Cirrhosis of the Liver

21 November, 2008 (21:08) | Alcoholism | By: Sobriety Online

Cirrhosis of the Liver

The liver, the largest organ in the body, is essential in keeping the body functioning properly. It removes or neutralizes poisons from the blood, produces immune agents to control infection, and removes germs and bacteria from the blood. It makes proteins that regulate blood clotting and produces bile to help absorb fats and fat-soluble vitamins. You cannot live without a functioning liver.

In cirrhosis of the liver, scar tissue replaces normal, healthy tissue, blocking the flow of blood through the organ and preventing it from working as it should. Cirrhosis is the twelfth leading cause of death by disease, killing about 26,000 people each year. Also, the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high.

Cirrhosis has many causes. In the United States, chronic alcoholism and hepatitis C are the most common ones.

Alcoholic liver disease. To many people, cirrhosis of the liver is synonymous with chronic alcoholism, but in fact, alcoholism is only one of the causes. Alcoholic cirrhosis usually develops after more than a decade of heavy drinking. The amount of alcohol that can injure the liver varies greatly from person to person. In women, as few as two to three drinks per day have been linked with cirrhosis and in men, as few as three to four drinks per day. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates.

Chronic hepatitis C. The hepatitis C virus ranks with alcohol as a major cause of chronic liver disease and cirrhosis in the United States. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis.

Chronic hepatitis B and D. The hepatitis B virus is probably the most common cause of cirrhosis worldwide, but it is less common in the United States and the Western world. Hepatitis B, like hepatitis C, causes liver inflammation and injury that over several decades can lead to cirrhosis. Hepatitis D is another virus that infects the liver, but only in people who already have hepatitis B.

Autoimmune hepatitis. This disease appears to be caused by the immune system attacking the liver and causing inflammation, damage, and eventually scarring and cirrhosis.

Inherited diseases. Alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, galactosemia, and glycogen storage diseases are among the inherited diseases that interfere with the way the liver produces, processes, and stores enzymes, proteins, metals, and other substances the body needs to function properly.

Nonalcoholic steatohepatitis (NASH). In NASH, fat builds up in the liver and eventually causes scar tissue. This type of hepatitis appears to be associated with diabetes, protein malnutrition, obesity, coronary artery disease, and treatment with corticosteroid medications.

Blocked bile ducts. When the ducts that carry bile out of the liver are blocked, bile backs up and damages liver tissue. In babies, blocked bile ducts are most commonly caused by biliary atresia, a disease in which the bile ducts are absent or injured. In adults, the most common cause is primary biliary cirrhosis, a disease in which the ducts become inflamed, blocked, and scarred. Secondary biliary cirrhosis can happen after gallbladder surgery if the ducts are inadvertently tied off or injured.

Drugs, toxins, and infections. Severe reactions to prescription drugs, prolonged exposure to environmental toxins, the parasitic infection schistosomiasis, and repeated bouts of heart failure with liver congestion can all lead to cirrhosis.

Many people with cirrhosis have no symptoms in the early stages of the disease. However, as scar tissue replaces healthy cells, liver function starts to fail and a person may experience the following symptoms:

loss of appetite
weight loss
abdominal pain
spider-like blood vessels (spider angiomas) that develop on the skin
As the disease progresses, complications may develop. In some people, these may be the first signs of the disease.
Complications of Cirrhosis
Loss of liver function affects the body in many ways. Following are the common problems, or complications, caused by cirrhosis.

Edema and ascites. When the liver loses its ability to make the protein albumin, water accumulates in the legs (edema) and abdomen (ascites).

Bruising and bleeding. When the liver slows or stops production of the proteins needed for blood clotting, a person will bruise or bleed easily. The palms of the hands may be reddish and blotchy with palmar erythema.

Jaundice. Jaundice is a yellowing of the skin and eyes that occurs when the diseased liver does not absorb enough bilirubin.

Itching. Bile products deposited in the skin may cause intense itching.

Gallstones. If cirrhosis prevents bile from reaching the gallbladder, gallstones may develop.

Toxins in the blood or brain. A damaged liver cannot remove toxins from the blood, causing them to accumulate in the blood and eventually the brain. There, toxins can dull mental functioning and cause personality changes, coma, and even death. Signs of the buildup of toxins in the brain include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits.

Sensitivity to medication. Cirrhosis slows the liver’s ability to filter medications from the blood. Because the liver does not remove drugs from the blood at the usual rate, they act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side effects.

Portal hypertension. Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood through the portal vein, which increases the pressure inside it. This condition is called portal hypertension.

Varices. When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more likely to burst. If they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention.

Insulin resistance and type 2 diabetes. Cirrhosis causes resistance to insulin. This hormone, produced by the pancreas, enables blood glucose to be used as energy by the cells of the body. If you have insulin resistance, your muscle, fat, and liver cells do not use insulin properly. The pancreas tries to keep up with the demand for insulin by producing more. Eventually, the pancreas cannot keep up with the body’s need for insulin, and type 2 diabetes develops as excess glucose builds up in the bloodstream.

Liver cancer. Hepatocellular carcinoma, a type of liver cancer commonly caused by cirrhosis, starts in the liver tissue itself. It has a high mortality rate.

Problems in other organs. Cirrhosis can cause immune system dysfunction, leading to infection. Fluid in the abdomen (ascites) may become infected with bacteria normally present in the intestines. Cirrhosis can also lead to impotence, kidney dysfunction and failure, and osteoporosis.
The doctor may diagnose cirrhosis on the basis of symptoms, laboratory tests, the medical history, and a physical examination. For example, during a physical examination, the doctor may notice that the liver feels harder or larger than usual and order blood tests that can show whether liver disease is present.

If looking at the liver is necessary to check for signs of disease, the doctor might order a computerized axial tomography (CAT) scan, ultrasound, magnetic resonance imaging (MRI), or a scan of the liver using a radioisotope (a harmless radioactive substance that highlights the liver). Or the doctor might look at the liver using a laparoscope, an instrument that is inserted through the abdomen and relays pictures back to a computer screen.

A liver biopsy will confirm the diagnosis. For a biopsy, the doctor uses a needle to take a tiny sample of liver tissue, then examines it under the microscope for scarring or other signs of disease.
Liver damage from cirrhosis cannot be reversed, but treatment can stop or delay further progression and reduce complications. Treatment depends on the cause of cirrhosis and any complications a person is experiencing. For example, cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by Wilson disease, in which copper builds up in organs, is treated with medications to remove the copper. These are just a few examples—treatment for cirrhosis resulting from other diseases depends on the underlying cause. In all cases, regardless of the cause, following a healthy diet and avoiding alcohol are essential because the body needs all the nutrients it can get, and alcohol will only lead to more liver damage. Light physical activity can help stop or delay cirrhosis as well.

Treatment will also include remedies for complications. For example, for ascites and edema, the doctor may recommend a low-sodium diet or the use of diuretics, which are drugs that remove fluid from the body. Antibiotics will be prescribed for infections, and various medications can help with itching. Protein causes toxins to form in the digestive tract, so eating less protein will help decrease the buildup of toxins in the blood and brain. The doctor may also prescribe laxatives to help absorb the toxins and remove them from the intestines.

For portal hypertension, the doctor may prescribe a blood pressure medication such as a beta-blocker. If varices bleed, the doctor may either inject them with a clotting agent or perform a so-called rubber-band ligation, which uses a special device to compress the varices and stop the bleeding.

When complications cannot be controlled or when the liver becomes so damaged from scarring that it completely stops functioning, a liver transplant is necessary. In liver transplantation surgery, a diseased liver is removed and replaced with a healthy one from an organ donor. About 80 to 90 percent of patients survive liver transplantation. Survival rates have improved over the past several years because of drugs such as cyclosporine and tacrolimus, which suppress the immune system and keep it from attacking and damaging the new liver.

How to Cut Down on Your Drinking

8 September, 2008 (21:39) | Alcoholism | By: Sobriety Online

How to Cut Down on Your Drinking

If you are drinking too much, you can improve your life and health by cutting down. How do you know if you drink too much? Read these questions and answer “yes” or “no”:

Do you drink alone when you feel angry or sad?

Does your drinking ever make you late for work?

Does your drinking worry your family?

Do you ever drink after telling yourself you won’t?

Do you ever forget what you did while you were drinking?

Do you get headaches or have a hang-over after you have been drinking?
If you answered “yes” to any of these questions, you may have a drinking problem. Check with your doctor to be sure. Your doctor will be able to tell you whether you should cut down or abstain. If you are alcoholic or have other medical problems, you should not just cut down on your drinking–you should stop drinking completely. Your doctor will advise you about what is right for you.

If your doctor tells you to cut down on your drinking, these steps can help you:

1. Write your reasons for cutting down or stopping.

Why do you want to drink less? There are many reasons why you may want to cut down or stop drinking. You may want to improve your health, sleep better, or get along better with your family or friends. Make a list of the reasons you want to drink less.

2. Set a drinking goal.

Choose a limit for how much you will drink. You may choose to cut down or not to drink at all. If you are cutting down, keep below these limits:

Women: No more than one drink a day

Men: No more than two drinks a day

A drink is:

a 12-ounce bottle of beer;
a 5-ounce glass of wine; or
a 1 1/2-ounce shot of liquor.
These limits may be too high for some people who have certain medical problems or who are older. Talk with your doctor about the limit that is right for you.

Now–write your drinking goal on a piece of paper. Put it where you can see it, such as on your refrigerator or bathroom mirror. Your paper might look like this:
My drinking goal 
I will start on this day ____________. 
I will not drink more than ______ drinks in 1 day. 
I will not drink more than ______ drinks in 1 week. or 
I will stop drinking alcohol.
3. Keep a “diary” of your drinking.

To help you reach your goal, keep a “diary” of your drinking. For example, write down every time you have a drink for 1 week. Try to keep your diary for 3 or 4 weeks. This will show you how much you drink and when. You may be surprised. How different is your goal from the amount you drink now? Use the “drinking diary” below to write down when you drink.
Now you know why you want to drink less and you have a goal. There are many ways you can help yourself to cut down. Try these tips: Watch it at home.

Keep a small amount or no alcohol at home. Don’t keep temptations around.

Drink slowly.

When you drink, sip your drink slowly. Take a break of 1 hour between drinks. Drink soda, water, or juice after a drink with alcohol. Do not drink on an empty stomach! Eat food when you are drinking.

Take a break from alcohol.

Pick a day or two each week when you will not drink at all. Then, try to stop drinking for 1 week. Think about how you feel physically and emotionally on these days. When you succeed and feel better, you may find it easier to cut down for good. 

Learn how to say NO.

You do not have to drink when other people drink. You do not have to take a drink that is given to you. Practice ways to say no politely. For example, you can tell people you feel better when you drink less. Stay away from people who give you a hard time about not drinking.

 Stay active.

What would you like to do instead of drinking? Use the time and money spent on drinking to do something fun with your family or friends. Go out to eat, see a movie, or play sports or a game.
Get support.

Cutting down on your drinking may be difficult at times. Ask your family and friends for support to help you reach your goal. Talk to your doctor if you are having trouble cutting down. Get the help you need to reach your goal.

Watch out for temptations.

Watch out for people, places, or times that make you drink, even if you do not want to. Stay away from people who drink a lot or bars where you used to go. Plan ahead of time what you will do to avoid drinking when you are tempted.

Do not drink when you are angry or upset or have a bad day. These are habits you need to break if you want to drink less. 


Most people do not cut down or give up drinking all at once. Just like a diet, it is not easy to change. That is okay. If you do not reach your goal the first time, try again. Remember, get support from people who care about you and want to help. Do not give up!

FAQ – Alcoholism

24 August, 2008 (23:19) | Alcoholism | By: Sobriety Online

1. What is alcoholism?

Alcoholism, also known as alcohol dependence, is a disease that includes the following four symptoms:

  • Craving–A strong need, or urge, to drink.
  • Loss of control–Not being able to stop drinking once drinking has begun.
  • Physical dependence–Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking.
  • Tolerance–The need to drink greater amounts of alcohol to get “high.”

For clinical and research purposes, formal diagnostic criteria for alcoholism also have been developed. Such criteria are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association, as well as in the International Classification Diseases, published by the World Health Organization.

2. Is alcoholism a disease?

Yes, alcoholism is a disease. The craving that an alcoholic feels for alcohol can be as strong as the need for food or water. An alcoholic will continue to drink despite serious family, health, or legal problems.

Like many other diseases, alcoholism is chronic, meaning that it lasts a person’s lifetime; it usually follows a predictable course; and it has symptoms. The risk for developing alcoholism is influenced both by a person’s genes and by his or her lifestyle.

3. Is alcoholism inherited?

Research shows that the risk for developing alcoholism does indeed run in families. The genes a person inherits partially explain this pattern, but lifestyle is also a factor. Currently, researchers are working to discover the actual genes that put people at risk for alcoholism. Your friends, the amount of stress in your life, and how readily available alcohol is also are factors that may increase your risk for alcoholism.

But remember: Risk is not destiny. Just because alcoholism tends to run in families doesn’t mean that a child of an alcoholic parent will automatically become an alcoholic too. Some people develop alcoholism even though no one in their family has a drinking problem. By the same token, not all children of alcoholic families get into trouble with alcohol. Knowing you are at risk is important, though, because then you can take steps to protect yourself from developing problems with alcohol.

4. Can alcoholism be cured?

No, alcoholism cannot be cured at this time. Even if an alcoholic hasn’t been drinking for a long time, he or she can still suffer a relapse. Not drinking is the safest course for most people with alcoholism. 

5. Can alcoholism be treated?

Yes, alcoholism can be treated. Alcoholism treatment programs use both counseling and medications to help a person stop drinking. Treatment has helped many people stop drinking and rebuild their lives.

6. Which medications treat alcoholism?  

Three oral medications–disulfiram (Antabuse®), naltrexone (Depade®, ReVia®), and acamprosate (Campral®)–are currently approved to treat alcohol dependence. In addition, an injectable, long-acting form of naltrexone (Vivitrol®) is available. These medications have been shown to help people with dependence reduce their drinking, avoid relapse to heavy drinking, and achieve and maintain abstinence. Naltrexone acts in the brain to reduce craving for alcohol after someone has stopped drinking. Acamprosate is thought to work by reducing symptoms that follow lengthy abstinence, such as anxiety and insomnia. Disulfiram discourages drinking by making the person taking it feel sick after drinking alcohol.

Other types of drugs are available to help manage symptoms of withdrawal (such as shakiness, nausea, and sweating) if they occur after someone with alcohol dependence stops drinking.

Although medications are available to help treat alcoholism, there is no “magic bullet.” In other words, no single medication is available that works in every case and/or in every person. Developing new and more effective medications to treat alcoholism remains a high priority for researchers.

7. Does alcoholism treatment work?

Alcoholism treatment works for many people. But like other chronic illnesses, such as diabetes, high blood pressure, and asthma, there are varying levels of success when it comes to treatment. Some people stop drinking and remain sober. Others have long periods of sobriety with bouts of relapse. And still others cannot stop drinking for any length of time. With treatment, one thing is clear, however: the longer a person abstains from alcohol, the more likely he or she will be able to stay sober.

8. Do you have to be an alcoholic to experience problems?

No. Alcoholism is only one type of an alcohol problem. Alcohol abuse can be just as harmful. A person can abuse alcohol without actually being an alcoholic–that is, he or she may drink too much and too often but still not be dependent on alcohol. Some of the problems linked to alcohol abuse include not being able to meet work, school, or family responsibilities; drunk-driving arrests and car crashes; and drinking-related medical conditions. Under some circumstances, even social or moderate drinking is dangerous–for example, when driving, during pregnancy, or when taking certain medications.

9. Are specific groups of people more likely to have problems?

Alcohol abuse and alcoholism cut across gender, race, and nationality. In the United States, 17.6 million people–about l in every 12 adults–abuse alcohol or are alcohol dependent. In general, more men than women are alcohol dependent or have alcohol problems. And alcohol problems are highest among young adults ages 18-29 and lowest among adults ages 65 and older. We also know that people who start drinking at an early age–for example, at age 14 or younger–are at much higher risk of developing alcohol problems at some point in their lives compared to someone who starts drinking at age 21 or after.


10. How can you tell if someone has a problem?

Answering the following four questions can help you find out if you or a loved one has a drinking problem:

  • Have you ever felt you should cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you ever felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

One “yes” answer suggests a possible alcohol problem. More than one “yes” answer means it is highly likely that a problem exists. If you think that you or someone you know might have an alcohol problem, it is important to see a doctor or other health care provider right away. They can help you determine if a drinking problem exists and plan the best course of action.

11. Can a problem drinker simply cut down? 

It depends. If that person has been diagnosed as an alcoholic, the answer is “no.” Alcoholics who try to cut down on drinking rarely succeed. Cutting out alcohol–that is, abstaining–is usually the best course for recovery. People who are not alcohol dependent but who have experienced alcohol-related problems may be able to limit the amount they drink. If they can’t stay within those limits, they need to stop drinking altogether.

12. If an alcoholic is unwilling to get help, what can you do about it?

This can be a challenge. An alcoholic can’t be forced to get help except under certain circumstances, such as a traffic violation dor arrest that results in court-ordered treatment. But you don’t have to wait for someone to “hit rock bottom” to act. Many alcoholism treatment specialists suggest the following steps to help an alcoholic get treatment:

Stop all “cover ups.” Family members often make excuses to others or try to protect the alcoholic from the results of his or her drinking. It is important to stop covering for the alcoholic so that he or she experiences the full consequences of drinking.

Time your intervention. The best time to talk to the drinker is shortly after an alcohol-related problem has occurred–like a serious family argument or an accident. Choose a time when he or she is sober, both of you are fairly calm, and you have a chance to talk in private.

Be specific. Tell the family member that you are worried about his or her drinking. Use examples of the ways in which the drinking has caused problems, including the most recent incident.

State the results. Explain to the drinker what you will do if he or she doesn’t go for help–not to punish the drinker, but to protect yourself from his or her problems. What you say may range from refusing to go with the person to any social activity where alcohol will be served, to moving out of the house. Do not make any threats you are not prepared to carry out.

Get help. Gather information in advance about treatment options in your community. If the person is willing to get help, call immediately for an appointment with a treatment counselor. Offer to go with the family member on the first visit to a treatment program and/or an Alcoholics Anonymous meeting.

Call on a friend. If the family member still refuses to get help, ask a friend to talk with him or her using the steps just described. A friend who is a recovering alcoholic may be particularly persuasive, but any person who is caring and nonjudgmental may help. The intervention of more than one person, more than one time, is often necessary to coax an alcoholic to seek help.

Find strength in numbers. With the help of a health care professional, some families join with other relatives and friends to confront an alcoholic as a group. This approach should only be tried under the guidance of a health care professional who is experienced in this kind of group intervention.

Get support. It is important to remember that you are not alone. Support groups offered in most communities include Al-Anon, which holds regular meetings for spouses and other significant adults in an alcoholic’s life, and Alateen, which is geared to children of alcoholics. These groups help family members understand that they are not responsible for an alcoholic’s drinking and that they need to take steps to take care of themselves, regardless of whether the alcoholic family member chooses to get help.

13. What is a safe level of drinking?

For most adults, moderate alcohol use–up to two drinks per day for men and one drink per day for women and older people–causes few if any problems. (One drink equals one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) Certain people should not drink at all, however:





  • Women who are pregnant or trying to become pregnant
  • People who plan to drive or engage in other activities that require alertness and skill (such as driving a car)
  • People taking certain over-the-counter or prescription medications
  • People with medical conditions that can be made worse by drinking  
  • Recovering alcoholics
  • People younger than age 21.  

14. Is it safe to drink during pregnancy?

No, alcohol can harm the baby of a mother who drinks during pregnancy. Although the highest risk is to babies whose mothers drink heavily, it is not clear yet whether there is any completely safe level of alcohol during pregnancy. For this reason, the U.S. Surgeon General released advisories in 1981 and again in 2005 urging women who are pregnant or may become pregnant to abstain from alcohol. The damage caused by prenatal alcohol includes a range of physical, behavioral, and learning problems in babies Babies most severely affected have what is called Fetal Alcohol Syndrome (FAS). These babies may have abnormal facial features and severe learning disabilities. Babies can also be born with mild disabilities without the facial changes typical of FAS.


15. Does alcohol affect older people differently?

Alcohol’s effects do vary with age. Slower reaction times, problems with hearing and seeing, and a lower tolerance to alcohol’s effects put older people at higher risk for falls, car crashes, and other types of injuries that may result from drinking. Older people also tend to take more medicines than younger people. Mixing alcohol with over-the-counter or prescription medications can be very dangerous, even fatal. In addition, alcohol can make many of the medical conditions common in older people, including high blood pressure and ulcers, more serious. Physical changes associated with aging can make older people feel “high” even after drinking only small amounts of alcohol. So even if there is no medical reason to avoid alcohol, older men and women should limit themselves to one drink per day.





16. Does alcohol affect women differently?

Yes, alcohol affects women differently than men. Women become more impaired than men do after drinking the same amount of alcohol, even when differences in body weight are taken into account. This is because women’s bodies have less water than men’s bodies. Because alcohol mixes with body water, a given amount of alcohol becomes more highly concentrated in a woman’s body than in a man’s. In other words, it would be like dropping the same amount of alcohol into a much smaller pail of water. That is why the recommended drinking limit for women is lower than for men.

In addition, chronic alcohol abuse takes a heavier physical toll on women than on men. Alcohol dependence and related medical problems, such as brain, heart, and liver damage, progress more rapidly in women than in men.

17. Is alcohol good for your heart?

Studies have shown that moderate drinkers are less likely to die from one form of heart disease than are people who do not drink any alcohol or who drink more.

If you are a nondrinker, however, you should not start drinking solely to benefit your heart. You can guard against heart disease by exercising and eating foods that are low in fat. And if you are pregnant, planning to become pregnant, have been diagnosed as alcoholic, or have another medical condition that could make alcohol use harmful, you should not drink.

If you can safely drink alcohol and you choose to drink, do so in moderation. Heavy drinking can actually increase the risk of heart failure, stroke, and high blood pressure, as well as cause many other medical problems, such as liver cirrhosis.

18. When taking medications, must you stop drinking?

Possibly. More than 150 medications interact harmfully with alcohol. These interactions may result in increased risk of illness, injury, and even death. Alcohol’s effects are heightened by medicines that depress the central nervous system, such as sleeping pills, antihistamines, antidepressants, anti-anxiety drugs, and some painkillers. In addition, medicines for certain disorders, including diabetes, high blood pressure, and heart disease, can have harmful interactions with alcohol. If you are taking any over-the-counter or prescription medications, ask your doctor or pharmacist if you can safely drink alcohol.

19. How can a person get help for an alcohol problem?

There are many national and local resources that can help. The National Drug and Alcohol Treatment Referral Routing Service provides a toll-free telephone number, 1-800-662-HELP (4357), offering various resource information. Through this service you can speak directly to a representative concerning substance abuse treatment, request printed material on alcohol or other drugs, or obtain local substance abuse treatment referral information in your State.

Many people also find support groups a helpful aid to recovery. The following list includes a variety of resources:

Alcoholics Anonymous (AA)
National Association for Children of Alcoholics (NACOA)
National Clearinghouse for Alcohol and Drug Information (NCADI)