“The problem is not the last drink, it is always the first.” At a meeting of Alcoholics Anonymous There are many readymade phrases. There are the mantras on the posters that adorn the suburban parish classroom: “What is said here, stays here.” The tagline with which its members say goodbye, “F24H!”, for ‘happy 24 hours’, which must be endured without drinking. And of course, the cinematic greeting every time someone participates. “Hello, my name is X and I am an alcoholic.”
Mr. without drinking before.” Among the dozen attendees there is a young supermarket cashier who got carried away by dangerous friendships, a Latin boy who relied on God to get out, and a very stylish lady with horn-rimmed glasses who ended up hooked on the benzodiazepines that were prescribed to her to quit. for drink. They are very different lives, but when X talks about the first drink, everyone knows what he is referring to.
“The question is not if an alcoholic is going to relapse, but when he will do so,” says Gabriel Rubio, head of psychiatry at Hospital 12 de Octubre and medal of merit from the National Plan on Drugs. “Relapse is part of the therapeutic process, I have not seen anyone quit on the first try.”
In his consultation, against a background of classical music, he details the phases of his successful program within the Madrid public health system: pure detoxification is two weeks on an outpatient basis. But it is only the beginning of the long process that comes later: about two years until discharge, months of cessation therapy, relapse avoidance, motivational groups, learning social skills… In addition to a lot of individual and group therapy, the Psychiatrists use tranquilizers such as gabapentin (“an antiepileptic that does not bind like benzos“) and prescribe aversive drugs, such as Antabus. “If you drink while you’re taking it, you feel like you’re going to die, but you still drink,” the youngest girl will say at the AA meeting.
“The pharmacological solutions that are being used are not tremendously effective,” admits neurologist Santiago Canals at the Alicante Institute of Neurosciences, which depends on the CSIC and the Miguel Hernández University. The laboratory he directs investigates with animal models (rats) how alcohol affects the brain of patients with chronic consumption, especially when they stop. “We focus on relapse because with a drug that is legal, easy to obtain, and socially acceptable you can only do two things: prevent, especially so that young people do not normalize consumption, and treat chronically ill patients so that they do not relapse. “, says the expert who believes that “the problem is not so much giving up alcohol as not consuming it again.” Early abstinence thus becomes a key “therapeutic window” in this disease that the neurologist considers “one of the most important psychiatric problems in Western society, perhaps only behind major depression.” Every year more than 15,000 people die in Spain from causes attributable to this legal drug. according to a report from the Ministry of Health published in 2021.
“Being the most visible drug, it is the most hidden,” continues psychiatrist Gabriel Rubio, “no one is ashamed of drinking, but they are ashamed of being an alcoholic, even though drinking is the main factor in being one.” Drinking is essential, but being an alcoholic does not depend only on drinking a lot. Genetic, psychosocial or type of consumption factors make some individuals more vulnerable than others to developing this “incurable and progressive” mental illness, according to the WHO, which for a few years has been called “alcohol use disorder.” It has physical, social and emotional manifestations, different degrees of intensity and its most obvious symptom is that the patient lacks control over his consumption: when he starts drinking he cannot stop. At the AA meeting, no one talks about quantities, but about lives that have become “unmanageable.”
The profile of who is sick has been changing in the forty years that the psychiatrist has been practicing. When he started, for every ten men (most of them over 50, with a pattern of daily consumption of wine and beer) there was one woman. Now, men and women are more equal, patients with previous psychiatric problems are becoming more frequent, more than half are weekend-only consumers and mixed drinks are the most frequent drink. The average age has dropped to 35/40 years.
Around 10% of the population could meet criteria for alcohol dependence, according to Dr. Rubio, patients condemned to a recovery that can last a lifetime in mutual support associations such as AA. His hospital is in close contact with them, as well as with primary care and mental health centers in his area. “There is a network that notifies us if the patient relapses,” says Dr. Rubio, “it is basic, because after four years, 80% of those who complete all the steps remain abstinent, compared to only 20% of those who stop the process halfway.”
Why do we relapse so much? In an addict, alcohol, the doctor explains, makes the brain believe that it needs the substance to survive. “It parasitizes its reward structure, it deceives the limbic system, the most primitive brain, where the survival instinct, hunger, desire, fear is recorded… We are not prepared to erase anything from there because it is where what is stored in us is stored.” keeps us alive as a species.” A person with this disorder drinks just as he eats, flees or seeks to mate, by instinct. But in addition to a parasitized brain, from the physiological, the key trigger for relapses is “the context,” experts agree. The streets full of bars, the beer advertisements, the celebrations where alcohol is ubiquitous… “85% of relapses occur in the first three months, because a brother-in-law or a friend gets annoying telling the addict that for a beer nothing happens,” says the psychiatrist.
93% of the population has tried alcohol
Relapse is very easy, because is very easy. Drinking is normal. In Spain, 93.2% of the population aged 15 to 64 has tried alcohol, 64.5% have drunk in the last month, 9% do so daily. Being drunk is not uncommon either: 17% admit to having been intoxicated in the last year (a figure that reaches 39% among young men) and 15% have had an alcohol binge in the last month (more than four drinks in one occasion), all according to the Survey on alcohol and other drugs in Spain (EDADES, 2022, Ministry of Health). Alcohol is the most abused psychoactive substance, far removed from the following. “It is the last drug that is left, the last refuge, because it is normalized,” says Rubio. “When you quit cocaine, people congratulate you; When you don’t drink, they ask you what’s wrong. He who doesn’t drink is a geek. To go out you have to cover the bottle, yes, but you also have to make countless changes in your lifestyle, your leisure, your friends, your routines…”
“If you can, you even have to change the way you walk,” says Sara Vigo González, director of the Arbor Center, a private detox clinic where the day costs 260 euros. In a charming chalet in the mountains of Madrid, a maximum of 12 people (accompanied by 22 workers) spend the first two or three months of sobriety. “The idea of admission is to cut it: at first they take the stimuli very badly,” says the director, who recognizes that her program is very strict. Urine tests (even for family members), no cell phones, clear routines (four hours a day of therapy, sports, scheduled meals, breaks and cleanliness…).
From this “bubble” we move on to supervised apartments with more independence. The manager explains that the majority of her clients have dual pathologies: “Only some gentlemen over 60 are pure alcohol drinkers, the rest are polydrug addicts, cocaine, ketamine, anxiolytics… Of course, everyone drinks, even the ladies at the bars. benzos They wash them down with white wine to enhance their effect.” That’s why, he says, “alcohol is the door to all relapses; “the cocaine addict returns to coke after drinking again.” For this reason, at the center all patients, even those who have been admitted for gambling or sex addiction, are forced to give up alcohol.
Back in the laboratory of the Alicante Institute of Neurosciences, a drunk rat dozes in a cage while a technician stimulates its companion’s brain with an electrode. They are common rats, of a wild phenotype. Given the choice between drinking water or diluted alcohol, one in ten individuals of their species choose the combination (a similar percentage to humans who develop a consumption disorder). For this project, the animals have been “primed,” vaporized for months with ethanol in the box they live in to become addicted. Along with a series of chronic patients admitted to a German hospital, the rodents are the protagonists of the cutting-edge study that focuses on early abstinence: both groups are perfect for investigating alcoholism, because neurologists are certain that they are not drinking secretly.
Thanks to animal models, Canals’ team, head of the Plasticity of Neural Networks group at the institute, has discovered that the neurological damage that alcohol produces in the brain continues, and is especially intense, during the first weeks after stop drinking. Whether a human or a rat, “when a habituated subject stops drinking, for at least six weeks of sobriety the damage to the white matter persists and accelerates,” says Canals.
The hypothesis is that withdrawal provokes “an inflammatory response,” further attacking myelin, the sheath that covers the axons, the figurative cables that join neurons and communicate different parts of the brain with each other. This inflammation had always been considered a side effect of alcohol consumption, but when it continues during abstinence (in the absence of alcohol) it becomes a factor that “causes or facilitates relapse.” And that is why those first weeks become a “critical phase to treat the disease.” The investigation could become a “game changer” says Canals, a radical change in how patients with alcohol use disorder are treated. His team is now investigating different ways to remyelinate the brains of abstinent people to help them avoid stumbling over the same stone again.
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