Alcoholics Anonymous, an informal fellowship of recovering alcoholics, has proven to be the single most effective force in the rehabilitation of alcoholic patients. The philosophy of this organization is embodied in its “12 Steps,” a series of principles for sober living that guide the patient to recovery. The AA approach stresses in particular the practice of making restitution, the necessity to help other alcoholics, trust in a higher power, the group confessional, and the belief that the alcoholic alone is powerless over alcohol. Although accurate statistics are lacking, it is said that about one-third of the members who express more than a passing interest in the program attain a state of long-sustained or permanent sobriety. The methods used by AA are not acceptable to every patient, but most who persist in its activities appear to benefit; in particular, the physician should not accept a patient’s initial negative reaction as reason to abandon AA as a mode of treatment.
Finally, it should be noted that alcoholism is very frequently associated with psychiatric disease of other types, particularly sociopathy and affective illness (the term dual diagnosis is used by psychiatrists to denote this combination of psychopathologies). In the latter case, the prevailing mood is far more often one of depression than of mania and is more often encountered in women, who are more apt to drink under these conditions than are men. In these circumstances, expert psychiatric help should be sought, preferably from someone who is also familiar with addictive diseases. Attempts are being made to treat alcohol addiction with invasive methods such as deep brain stimulation of various sites but these can only be considered experimental.
The role of physicians in caring for patients with alcohol problems has been outlined by several governmental agencies and is summarized in the review article by O’Connor and Schottenfeld.
The opiates, or opioids, strictly speaking, include all the naturally occurring alkaloids in opium, which is prepared from the seed capsules of the poppy Papaver somniferum. For clinical purposes, the term opiate refers only to the alkaloids that have a high degree of analgesic activity, that is, morphine. The terms opioid and narcotic-analgesic designate drugs with actions similar to those of morphine. Compounds that are chemical modifications of morphine include diacetylmorphine, or heroin, hydromorphone (Dilaudid), codeine, hydrocodone, oxycodone (OxyContin), and from the Victorian era and later, laudanum and paregoric. A second class of opioids comprises the purely synthetic analgesics: meperidine (Demerol) and its congeners, notably fentanyl, methadone, levorphanol, propoxyphene (Darvon), loperamide (the active ingredient in Imodium), and diphenoxylate (the main component of Lomotil). The synthetic analgesics are similar to the opiates in both their pharmacologic effects and patterns of abuse, the differences being mainly quantitative.
Opioids activate G-coupled transmembrane receptors, meaning they influence neuronal activity through the intermediate of cAMP; the receptor types are denominated as mu, delta, and kappa. An understanding of the clinical effects of opioids is clarified by the knowledge that these receptors are concentrated in the thalamus and dorsal root ganglia (mu receptors, pain), amygdala (affect) and brainstem raphe (alertness), and Edinger-Westphal nuclei (pupillary miosis). Receptors in the brainstem, also of the mu type, are involved in modulating respiratory responses to hypoxia and hypercarbia (respiratory suppression). Receptors are also widely distributed in neural components of other organs, particularly the gastrointestinal tract, accounting for the constipation that is an effect of the administration of this class of drugs.
The clinical effects of the opioids are considered from two points of view: acute poisoning and addiction.