October 1 9 6 8

harmacological Approach to Alcoholism by Stanley E. Gitlow, MD ciate Clinical Professor of Medicine, “The simple act of prescribing sedatives in order to Mt. Sinai Medical School, relieve the anxiety symptoms of the alcoholic is the New York, N . Y . one thing that will guarantee failure almost 100% of the time. There are for the most part no drugs o f any great value in treating alcoholism.”

thing against pain but do put one be “sedativism.” This “sedativism” significant amounts through the to sleep. They all belong to one is addiction to any one of the stomach lining. Thus, it will reach group of compounds, the members soporifics, and they are all grouped the bloodstream faster than most o f of which possess similar pharma- together in any good pharmacology the other sedatives and will work cological behavior. Quantitatively, text. What is it that they have in sooner. Ethyl alcohol reaches there are differences in how quickly common? What is it that they do? measurable blood levels within fifthey start to act and how long they We will take one example, ethyl teen to twenty minutes after it is last, but they are all sedatives with alcohol, and examine its properties. imbibed. Obviously, if you want to the same qualitative effects. First of all, it’s an irritant. When it get a very quick blood level, you T HE DRUG I intend to discuss is ethyl alcohol, also commonly known as ethanol, and I want to The reason ethyl alcohol has deserved special attention and has a disease associated with it called is ingested, it irritates the stomach can breathe ether and get it in a lining and increases the secretion of matter of seconds; indeed, there are start by orienting you as a pharma- hydrochloric acid. Hence, other people addicted to breathing ether, alcoholism is, perhaps, that it was lesions of the stomach, such as pep- chloroform or nitrous oxide, but cologist would be oriented. Alcohol the first of the sedatives to be tic ulcer, esophagitis, and diaphrag- these drugs are not so easily obis one of a group of aliphatic seda- discovered and it has always been tives or soporifics, which include matic hernia, which are made worse tained. used socially. Alcohol is easily by the presence of acid, are all Once alcohol reaches the bloodliquid substances such as paralde- available without a prescription, hyde, solid drugs such as the exacerbated by alcohol. It is also an stream, three things can happen to without a physician, and has be- irritant to the lower gastrointestinal it. It can be excreted through the barbiturates, and gases like ether come interwoven with the fabric of and chloroform. These drugs are tract, increasing motility and pro- lungs, and anyone who has taken our society and our social func- ducing an outpouring of fluid, which a few drinks knows that others can not narcotics, which take away pain tioning. That, I think, is the reason but do not necessarily put one to will not infrequently cause enteritis smell alcohol on his breath. It can why alcohol, rather than one of or colitis. also be excreted through the urine. sleep. The soporifics don’t do any- the other sedatives, has become the In addition to its properties as an Both of these pathways take care of * Edited from transcripts of a lecture delivered basis for the title of a disease, but irritant, ethyl alcohol is the only minimal amounts compared to the for the Alcoholism Interagency Training Pro’ ect of the Community Council of Greater N.$ a more correct title would actually drug known which is absorbed in total amount of alcohol that has

been ingested. Most of it is broken they depressed everything simuldown to two carbon chain com- taneously down the line, they would pounds which are the basic food- hit not only the thinking centers, stuffs of the body. Once these have not only the centers concerned with been formed, the particular food balance, but also the vital centers from which they came is no longer in the medulla which are necessary important; the body doesn’t care to keep the heart beating, the blood whether calories come from alcohol vessels contracting, and the lungs or potatoes or carrots. However, the end of the second hour, it starts with a “chemical hammerM-it breathing. Any sedative which alcohol goes through an intermedi- down. The blood level reaches a doesn’t make any difference which. worked on these things evenly ate acetaldehyde step, which is im- normal (meaning unmeasurable) If you were to use a large dose of would be totally useless, because it portant only because the body level within twelve hours. If the cyanide to do this, you could would kill as quickly as it would cannot tolerate acetaldehydes. Nor- individual takes a very large dose, permanently stop the nerve cells sedate; but all of the soporifics mally they are broken down very the peak will be higher and last from working. On the other hand, work first on the cerebrum and the quickly by an enzyme called alde- a bit longer, but the blood level ethyl alcohol will stop the cells cerebellum, second on the spinal hyde dehydrogenase to produce will nevertheless reach zero within from working, but in a reversible cord, and last on the vital centers. acetic acid, which is innocuous and twenty-four hours. In other words, fashion: It will interfere with func- Hence a little alcohol works only can be burned up as a foodstuff. no matter how much the individual tion, but the body is able to fight off on the cerebrum (the individual However, there is an enzyme-in- is capable of drinking at one sitting, the drug and repair itself. However, gets a little confused or high); a hibitor known as disulfiram (Anta- all of the alcohol is gone from his if you take enough, you can kill larger dose knocks the person out buse) which prevents the action of body within twenty-four hours. If the nerves. Now I can hit you on and he’s unconscious with no rethe dehydrogenase. Hence the he has any left, he has been drink- the head with a hammer so as to flexes; and a large enough dose will acetaldehydes can no longer be ing after that first drink. If that leave you unconscious, or I can hit kill him. gotten rid of, and they are very were all there was to it, people you on the head with a hammer so When alcohol depresses the toxic. If an individual takes Anta- would not be drinking alcohol you are dead. It’s the same hammer, brain, it diminishes the psychomotorbuse, the enzyme-inhibitor, and socially, because it wouldn’t be but it’s a question of how hard I hit. activity level. The psychomotor-acthen drinks alcohol, he is left with serving any purpose. But when the So, too, with this drug ethyl alcohol: tivity level may be measured by the the toxic acetaldehyde and this will alcohol blood level goes up, some- I can give enough of it to kill or a amount of anxiety or tension noted. make him sick. thing happens in the brain, and that small dose to stop only certain of Diminished psychomotor-activity What determines the blood level is the only reason alcohol is used. the neurones from working. Man level means relief from anxiety, of alcohol? The body has a limit as The brain is essentially a switch- discovered long ago that stopping from whatever it is that bothers the 1 to how fast it is able to get rid of board with a large number of nerve some of the neurones from working individual: insomnia, tension, job ‘ blood alcohol. The individual can cells (neurones) whose function is on a temporary basis may be and family pressures. When the metabolize about an ounce every to transmit impulses from one point pleasurable. person’s blood alcohol rises, his psytwo hours, and his blood-alcohol to another. The transmission of im- All of the sedatives or soporifics chomotor-activity level goes down; level will remain fairly constant. pulses depends on a group of -alcohol being only one of them- he is relieved, relaxed, less anxious, When alcohol is ingested, a measur- biochemical events, and if you inter- are irregular depressants of the cen- less frightened, less worried than able blood level is attained within fere with any one of these, you stop tral nervous system. By depressant before. But as soon as the bloodfifteen to twenty minutes and the neurone from functioning. You is meant a substance which dimin- alcohol level starts to fall, this reaches a peak at the end of the can stop it with a sledgehammer, ishes or stops normal function. The sedative effect begins to get lost first hour or hour and a half. By with a right cross to the chin, or sedatives are irregular, because if and even with a big dose, such as a

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couple of jiggers, wears off very diminish again. But in about two rapidly after the second hour. If hours, the psychomotor-activity level to return to its normal state. individual behaves as though somethat were all, there is a distinct level will rise again, higher than The person who has taken so one were attempting to kill him. possibility, in my opinion, that we ever. This cycle of increased ten- much alcohol over a protracted pe- His psychomotor activity may reach might not have the disease called sion, drinking, short-term sedative riod of time that his psychomotor- the point of causing spontaneous alcoholism, because under those effect, longer-term agitating effect, activity level is extremely elevated generalized convulsions. circumstances an individual could higher tension, drinking again, can may suffer one of several effects. Basically, this is a condition in drink to get relief, his anxiety level go on for some time. Eventually, He may start to shiver and shake, which the brain is tremendously would diminish, the drink would however, a point is reached when pace back and forth, sweat, palpi- overagitated. Thus, the guy who wear off, and he would come back decreasing the psychomotor-activity tate, and show great agitation and merely had six drinks last night and to where he was before. But that is level to a really low state is difficult, tremulousness. This has been called is edgy this morning and the guy not what happens, because there is no matter how much alcohol is a withdrawal state or syndrome, with spontaneous seizures and a another effect and this acts in the taken. This is because the agitating which is something of a misnomer, full-blown case of delirium tremens opposite direction. effects from all of the previous since the individual may still be are suffcring from the same disease, The second effect is to increase drinks add to one another. drinking all he can hold. However, and this is caused by the pharma- This agitating effect occurs in his agitated condition is breaking cologic effects of the sedative drug. the psychomotor-activity level. This experimental animals and in hu- through because he has raised it so It’s just a matter of how much you increase takes place immediately, ‘

right after the drink, but is not im- mans; it’s the pharmacology of the high that no amount of current take and how long you take it. One mediately felt because it is a change drug. You don’t have to be an alco- sedation can possibly reduce it to can produce D.T.’s with seizures in of less intensity than the sedative holic in order to experience it; bearable levels. If at this point he any individual at will, and in fact anyone gets this effect if he drinks runs out of money or has an acci- this has already been done with effect. This latter lasts two to three : hours, while the opposite or agitating effect usually lasts for about enough. For example, after an evening of heavy social drinking, you dent or for some other reason stops drinking and is left in his agitated human volunteers who were not alcoholics. Probably the greatest have a hangover, the common name state with no current sedation, he single cause of convulsions in the twelve hours after one big drink. given to this condition of after-agi- may get an extremely severe with- U.S. today is alcohol, not epilepsy. Therefore, as the short-term seda- drawal syndrome. He may get, tive effect wears off, the other effect tation. A drink will relieve this With a man who develops seizures because it provides sedation to alcoholic hallucinosis, which means in middle life, has never had them of alcohol, increased psychomotor basically that his brain is so irriactivity, becomes apparent. No one counteract the agitation of last before, and is a pretty heavy night’s drinking. Of course, the table it sees, hears, feels things that drinker, it’s usually alcohol,, not a in this world can get a sedative aren’t there. It makes up its own morning drink is going to be fol- brain tumor. effect from any known drug without sensory input. And if the individual it being followed by an agitating lowed by its own agitation for an- Up to now, we have assumed that other twelve hours, but the drink is one step sicker, he will go all the what is happening is a reversible effect which wears off more slowly. way to a condition known as demay get you through a trying period phenomenon, but this is true only The piper must always be paid. lirium tremens (D.T.’s), in which Around the end of the second until you begin to get a decrease of up to a point. The central nervous the agitating effects of the heavy not only the sensory input but the system has the only cells of the hour after the original drink, when motor output has become trethe sedative effect wears off and the drinking of the night before. By human body which never regenerafternoon, you are feeling pretty mendous, and he is literally unable ate. Every other cell, including agitating effect starts to gather to stop moving. He paces around, momentum, the individual is more well again. If, however, an individ- those of the peripheral nerves, can tears at his bed linen, hallucinates grow back or reduplicate, but brain tense than he was before he drank ual has been drinking heavily over a long period, it may take many actively. A sine qua non to this cells, once destroyed, do not. The at all. And so he will have another delirium is not only the tremulousdrink and the anxiety level will days for his psychomotor-activity individual is born with the maxiness, but absolute terror. The mum number of brain cells he will

stance in which a drug has been utilized and is now gone from the body, totally gone, but has resulted in an organic, measurable, overt disease state, a condition which de- alcoholic who is also a narcotic mands more of the drug in order addict, or vice versa. ever have, and from then on, he has but not always, so that eventually to get relief, This doesn’t necessarily The withdrawal state from nara decreasing amount throughout brain cells will get destroyed. When mean the individual is habituated cotic drugs is less severe than withlife. He never gets any more, and enough of them are damaged, you or emotionally dependent, but just drawal from sedatives. Addicted inhe is losing some, probably, every get irreversible changes in the be- that he is measurably sick after the dividuals rarely, if ever, die from day of his life. Brain cells are de- havior and the psychological status drug is gone, and he requires more narcotic withdrawal, whereas death stroyed by traumatic injury, by of the individual. These may never of it for relief. Alcoholism was for from alcohol (or other sedative) arteriosclerosis (less blood supply return to normal, no matter how years mistakenly considered to be withdrawal is quite common. Secgoing to the brain as the person gets long he’s sober and eats a good diet. a habituation, but alcohol is a true ondly, an individual who is taking older), or by toxic substances. For- The effects of alcohol on other addicting substance, as is every one a new dose of sedative to control tunately, the individual has many parts of the body are relatively un- of the aliphatic sedatives or soporif- the psychomotor agitation caused more brain cells than he needs, and important, since they involve but a ics. Now what is cross-addiction? by yesterday’s intake is not a wellif ten percent of them are destroyed, minority of heavy drinkers when This simply means that among this functioning human being. Either the probability is that nobody will compared with the effects upon the group of sedative drugs, I can re- he is near to sleep or he is very know the difference. On the other brain, reversible or not, which take place one with any other at any uncomfortable and functioning hand, if you lose twenty to thirty place in 100 percent of alcoholics. time, at random. I can replace al- poorly. On the other hand, if percent, even you may become For example, cirrhosis of the liver cohol with nembutal, nembutal with narcotics are given to the narcotic aware that the memory isn’t quite occurs in about eight percent of pentothal, pentothal with paralde- addict to stop the withdrawal synthere, that you can’t think your way alcoholics and one percent of the hyde, paraldehyde with chloral hy- drome, he can function and he need through a problem the way you nonalcoholic population. Then there drate, and if I adjust the dosage not continue up a scale of increasing used to. The brain just shrinks and is pancreatic disease in a very small correctly and give it intravenously, psychomotor activity. A narcotic eventually will be half the size of a percentage. There is an increased the individual will probably not addict can be maintained on a normal brain. In a chronic alco- likelihood of pulmonary infections, know which he is getting, because stable amount of drug for years and holic, after many years of drinking, perhaps due to the sedation of the the effect upon the brain is almost can function all during that period postmortem examination will show patient so that he doesn’t clear the identical. Hence there is cross- of time. Thus the narcotic addict that not much of the brain is left. secretions out of his chest well addiction among the different mem- can maintain a plateau, whereas the Now the alcoholic may of course enough. There is also alcoholic bers of this group of compounds, alcoholic, due to the pharmacology do other things to his nervous sys- cardiomyopathy, a disease of the but there is not cross-addiction of his drug, is compelled to reach tem from bad eating habits, but the heart muscle due to heavy intake of between these and narcotics. Both beyond, losing functional capacity probability is that he can do this alcohol over a period of years and sedatives and narcotics are capable in the process. damage just with ethyl alcohol, especially prevalent in Negro males. of addicting, but these addictions are Now I want to discuss tolerance. eating a beautiful diet the whole All of these complications of heavy separate disease states. Of course, Suppose you take ten drinks and I time, because ethyl alcohol per se ethanol ingestion are comparatively one individual can become addicted take ten drinks, and within an hour can apparently injure the brain rare. to both groups of compounds, but I am lying asleep on the floor and biochemically. It’s probably a re- Now let us consider the nature of this is very rare. We don’t know you are walking around appearing versible injury most of the time, addiction. Addiction is a circum- why, but it is unusual to find an as though nothing had happened.

This means that you are more ing countermanded by agitation tolerant of the pharmacologic from past drinking, and which really alcohol addiction and alcoholism, do not feel like other people until effects of alcohol than I. Thus, isn’t tolerance at all. Take, for ex- for they are not the same. One is their psychomotor level is artificially tolerance accounts for variability of ample, an alcoholic who is knocking a pharmacological term; the other, brought down by sedatives. This effect relative to a single dosage of off a quart a day. Give him ten or a medical term for a disease state may or may not be so, but many a drug. There are individual differ- twelve drinks. You or I would be (and, as indicated before, it really people believe that such a bioences in the rapidity with which lying on the floor, but he is not even should be “sedativism” rather than chemical defect does exist. alcohol is metabolized. In addition, “alcoholism”). I can produce alco- There is a clue in the frequent sleeping. His psychomotor-activity if we look at one individual over level from past drinking is very high, hol addiction in any one of you by statement of alcoholics: “I had my his lifetime, we will find that his and he can take a heavy load of giving you ten drinks today, twenty first drink at eighteen, and I finally tolerance diminishes with age. For sedation just to bring him to a rela- tomorrow, twenty the next day, the found out what it was like to feel example, if an alcoholic is abstinent tively normal psychomotor level. next, and so on until I stop the normal. I had felt abnormal all my for ten years and then relapses, he He demonstrates the two opposite alcohol and you start having life until that first drink, and then I will get much sicker, with less pharmacological effects of alcohol seizures. You are in a withdrawal felt like everybody else. If I could alcohol intake, than he used to. operating together, and such indi- state, alcohol-addicted, but that just maintain that level . . .” But of The difference is simply that his dividuals will not infrequently be does not make you an alcoholic. course an alcoholic can’t. If his body and especially his brain are found walking around with blood- The sine qua non of alcoholism is initial level of anxiety was already ten years older, and every year his alcohol levels above one-half of one that the individual goes back and too uncomfortable, too agonizing to tolerance for alcohol has decreased, percent, which is usually considered does it again and again, even though bear, how can he tolerate the ineven though he wasn’t drinking. to be within the lethal range. These he suffers loss of job, loss of health, creased anxiety from the agitating From this point of view, alcoholism people may be driving a car, walk- loss of family. The definition of the effect of the sedative? The only way is a self-limiting disease because, ing around, talking for hours on the disease includes not just addiction, he knows to relieve it is to take anwith diminishing tolerance, the but compulsivity. Now why, when other drink, and so he’s off and telephone-but with one difference: amount the alcoholic can drink he suffers so much, does he do it running. His decision to drink or Tomorrow they will be amnestic for eventually is very little and the again and again? Because he is not to drink has to be made before the event. This is called a blackout, amount of suffering he does for it and people get these quite soon compelled to, but not primarily he takes the first one. because of the suffering that goes If you or I have a hangover after is very great. Sooner or later, ei- after they start to drink in an alcother the disease kills, or he decides holic fashion; yet there is already a with it. He would like to find a way a party, it is unlikely that we are to stop drinking, and our job is to considerable amount of dysfunction, of avoiding the suffering and not going to drink to relieve out try to convince him to quit before of illness, in a brain which achieves infrequently will come to the physi- temporarily elevated psychomotorit kills him. a blackout state. It isn’t that the cian asking for medication that will activity level, unlikely that we are So far, we have discussed true individual forgets what he was do- let him have the sedation but pre- going to take a “hair of the dog,” tolerance, tolerance to both the ing; even while he was doing it, his vent the suffering. The reasons for except perhaps one Bloody Mary, sedative and the agitating effects of consciousness was clouded and he the compulsion to drink may be and the majority of us won’t even alcohol. There is another phenom- did not consciously “know” what he psychological; I used to think that, do that. Most of us will say: “I enon often described as tolerance, was doing. but now I am not so sure. These shouldn’t have drunk so much, and which refers to current sedation be- I want to distinguish between individuals may have a different I won’t do it again for a long time.” psychomotor-activity level on a We can tolerate this degree of biochemical basis. The norm, for psychomotor activity, and after a them, may be higher than other few hours we begin to feel better. people’s because of a biochemical The alcoholic can’t tolerate it and defect within the brain, so that they must drink again. This is not voli-

tional; he must drink again to re- cause greater agitation later. The Obviously, the way to handle lieve the discomfort which he docfor is in a circumstance where this individual in order to keep him couldn’t tolerate even when it was he’s damned if he does and damned from drinking again is not through less intense before. It is relatively if he doesn’t. Hence Rule One: If the use of sedative drugs, because easy to understand continual drink- you’re going to have to relieve the as soon as you give sedation of any ing under these circumstances; but symptoms of this alcoholic by giving sort, he’s off and running again. In suppose we see this man after he a sedative drug, you must rarely if fact, the simple act of prescribing has been sober six months or six ever give it outside the hospital. sedatives in order to relieve the years. He gets anxious, takes a Give it only in a situation where you anxiety symptoms of the alcoholic drink, and in the majority of cases have complete control of the patient is the one thing that will guarantee begins the cycle again. He can’t and the dosage of medication. In a failure almost 100 percent of the plead ignorance, and he did it cold hospital, the physician can give time. There are for the most part no sober. some sedatives in association with drugs of any great value in treating For this, there are only two phenothiazines, drugs such as alcoholism. Librium, Valium, Milpossible reasons. One is that alco- Thorazine or Sparine. These drugs town (Equanil), and Doriden are holism is a compulsive psychiatric will not usually prove addicting, will often used, but share an undesirable syndrome of such a nature that his increase the effects of the sedatives propensity for being variably adpsyche is going to force him at the physician is giving, and will dicting. Remember, we noted at usually don’t like them, don’t get knifepoint to drink throughout his enable him to relieve the patient the outset that all of the sedative the relief they want. Thorazine does life. The other possibility is that on without causing a marked increase drugs are qualitatively identical and not significantly increase the psya biochemical basis the alcoholic is in agitation. By the fourth or fifth can replace one another: alcohol, chomotor-activity level and hence truly uncomfortable without seda- day, the alcoholic will perhaps still barbiturates, chloral hydrate, par- is practically nonaddicting, but I tion. How much is psychological be a little tremulous, but will usually aldehyde. The individual develops believe that the individual who and how much is biochemical? Is feel well enough to go back to his a cross-tolerance, so that if, for takes it will more readily make a the individual starting out with a job. But, though the withdrawal example, he builds up a huge transfer back to alcohol than those normal anxiety level, or at a level state is at its worst for only a few tolerance for alcohol, it will take a who use no drugs. Since Thorazine higher than normal? If the psycho- days, its more subtle effects- huge amount of ether to knock him doesn’t give the alcoholic what he motor-activity state can be mark- psychological abnormality, char- out on the operating table, a fact wants, he is almost bound to take edly modified by drugs, as it can, acter disorganization-may last for which all anesthesiologists know. something else in short order. I’m . how do we know it was “right” in weeks. If you use other sedatives to treat also convinced that if you give any the first place? We don’t. It is quite Now the patient has been with- the alcoholic, you go back and forth sort of “oral magic” to an alcoholic, possible that the individual has a drawn from alcohol and is ready for between the two and never solve you are almost guaranteeing a rebiochemical defect to start with, long-term therapy for the recidivism anything-the individual remains lapse. If you give a pill (even if which creates a fertile soil for thc or compulsivity that makes him addicted. Patients who take Mil- you fill it with sugar), you are in growth of alcoholism. start the whole cycle again, over town or Librium often get so jittery essence saying: “Yes, there is some- The treatment of this disease is and over again. You’ve got to help on these drugs that they go back to thing wrong that is correctable by to stop the use of the causative him build some sturdy walls before alcohol to get sedation. some magic taken by mouth.” But agent. When the physician first sees the wolf comes to blow again at his The case of the phenothiazines is the fact of the matter is, there are the alcoholic, he is a very agitated house. And you begin to appreci- somewhat different. These drugs no sedatives or tranquilizers that fellow and needs sedation, but if we ate the vigor and persistence neces- (Thorazine, etc.) work on a differ- do anything for this disease except sedate him, whatever we use will sary in therapy. ent Dart of the brain. and alcoholics cause trouble, and one should do

everything possible to assist patients be for one of these reasons: “I ran how terribly trapped I am. All recourse to sedation. Obviously, he to realize that there is no magic. out and forgot to buy more”; “I people say is, I just won’t quit drink- has to be given something to re- Antabuse, on the other hand, has forgot to take it”; “I went on a ing, or I bring it on myself.” When place the “oral magic,” and the only something to offer in the treatment trip and forgot to pack it”; “I the alcoholic becomes aware that thing I know is a helping hand. The of this disease. Antabuse is not a wanted to do it on my own and not you do understand, you may have helping hand may be Alcoholics drug which works on the central use a crutch”; “I was so well, I a successful patient. With com- Anonymous or psychotherapy; it nervous system; it does not relieve thought I had no further need for passion and consistency, a great may be the clergyman, the social anxiety; it does not change the it.” .Now, if he relapses, I have deal can be accomplished. worker, or the physician. The alcopsychomotor-activity level of the predicted these “reasons” in ad- The long-term treatment of alco- holic needs people who understand brain. It has no effect whatever, un- vance and so can help the patient holism must be directed toward in- and are compassionate, who offer less the individual takes alcohol on see that he planned the drunk, and creasing the abstinent alcoholic’s the ear, the time, and the hand to top of it, in which case alcohol then we can get down to the real capacity to tolerate anxiety without help him through all his discomfort. metabolism stops at the acetalde- precipitating causes, not the phony hyde stage. The acetaldehyde level ones. builds up in the bloodstream, and The third thing Antabuse does is it gives a toxic reaction, which in- to assist patients to answer, once a cludes nausea, vo’miting, flushing, day, the question of drinking or not vasomotor collapse, and, in extreme drinking. They are not preoccupied cases, death. Most patients, even about drinking all day long, and without trying it out, will believe they feel a tremendous relief, at this. Antabuse is taken every day least for a temporary period. Cerand gives four or five days’ protec- tainly by itself Antabuse is not the tion against drinking. answer, but it is a helpful tool, Suggesting Antabuse permits me and it gives you time to work with quickly to gauge the degree of your patient. Some people take it motivation of the patient. If I get for years in order to guarantee their a negative attitude, I know the odds sobriety, but it must be taken of doing anything with this patient voluntarily and only because the are poor. But if the patient is will- individual wants to stop drinking. ing to take it, I know I have a more In treatment, cessation of alcohol promising situation. Second, Anta- intake is the first goal. Education buse stops impulsive drinking com- about the nature of the disease is pletely, because if the person on essential, but most important is to Antabuse drinks, he will be quite ill. bridge the alcoholic’s isolation by If he comes in with a relapse, I the use of simple understanding and have the opportunity to prove to compassion. Usually the alcoholic him that he decided in advance to has been trying to say right along get drunk and so stopped taking the (and pretty much no one in his en- Antabuse several days ahead. I vironment has understood) : “I’m always have told him in advance strung up, I’m caught, and nobody that if he stops his Antabuse, it will seems to realize how violently ill,