While a trial period of controlled drinking with careful follow-up might be appropriate for a diagnosis of alcohol abuse, this approach increases a physician's professional liability. Complete abstinence is the only treatment for alcohol dependence. Emphasize that the most common error is underestimating the amount of help that will be needed to stop drinking. The differential diagnosis between alcohol abuse and dependence can be a difficult judgment call.
Pharmaceutical opiates are now considered to be a more serious threat to public health than illicit drugs like heroin or cocaine. The widespread popularity of prescription analgesics like Vicodin (a combination of hydrocodone and acetaminophen), oxycodone (OxyContin), and Percocet (a combination of oxycodone and acetaminophen) has made these drugs much more accessible to Americans, many of whom obtain the drugs without a prescription. The journal Pain Physician reports that out of the 5 million Americans who admitted to abusing pain relievers in 2010, only 17 percent obtained the drugs through a legitimate prescription.
In addition to CREB, it is hypothesized that stress mechanisms play a role in dependence. Koob and Kreek have hypothesized that during drug use, CRF activates the hypothalamic–pituitary–adrenal axis (HPA axis) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with psychological dependence. They found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid. In rat models, the separate use of CRF inhibitors and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed dysregulation of other neuropeptides that affect the HPA axis, including enkephalin which is an endogenous opioid peptide that regulates pain. It also appears that µ-opioid receptors, which enkephalin acts upon, is influential in the reward system and can regulate the expression of stress hormones.[18]

The physician must state firmly, but empathically, that alcohol is a problem for the patient and that the patient determines the solution. Patients come for treatment through several means, often from a mixture of both coercion and concern. The clinician needs to understand the extent of resistance to effectively work with the patient. A good strategy is to learn about patients' goals and indicate discrepancies between their goals and their choices. Pointing out discrepancies is more effective initially than statements such as, "You have to quit," or, "You have to go to AA."

For others, dependency comes after a prolonged period of difficulty in their life. Drinking might appear to be a good method of coping in these situations, and sufferers will often start as a ‘stop-gap’, just to tide them over until conditions improve. Nevertheless, as drinking begins to impact relationships and responsibilities, and hangovers exacerbate the very stress the drinking sought to avoid, the difficulties can increase, encouraging yet more drinking and leading to a vicious cycle.
This is an ongoing debate in the medical community, but it is generally agreed that there is no one cause for the development of addiction. According to the National Institute on Drug Abuse, contributing factors may include a genetic predisposition to develop addictive tendencies, an environment that is permissive of drug abuse, access to illicit substances, and certain developmental issues. The existence of a Dual Diagnosis is one of the biggest risk factors for the development of addiction. Heroin Withdrawal | First Week In
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