., Wand, G. S., Dannals, R. F., Lee, J. S., Frost, J. J. & McCaul, M. E. (2008). Differences in δ- and μ-Opioid Receptor Blockade Measured by Positron Emission Tomography in Naltrexone-Treated Recently Abstinent Alcohol-Dependent Subjects. Neuropsychopharmacology, 33(3), 653-665. https://doi.org/10.1038/sj.npp.1301440

Wikipedia. (2019). Nalmefene. Hentet 1 december 2019 fra https://en.wikipedia.org/wiki/Nalmefene

Wikipedia. (2019, 13 oktober). Acamprosate. Hentet 27 november 2019 fra https://en.wikipedia.org/wiki/Acamprosate

Wilson, E. W. (2019). AA- Who it helps, Who it harms, Who it kills & Why. Calabasas, California: PCM Printing.

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