Anxiety alcohol

Bowen RC, Cipywnyk D, D Arcy C, et al. Alcoholism, anxiety disorders, and agoraphobia. Alcohol Clin Exp Res 1984 8 48-50. 

Positron emission tomography (PET) is another imaging technique that employs radioactive tracers to image brain activity. PET can detect and map the presence of glucose, neurotransmitters, and a dozen other chemicals critical to brain function. Subtle changes in brain structure or function that correlate to diseases have been used to distinguish brain chemistry changes associated with Alzheimer s disease, schizophrenia, alcoholism, anxiety disorders, and posttraumatic stress disorder. PET can also be used to detect emotional responses and perceptions of emotion. 

Pharmacological Profiles of Anxiolytics and Sedative—Hypnotics. Historically, chemotherapy of anxiety and sleep disorders rehed on a wide variety of natural products such as opiates, alcohol, cannabis, and kawa pyrones. Use of various bromides and chloral derivatives ia these medical iadications enjoyed considerable popularity early ia the twentieth century. Upon the discovery of barbiturates, numerous synthetic compounds rapidly became available for the treatment of anxiety and insomnia. As of this writing barbiturates are ia use primarily as iajectable general anesthetics (qv) and as antiepileptics. These agents have been largely replaced as treatment for anxiety and sleep disorders. 

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Cessation of prolonged heavy alcohol abuse may be followed by alcohol withdrawal or life-threatening alcohol withdrawal delirium. Typical withdrawal symptoms are autonomic hyperactivity, increased hand tremor, insomnia and anxiety, and are treated with benzodizepines and thiamine. Alcoholism is the most common cause of thiamine deficiency and can lead in its extreme form to the Wernicke s syndrome that can be effectively treated by high doses of thiamine. 

In addition, if possible, die nurse obtains a history of any past drug or alcohol abuse. Individuals with a history of previous abuse are more likely to abuse odier drug s, such as the antianxiety drug s. Some patients, such as diose with mild anxiety or depression, do not necessarily require inpatient care. These patients are usually seen at periodic intervals in die primary health care provider s office or in a psychiatric outpatient setting. The preadministration assessments of the outpatient are the same as diose for the hospitalized patient. 

Verheul et al. (2004) pooled data from seven European acamprosate studies in an effort to identify patient-related predictors of response to the medication. Although they examined a number of potential predictors, including patients level of physiological dependence before treatment, family history of alcoholism, age of onset of alcoholism, baseline anxiety symptom severity, baseline craving, and gender, none was shown to interact with acamprosate treatment. These findings led the authors to conclude that, although the effect size for acamprosate was moderate, the medication can be considered potentially effective for all patients with alcohol dependence. 

Medications that have been used as treatment for anxiety and depression in the postwithdrawal state include antidepressants, benzodia2epines and other anxiolytics, antipsychotics, and lithium. In general, the indications for use of these medications in alcoholic patients are similar to those for use in nonalcoholic patients with psychiatric illness. However, following careful differential diagnosis, the choice of medications should take into account the increased potential for adverse effects when the medications are prescribed to alcoholic patients. For example, adverse effects can result from pharmacodynamic interactions with medical disorders commonly present in alcoholic patients, as well as from pharmacokinetic interactions with medications prescribed to treat these disorders (Sullivan and O Connor 2004). 

Benzodiazepines and other anxiolytics. Although benzodiazepines are widely used in the treatment of acute alcohol withdrawal, most nonmedical personnel involved in the treatment of alcoholism are opposed to the use of medications that can induce any variety of dependence to treat the anxiety, depression, and sleep disturbances that can persist for months following withdrawal. Researchers have debated the pros and cons of the use of benzodiazepines for the management of anxiety or insomnia in alcoholic patients and other substance abuse patients during the postwithdrawal period (Ciraulo and Nace 2000 Posternak and Mueller 2001). 

Despite the risks of benzodiazepine dependence and overdose among alcoholic patients beyond the period of acute withdrawal, there may be a role for the judicious use of benzodiazepines in treating these patients. To the degree that early relapse, which commonly disrupts alcoholism treatment, is a result of continued withdrawal-related symptoms (e.g., anxiety, depression, insomnia) that can be suppressed by low doses of benzodiazepines, retention in treatment could be enhanced by the use of benzodiazepines (Kissin 1977). Moreover, for some patients, benzodiazepine dependence, if it does occur, may be more benign than alcoholism. 

Ciraulo DA, Jaffe JH Tricyclic antidepressants in the treatment of depression associated with alcoholism. Clin Psychopharmacol 1 146—150, 1981 Ciraulo DA, Nace E Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am J Addict 9 276—284, 2000 Ciraulo DA, Barnhill JG, Jaffe JH, et al Intravenous pharmacokinetics of 2-hydroxy-imipramine in alcoholics and normal controls. J StudAlcohol 51 366-372, 1990 Ciraulo DA, Knapp CM, LoCastro J, et al A benzodiazepine mood effect scale reliability and validity determined for alcohol-dependent subjects and adults with a parental history of alcoholism. Am J Drug Alcohol Abuse 27 339—347, 2001 Collins MA Tetrahydropapaveroline in Parkinson s disease and alcoholism a look back in honor of Merton Sandler. Neurotoxicology 25 117-120, 2004 COMBINE Study Research Group Testing combined pharmacotherapies and behavioral interventions in alcohol dependence rationale and methods. Alcohol Clin Exp Res 27 1107-1122, 2003a... 

Goldberg HL, Finnerty RJ The comparative efficacy of buspirone and diazepam in the treatment of anxiety. Am J Psychiatry 136 1184-1187, 1979 Goldman D Recent developments in alcoholism genetic transmission. Recent Dev Alcohol 11 231-248, 1993... 

Grant BF, Stinson FS, Dawson DA, et al Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61 807-816, 2004b... 

Iwata N, Cowley DS, Radel M, et al Relationship between a GABA alpha g Pro385Ser substitution and benzodiazepine sensitivity. Am] Psychiatry 156 1447—1449,1999 Jacobson AF, Dominguez RA, Goldstein B, et al Comparison of buspirone and diazepam in generalized anxiety disorder. Pharmacotherapy 5 290—296, 1985 Jaffe JH, Ciraulo DA, Nies A, et al Abuse potential of halazepam and diazepam in patients recently treated for acute alcohol withdrawal. Clin Pharmacol Ther 34 623-630, 1983... 

Tollefson GD, Montague-Clouse J, Tollefson SL Treatment of comorbid generalized anxiety in a recently detoxified alcohol population with a selective serotonergic drug (buspirone). J Clin Psychopharmacol 12 19-26, 1992... 

Lejoyeux et al. 1998). Similar to opioid-dependent persons, these patients reported that they use benzodiazepines to self-medicate anxiety, insomnia, and alcohol withdrawal and, less commonly, to enhance the effects of ethanol. Approximately l6%-25% of patients presenting for treatment of anxiety disorders abuse alcohol (Kushner et al. 1990 Otto et al. 1992). Controversy exists concerning appropriate benzodiazepine prescribing in this population (Cir-aulo and Nace 2000 Posternak and Mueller 2001). 

Benzodiazepines have a low risk for abuse in anxiety disorder patients without a history of alcohol or other substance abuse. Among the benzodiazepines there may be a spectrum of abuse liability, with drugs that serve as prodrugs for desmethyldiazepam (e.g., clorazepate), slow-onset agents (e.g., oxazepam), and partial agonists (e.g., abecarnil) having the least potential for abuse. However, there is no currently marketed benzodiazepine or related drug that is free of potential for abuse. 

Ciraulo DA, Nace EP Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am J Addict 9 276—284, 2000 Ciraulo DA, Barnhill JG, Greenblatt DJ, et al Abuse liability and clinical pharmacokinetics of alprazolam in alcoholic men. J Clin Psychiatry 49 333—337, 1988a... 

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