The prevention of alcoholic liverdisease

In PRIMARY prevention the most important thing is to limit consumption of alcohol per capita, which can be achieved in the following way:

BY THE INSPECTION OF ALCOHOL PRODUCTION AND ITS CONSUMPTION

It is important to study all the changes in alcohol distribution as well as the number of consumers the changes are related to:

- the production of large alcohol amounts should be prohibited if it is not the family basic activity for which various taxes are paid according to the regulations.

- nowadays, production of alcoholic drinks per capita should be determined in Serbia and Montenegro as well as alcohol consumption in definite groups of population (over 15 years old). Gender should be also taken into consideration in order to apply preventive measures among endangered population.

Many countries have regulations aimed to control the production and trade of alcoholic drinks (tax rate, strict control of alcoholic drinks quality, fines for selling alcoholic drinks to juveniles, fines for traffic accident or other troubles with damage caused by an alcoholic...). Thus, it is necessary to study the possibility of using and changing such kind of regulations in our country.

High prices or increasing current prices of alcoholic drinks lead to stabilization or reduction of alcohol consumption. This fact is considered as one of the most important preventive measure beside the prohibition of alcoholic drinks production and sales.

Inspection of opening hours and the time when alcoholic drinks start to be sold at hotels, cafés, barrooms, restaurants, bars etc. is very important, it must be controlled and the violation of these regulations must be strictly fined and sanctioned.

Taking into consideration the fact that supermarkets and other shops sell alcoholic drinks, allowing accessibility to the juveniles, it is necessary to limit selling of alcohol only to adults and all kinds of machinations must be sanctioned.

Many countries introduced so called “alcoholic police” in order to control the regulations and financial programmes for improving health and socio-economical development.

EDUCATION AND PUBLIC CONTROL

The purpose of the educational programme is increasing patient’s current knowledge about harmful effect of alcoholism as well as its consequences and thus to provoke changing attitude to alcohol consumption. This would allow making a resolution to stop drinking or reduce alcohol consumption, or being aware of all the consequences of continual intake of alcohol.

The greatest success is achieved by school programmes, which should be carried out even in primary and especially in high schools.

The education programmes should be applied in so called “risk groups”, determined after general epidemiological research (sales representatives, waiters, divorced...)

Considering tha fact that the family and public community has educational role, it is necessary that, in a way, parents should take part in this programme.

Knowning that the influence of the religion and ethical standards in the process of education, it is recommended taht the clergy should be involved in this programme.

REDUCE MOTIVATION FOR ALCOHOL CONSUMPTION AND PROVIDE ALTERNATIVE ACTIVITIES

Regarding the large amounts of money spent on alcoholic drinks advertising, it is necessary to put a ban on it, which would not allow presenting alcohol as a status symbol or as a healthy substance.

Alternatives for alcohol consumption could be introduciong of different social and sport activities, considering different kinds of associations, parties accessible to everybody with serving soft drinks.

THE SECONDARY prevention is, in fact, early diagnosis of alcoholic liver disease uncovered with the help of standard laboratory analyses, radiology, endoscopy examinations and liver biopsy. The secondary prevention is also an adequate treatment in order to prevent disease progression. First, “risk groups” must take such physical examinations (diagnostic and therapeutic treatment).

THE TERTIARY prevention is, less or more, a synonym of patient treatment including rehabilitation.

Group therapy is performed several times a week. Family therapy helps the patients not to feel isolated. Alcoholics are often in a bad physical condition, so it is very important to organize a group for physical exercises. Working therapy is used where patients organize work and fulfill definite tasks, and in that way achieve self-.respect and confidence. The recreation therapy teaches patients how to organize free time, so to say, it suggests them to go in for sport, to visit museums and theatres.

Patient’s education – patients should be educated about alcoholism. It is attained by films, lectures, discussions in groups about various subjects, mutual interests and contacts with the personnel. The most frequent subjects are individual psychological aspects, family, medicamentous treatment, nutrition, the way of life, free time, profession, job and then the process of recovering.

Expert-educational counseling – expert counselor’s skill can help a patient not to lose the job, so to say to reduce stress at work and makes him know the colleagues better. The education of the patient’s supervisor, as well as good contact with him makes possible to improve working conditions in the working surroundings and make positive pressure on the patient to continue the therapy. The unemployed patients are given help with expert tests, writing applications, that is, looking for a job.

There is no programme of alcoholics’ treatment which is complete if it is not used the experience of Anonymous Alcoholic (AA). The group finds AA and gives possibility for patients to meet alcoholics who would share personal experience connected with treatment and recovering from alcoholism. The clergymen (the Popes) should help alcoholics in treatment, so to say, in finding spiritual peace. An individual adviser, who is an integral part of every programme for alcoholics’ treatment, helps the patients, who cannot share their own problems with the others at the beginning of the treatment, to adopt the programme and to join the group treatment.

Inpatient-treatment. Those are places where an alcoholic stay with the other alcoholics. The places are something like houses or variants of such concept, where the patients stay for three to six months and longer. During the first month they did not often do anything but adapt to the situation and surrounding. Later they take an active part in everyday home activities. The treatment should be active, but not so intensive as to applying different modalities mentioned in hospital treatment.

Outpatient treatment. Less intensive and long-termed treatment (two and more years) is provided in this way. Group therapy is more often used here. The group consists of eight to twelve alcoholics who meet once a week and discuss about different subjects (support to psychological subject). The membership in such group usually lasts for a year. Family group consists of five couples or several families who also meet for about a year. Policlinical supervision is the last phase which should be carried out for about a year and the patients in that period of time can visit one-month patients’ gatherings, patients who persevere in treatment from alcoholism.

U PRIMARNOJ prevenciji najznačajnije je limitirati unos alkohola po glavi stanovnika, a to se može postići na sledeći način:

KONTROLA PROIZVODNJE I POTROŠNJE ALKOHOLNIH PIĆA

Da bi se pravilno razmotrio efekat povećane proizvodnje alkoholnih pića veoma je važno proučiti promene u distribuciji alkoholnih pića kao i na koji broj konzumenata se odnose ove promene.

- sankcionisati proizvodnju velikih količina alkohola ukoliko to nije osnovna delatnost porodice za koju se plaća porez i ostale dažbine predviđene zakonom.

- neophodno odrediti sadašnju proizvodnju alkoholnih pića po glavi stanovnika u Zajednici Srbije i Crne Gore kao i potrošnju alkohola u određenim populacionim grupama (preko 15 godina) i prema polu, kako bi naše preventivne mere bile primenjene u najugroženijim populacionim grupama.

Mnoge zemlje imaju zakonsku regulativu koja kontroliše proizvodnju i trgovinu alkoholnim pićima (poreske stope, stroga kontrola kvaliteta pića, kazne za prodaju alkoholnih pića maloletnicima, rigorozne kazne za konzumente ukoliko su maloletni ili ako alkoholičari izazovu saobraćajnu nezgodu ili dovedu do neke druge štete...). Zato je neophodno proučiti mogućnost primene i promene ovih zakona i kod nas.

Visoke cene ili povećanje postojećih cena alkoholnih pića dovode do stabilizacije ili smanjenja konzumiranja alkohola i zato se smatra da je ovo jedna od najvažnijih preventivnih mera pored prohibicije odnosno zabrane proizvodnje i trgovine alkoholnim pićima.

Kontrola vremena otvaranja i vremena kad počinje točenje pića u hotelima, kafićima, restoranima, barovima je veoma značajno i zato ga treba kontrolisati a njegovo kršenje strogo sankcionisati.

Obzirom da supermarketi i druge prodavnice prodaju alkoholna pića i samim tim su dostupna maloletnicima neophodno je ova pića prodavati samo punoletnim osobama a mahinacije strogo sankcionisati.

Mnoge vlade su uvele »alkoholnu policiju« koja kontroliše primenu zakonskih mera a takođe i finansiraju programe za unapređenje zdravlja i socio-ekonomski razvoj.

EDUKACIJA I DRUŠTVENA KONTROLA

Program edukacije ima za cilj da uveća pacijentovo postojeće znanje o alkoholizmu i njegovoj štetnosti odnosno posledicama i samim tim dovede kod pacijenta do promene stava prema konzumiranju alkohola odnosno da donese odluku da li će prestati da pije, smanjiti količinu alkohola koju konzumira ili nastaviti da pije svestan svih posledica.

Najveći uspeh imaju školski programi i zato ih treba sprovoditi već u osnovnoj a naročito srednjoj školi.

Programe edukacije treba sprovesti u rizičnim grupama koje će biti određene nakon opsežnog epidemiološkog istraživanja (komercijalisti, kelneri, razvedeni...).

Edukatornu ulogi prema shavatanju društva ima porodica kao i šira društvena zajednica i zato je neophodno da ovim programom na određeni način budu obuhvaćeni i roditelji.

Religija i etičke norme imaju značajnu ulogu u procesu edukacije pa se preporučije da i sveštenstvo bude uključeno u ovaj program.

REDUKOVATI PODSTICANJE NA KONZUMIRANJE ALKOHOLA I OBEZBEDITI ALTERNATIVNE AKTIVNOSTI

Ogromne sume novca se troše na reklamiranje alkoholnih pića, zato je neophodno zabraniti njegovo reklamiranje odnosno prikazivanje alkohola kao statusnog simbola i sredstva koje povoljno deluje na zdravlje.

Alternativa konzumiranju alkohola su razne društvene i sportske aktivnosti odnosno razni vidovi druženja koji su svima dostupni i na kojima će se služiti bezalkoholna pića.

SEKUNDARNA prevencija je u stvari rana dijagnoza alkoholne bolesti jetre standardnim laboratorijskim analizama, radiološkim i endoskopskim pregledima i biopsijom jetre kao i adekvatnim lečenjem kako bi se sprečila progresija bolesti. Ovim dijagnostičkim i terapijskim postupcima prvenstveno treba da budu podvrgnute rizične grupe.

TERCIJARNA prevencija je manje više sinonim za lečenje uključujući i rehabilitaciju pacijenta.

Grupna terapija se sprovodi nekoliko puta nedeljno. Porodična terapija pomaže pacijentima de se ne osećaju izolovano. Alkoholičari su najčešće u lošoj fizičkoj kondiciji i zato je veoma važno oformiti grupu za fizičke vežbe Radna terapija u kojoj pacijenti organizuju obavljanje i obavljaju određene zadatke i na taj način stiču samopoštovanje i samopouzdanje, Rekreativna terapija uči pacijente kako da organizuju svoje slobodno vreme odnosno preporučuje im se bavljenje sportom, poseta muzejima i pozorištima.

Edukacija pacijenta - pacijenta treba edukovati o alkoholizmu a to se postiže putem filmova, predavanja, diskusijama o raznim temama u okviru grupa, međusobnim učenjem kao i u kontaktu sa osobljem. Najčešće teme su individualni psihološki aspekti, porodica, lečenje medikamentima, ishrana, životni stil, slobodno vreme, zanimanje odnosno posao zatim proces oporavka.

Stručno-edukativna savetovališta - iskustvo stručnog savetnika može pomoći pacijentu da ne izgubi posao odnosno da se smanji pacijentov stres na poslu i omogući bolje upoznavanje zaposlenih. Edukacijom pacijentovog supervizora kao i dobra veza sa njim omogućuje nam da poboljšamo uslove rada u radnoj sredini i ostvarimo pozitivan pritisak na pacijenta da nastavi sa lečenjem. Nezaposlenim pacijentima pomažu oko stručnih testova, u pisanja molbi odnosno u traženju posla.

Ni jedan program za lečenje alkoholičara nije kompletan ukoliko ne koristi iskustvo Anonimnog Alkoholičara (AA). AA grupa obezbeđuje i omogućuje pacijentu da sretne alkoholičare koji će mu preneti lična iskustva u vezi lečenja i oporavka od alkoholizma.Sveštenici takođe treba da pomognu alkoholičarima u lečenju odnosno pronalaženju duhovnog mira.

Individualni savetnik koji je integralni deo svakog programa za lečenje od alkoholizma pomaže pacijentima koji u početku lečenja ne mogu svoje probleme da podele sa grupom da se adaptiraju na program i uklope u grupni tretman.

Stacionarno lečenje To su mesta u kojima alkoholičar živi sa drugim alkoholičarima. To su polukuće ili varijacije tog koncepta u kojima pacijenti borave tri do šest meseci i duže. Prvi mesec najčešće ne rade ništa već se prilagođavaju i upoznaju sa novom sredinom a zatim aktivno učestvuju u svakodnevnim kučnim aktivnostima. Lečenje treba da je aktivno ali manje intenzivno primenjujuće različite modalitete koji su navedeni u bolničkom lečenju.

Ambulantni tretman Na ovaj način je obezbeđeno dugotrajno, dve i više godina, manje intenzivno lečenje. Najčešće se primenjuje grupna terapija, grupu čine osam do dvanaest alkoholičara koji se sastaju jednom nedeljno i raspravljaju o raznim temama (podrška, psihološke teme). Članstvo u ovoj grupi obično traje oko godinu dana. Porodične grupe čine pet parova ili nekoliko porodica koje se sastaju takođe oko gidinu dana.

Ambulantni nadzor pacijenta je poslednja faza koju treba sprovoditi oko godinu dana a pacijenti u tom periodu mogu da posećuju jednomesečne skupove pacijenata koji istrajavaju u lečenju od alkoholizma.

Veoma je značajno da se unapredi dosadašnja i organizuje, ukoliko je potrebno, nova mreža svih gore navedenih vidova lečenja, edukuju novi i usavršavaju sadašnji kadrovi, obezbedi potreban prostor i adekvatni uslovi za funkcionisanje ove mreže.