Alcoholism: a challenging physician-patient encounter

Microsurgical tissue transfers for head and neck reconstruction in patients with alcohol-induced mental disorder

BACKGROUND

Free tissue transfer in patients with organic mental disorder has always been known to be risky. Herein, the outcomes of free tissue transfers for head and neck reconstruction in those with alcohol-induced mental disorder were analyzed.

MATERIALS AND METHODS

We retrospectively reviewed and analyzed data from the past 10 years of 1,364 patients who had undergone microsurgical tissue transfers after head and neck cancer ablation. Among them, 54 patients had been diagnosed with alcohol-induced mental disorders post-operatively. Age ranged from 33 to 71 years. Alcohol-drinking history averaged 17.5 years. Reconstructive procedures included 25 forearm flaps, 13 anterolateral thigh (ALT) flaps, 10 fibula osteocutaneous flaps, and 6 double flaps (fibula+ALT). The outcomes and complications were analyzed.

RESULTS

Onset periods ranged from the first to fourth days post-operatively. Duration of alcohol withdrawal or delirium tremens was 3-10 days. All patients gradually stabilized after immediate psychiatric consultation and intensive medical treatment. The flap survival rate in patients with alcohol withdrawal was significantly decreased in comparison with patients not suffering alcohol withdrawal (83% versus 96.4%, P < 0.001). During this critical post-operative period, 28 (52%) patients with alcohol withdrawal syndrome experienced complications; 26 (48%) suffered flap-related complications, and 19 (35.2%) required additional surgery. The analytical parameters revealed that secondary operative procedures and duration of hospitalization differed significantly between the complication and non-complication groups (P < 0.001).

CONCLUSION

Higher rates of complications and level of critical care were needed in patients with alcohol-induced mental disorder after head and neck microsurgical reconstructions. Treatment requires a multidisciplinary approach, rapid diagnosis, and intensive medical care.

Three perspectives on addiction

Three perspectives on addiction promulgated during the 1990s are reviewed, along with many earlier contributions to the understanding of addictive illness. It is suggested that these distinct yet overlapping formulations of the dynamics of addiction form a hierarchy for each patient suffering from an addiction. Assessment of a patient's ego strength, and of the relative importance of addictive behaviors in overall character structure, allows referral to various types of treatment, including psychoanalytic therapy. Case examples are presented, including material from the psychoanalysis of a woman addicted to heroin, methadone, cocaine, amphetamines, nicotine, alcohol, and shopping.

Alcohol counseling: physicians will do it

OBJECTIVE

To assess the use of a brief provider-delivered alcohol counseling intervention of 5 to 10 minutes with high-risk drinking patients by primary care provider* trained in the counseling intervention and provided with an office support system.

DESIGN

A group randomized study design was used. Office sites were randomized to either a usual care or special intervention condition, within which physicians and patients were nested. The unit of analysis was the patient.

SETTING

Primary care internal medicine practices affiliated with an academic medical center.

PARTICIPANTS

Twenty-nine providers were randomized by practice site to receive training and an office support system to provide an alcohol counseling special intervention or to continue to provide usual care.

INTERVENTION

Special intervention providers received 2 1/2 hours of training in a brief alcohol-counseling intervention and were then supported by an office system that screened patients, cued providers to intervene, and made patient education materials available as tip sheets.

MEASUREMENTS AND MAIN RESULTS

Implementation of the counseling steps was measured by patient exit interviews (PEI) immediately following the patient visit. The interval between the date of training and the date of the PEI ranged from 6 to 32 months. Special intervention providers were twice as likely as usual care providers to discuss alcohol use with their patients. They carried out every step of the counseling sequence significantly more often than did usual care providers (p < .001). This intervention effect persisted over the 32 months of follow-up.

CONCLUSIONS

Physicians and other health-care providers trained in a brief provider-delivered alcohol intervention will counsel their high-risk drinking patients when cued to do so and supported by a primary care office system.

Treatment of alcohol withdrawal in hospitalized patients

Alcoholism can be encountered in many aspects of medicine. Frequently, primary-care physicians are asked to treat patients who are experiencing various stages of alcohol withdrawal while hospitalized for intercurrent illness. A thorough assessment of the patient is important because the symptoms and signs of alcohol withdrawal are nonspecific. Recognizing the patient who is at risk for alcohol withdrawal and initiating appropriate treatment can prevent progression to more serious symptoms and complications. Benzodiazepines are the drugs of choice for pharmacologic treatment of alcohol withdrawal. Their application by means of a symptom-triggered approach based on frequent, objective assessment of the patient is recommended. Adjunctive therapy for specific complications of alcohol withdrawal is discussed. After the acute withdrawal symptoms have been controlled, psychiatric or chemical dependence assessment (or both) is strongly encouraged.

Alcoholism: the keys to the CAGE

PURPOSE

To compare the efficiency of screening for alcoholism using two different introductions to the CAGE questions.

PATIENTS

Forty-three alcoholics on inpatient medical and surgical services were identified through random distribution of the Michigan Alcoholism Screening Test.

METHODS

Participants were randomized to two groups receiving different introductions to the CAGE questions. Group I was introduced by a simple open-ended question. Group II patients were asked first to quantitate the volume and frequency of their drinking. The outcome measures were the scores on the four CAGE questions recorded by an independent observer.

RESULTS

Eighteen of 21 (86%) patients in Group I admitted to prior attempts to cut back on their drinking as compared with 8 of 22 (36%) in Group II (p = 0.002). Likewise 10 of 21 (49%) patients in the first group admitted to annoyance compared with just 3 of 22 (14%) in Group II. The average scores per patient in the two groups were significantly different: Group I = 2.52 versus Group II = 1.23 (p = 0.0002). Using a screening CAGE score of two or more to identify an alcoholic patient, the open-ended introduction identified 95% of the alcoholics compared with only 32% when the closed-ended introduction was used (p < 0.0001).

CONCLUSION

Our study demonstrates that the sensitivity of the CAGE questionnaire in screening for alcoholism is dramatically enhanced by an open-ended introduction. In contrast, the sensitivity of these questions is greatly reduced when preceded by inquiries that seek to define the quantity and frequency of drinking.

A developmental model of addictions, and its relationship to the twelve step program of alcoholics anonymous

A shift in the psychoanalytic literature is seen to have taken place in the 1960s, when psychoanalysts abandoned the psychoanalysis of patients suffering from addictions. This was due to poor outcomes, and assertions such as Kohut's, that addiction was not analyzable. The author asserts that there is a similarity in the psychological part of all addictions, and that this is seen in his work with addicted patients, including psychoanalysis of addicted patients. Addiction is presented as a pathological solution to a fixation during separation-individuation. This conceptualization helps to explain why such varying previous psychoanalytic formulations have been offered. The addictive solution to a fixation during separation-individuation is compared and contrasted to a similar fixation seen in patients suffering from borderline personality disorder and patients suffering from pathological narcissism. The developmental model presented clarifies how denial of addiction can be an interpersonal expression of an intrapsychic defense.

The psychosocial review of systems

Psychosocial problems have a significant impact on the course and cost of medical illness. However, many of these areas are generally neglected in medical interviews. This manuscript presents a condensed review of the major psychosocial domains, which together constitute what we term a psychosocial review of systems (PROS). Selected references are provided which document the importance of these areas to medical care, and serve as background reading for further inquiry. The psychosocial areas which are covered include: substance use, stress and life events, subjective views of symptoms, daily activity, social support, sexual concerns, finances, psychiatric history and symptoms, cultural issues, and functional status. The Psychosocial Review of Systems (PROS) can serve as a basic overview for the psychosocial aspects of medical education, and also as a content based instrument which has potential for development as an assessment tool to measure physician competence in eliciting relevant psychosocial data.