alcoholism

Alcoholism is the consumption of or preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic's normal personal, family, social, or work life. The chronic alcohol consumption caused by alcoholism can result in psychological and physiological disorders. Alcoholism is one of the world's most costly drug use problems; with the exception of nicotine addiction, alcoholism is more costly to most countries than all other drug use problems combined^{citation needed]}.

While alcohol use is required to trigger alcoholism, the biological mechanism of alcoholism is unknown. For most people, moderate alcohol consumption poses little danger of addiction. However, the development of alcoholism is more complex than use of alcohol: other factors must exist for alcohol use to develop into alcoholism. These factors may include a person's social environment, emotional health and genetic predisposition. In addition, an alcoholic can develop multiple forms of addiction to alcohol simultaneously such as psychological, metabolic, and neurochemical. Each type of addiction must be treated individually for an alcoholic to fully recover.

Terminology

Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The introduction of politics and religion further muddles the issue and exacerbates ambiguity.

Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol.

Misuse and heavy use do not have standard definitions, but suggest consumption of alcohol beyond the point where it causes physical, social, or moral harm to the drinker. Social and moral harm are highly subjective and therefore differ from individual to individual.

The term abuse has a variety of possible meanings. Within psychiatry, the DSM-IV has a specific definition involving a set of life circumstances which take place because of substance use. Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescribed medication in excess of the prescribed dosage or to use of a prescription drug without a prescription. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion due to audiences that do not necessarily share a single definition.

Dependence also has multiple definitions, but is not as commonly used as abuse outside of the medical profession. Physical medicine considers dependence to be the body's physical adaptation to the persistent presence of alcohol. Psychological medicine considers dependence to be a person's mental reliance upon something to maintain their mental status quo. These two are occasionally differentiated as physical and psychological dependence.

The precise definition of addiction is debated, but in general it refers to any condition which causes a person to continue behaviors demonstrated as harmful to that person. For alcoholism, that behavior is the consumption of alcoholic beverages. Some conditions which contribute to alcoholism include physical dependence, neurochemical conditioning, and a person's perception that alcohol benefits them psychologically or socially.

Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full. Others (most notably Alcoholics Anonymous) use the term exclusively to describe those who have completely stopped consumption of alcohol.

Epidemiology

Substance use disorders are the major public health problem facing many countries. In the United States today, more than 15 million Americans are estimated to suffer from alcoholism. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol."^[1] In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.^[2].

There is considerable debate regarding the Disease Theory of Alcoholism. Proponents argue that any structural or functional disorder having a predictable course, or progression, should be classified as a disease. Opponents cite the inability to pin down the behavioral issues to a physical cause as a reason for avoiding classification.

Identification and diagnosis

Identification of alcoholism may be difficult because there is no detectable physiological difference between a person who drinks a lot and a person who can't control his or her drinking. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared to the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are still a large number of borderline cases that can be difficult to classify.

Genetic predisposition testing

At least one genetic test^[3] exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol^[4]. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism. This test is used primarily for research purposes and is not generally provided in medical treatment settings.

Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

• The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?^[5][6]

The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.

• The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally^[7]. Like the CAGE questionnaire, it uses a simple set of questions - a high score earning a deeper investigation.

• The Alcohol Dependence Data Questionnaire^[8] is a more sensitive diagnostic test than the CAGE test. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.

• The Michigan Alcohol Screening Test (MAST)^[9] is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses, driving under the influence being the most common.

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcoholism diagnosis is:

“...maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.”

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

• Macrocytosis (enlarged MCV)¹
• Elevated GGT²
• Moderate elevation of AST and ALT and an AST:ALT ratio of 2:1.
• High carbohydrate deficient transferrin (CDT)

Effects

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging. The secondary damage caused by an inability to control one's drinking manifests in many ways.

Long-term physical health effects

See also: Alcohol consumption and health

The long-term health effects caused by the consumption of large amounts of alcohol (both by alcoholics and non-alcoholics) may include:

• death from many sources, primarily alcohol toxemia; having a blood alcohol content that is too high for the body to tolerate.
• cirrhosis of the liver, a chronic disease characterized by destruction of liver cells and loss of liver function: it has numerous complications, including bleeding from esophageal varices
• pancreatitis, or inflammation of the pancreas: acute and chronic
• heart disease, including dilated cardiomyopathy
• polyneuropathy, or damage to the nerves leading to poor sensation of pain and impaired mobility
• Alcoholic dementia, also known as "wet brain," as a result of widening fissures in the cortex, symptoms including diminished mental capacity, impaired motor function, and vision loss
• psychological effects: depression, insomnia, anxiety, and suicide-risk
• increased incidence of many types of cancer: breast cancer, head and neck cancer, esophageal cancer and colorectal cancer
• nutritional deficiency: folic acid, thiamine (vitamin B1) and several others
• sexual dysfunction
• Osteoporosis and osteonecrosis ^[10]

Social effects

The social problems arising from alcoholism can be significant. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of accommodation. Drinking at inappropriate times and behavior caused by reduced judgment can earn criminal convictions, such as drunk driving or public disorder. An alcoholic's behavior and prioritization while drunk can profoundly impact the family and friends around them possibly leading to marital conflict and divorce. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).^[11][2]

Alcohol withdrawal

Alcohol withdrawal is significantly different from withdrawal from other drugs in that it can be directly fatal. While it is possible for heroin addicts, for instance, to die from other health problems made worse by the strain of withdrawal, an otherwise healthy alcoholic can die from the direct effects of withdrawal if it is not properly managed. Heavy consumption of alcohol reduces the production of GABA, which is a neuroinhibitor. An abrupt stop of alcohol consumption can induce a condition where neither alcohol nor GABA exists in the system in adequate quantities, causing uncontrolled firing of the synapses. This manifests as hallucinations, shakes, convulsions, seizures, and possible heart failure, all of which are collectively referred to as delerium tremens.

Treatments

Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach the condition medically as disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.^[1]

While treatment programs vary in their effectiveness, relapse is common.

Detoxification

Detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking, generally coupled with the substitution of drugs that have similar effects to offset the withdrawal symptoms. Benzodiazepines are the standard treatment, particularly such long-acting benzodiazepines as diazepam or clonazepam.

Detoxes are done in multiple ways. The first takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur, which is safe only with relatively mild alcohol users.

Detoxification treats the physical effects of ongoing use of alcohol. After sobriety is accomplished, other treatments try to reduce the risk of relapse. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.

Group therapy and psychotherapy

After detoxification various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service, including Alcoholics Anonymous, LifeRing Secular Recovery, Rational Recovery, Smart Recovery, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs do not mandate complete abstinence. Since one of the effects of alcohol is to reduce a person's judgment, each drink makes it more difficult to decide that the next drink is a bad idea. Additionally, for those who are predisposed towards alcoholism, drinking in moderation can result in the strengthening of the endorphin-based addiction.

While most alcoholics are unable to limit their drinking in this way, moderate drinking works for some people, and it may avoid the physical, financial, and social costs of other treatments - particularly in the early phase of recovery. Research by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that nearly 18% of such individuals in the US whose drinking habit began more than one year earlier are now drinking in moderation. ^[12] Professional help can be sought for rationing from programs such as Moderation Management.

Medications

Certain medications are designed to supplement a person's willpower in encouraging abstinence. These medications ease the transition to sobriety, as well as simply make it hard to stay drunk and be comfortable at the same time. Either way, the over all desired effect is to have an alcoholic abstain from drinking.

• Antabuse (disulfiram) prevents the elimination of (acetaldehyde), a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hang over symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast acting and long lasting uncomfortable hang over. This prevents an alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on antabuse can cause severe illness and death.

• Naltrexone is used in two very different forms of treatment. It is a competitive antagonists at μ- and κ-opioid receptors, and to a lesser extent at δ-opioid receptors. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcoholism.

• Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse...Campral proved superior to placebo in maintaining abstinence for a short period of time...^[13]" While effective alone^[14], it is often paired with other medication treatments like naltrexone with great success^[15].

Acamprosate reduces glutamate release. The COMBINE study was unable to determine the presence of efficacy for Acamprosate.

• Vivitrol is a time-release formulation of naltrexone that may alleviate the problems caused by intermittent usage. Approved by the FDA in June 2006, Vivitrol is injected in the buttocks once a month by a health care professional. This means that the decision to continue to use the medication only needs to be made once a month rather than daily.Injectable drugs have clear advantages over pills because of a steady level of the drug in the blood stream .Alcohol consumption is known to enhance the release of opiates and dopamine and naltrexone reduces the high from drinking. Naltrexone also appears to act on glutamate neurotransmission but in a different mechanism than acamprosate thereby reducing the reinforcing effects of alcohol.

• Sodium oxibate, the sodium salt of gamma-hydroxybutyric acid (GHB) is used in Italy in small amounts. Under the trade name Alcover, it is used for both acute alcohol withdrawal and medium to long-term detoxification.This drug enhances GABA neurotransmission and reduces glutamate levels.
• Baclofen, baclofen has been shown in animal studies and in small human studies to enhance detoxification.This drug acts as a GABA B receptor agonist and this may be beneficial.

Pharmacological extinction

See also: Sinclair Method

Pharmacological extinction is the use of opioid antagonists like naltrexone combined with normal drinking habits in order to eliminate the craving for alcohol^[16]. This technique has had success in Finland^[17], Pennsylvania^[18], and Florida^[19], and is sometimes referred to as the Sinclair Method. While standard naltrexone treatment uses the drug to curb craving and enforce abstinence, pharmacological extinction targets the endorphin-based neurological conditioning. Our behaviors become conditioned when our neurons are bathed in endorphins following that action. Conversely, we receive negative reinforcement when we perform that action and yet do not get our endorphins. By having the alcoholic go about their normally drinking habits (limited only by safety concerns), and while preventing the endorphins from being released by the alcohol, the pull to drink is eliminated over a period of about three months. This allows an alcoholic to give up drinking as being sensibly unbeneficial. The effects persist after the drug is discontinued, but the addiction can return if the person drinks without first taking the drug. This treatment is also highly unusual: it works better if the patient does not go through detoxification prior to starting it.

There is a lot of professional resistance to this treatment for two reasons. Studies have demonstrated that controlled drinking for alcoholics was not a useful treatment technique^[20]. Other studies have also shown naltrexone to be of questionable value in supporting abstinence alone.^[21][22][23]. The individual failure of these two separate treatments suggests that their use in combination is equally ineffective. This would be the case if the two treatments were merely additive, as for two people pushing a car. Experimental evidence^[16] indicates that the presence of naltrexone causes alcohol to have a reverse effect on drinking, decreasing the alcoholic's attachment to it when they drink instead of increasing it.

Nutritional therapy

Preventative treatment of alcohol complications includes long-term use of a multivitamin as well as such specific vitamins as B12 and folate.

While nutritional therapy is not a treatment of alcoholism itself, it treats the difficulties that can arise after years of heavy alcohol use. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be diminished by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, causing poor treatment outcomes.^[24]

Societal impact

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, e.g. money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there is also the pain and suffering of the all individuals besides the alcoholic affected. For instance, heavy alcohol consumption by a pregnant woman can lead to fetal alcohol syndrome, an incurable and damaging condition.

Today, alcohol use and alcohol dependence are major public health problems in countries like North America, costing the region's inhabitants by some estimates as much as 170 billion dollars annually. Of the 50% of the North American population who consume alcohol, it has been estimated that 10% are heavy alcohol users and alcohol dependents, and 6% account for more than half of all the alcohol consumption in the region.^{citation needed]}

Stereotypes

Stereotypes of alcoholics are often found in fiction and popular culture. Common examples include the 'town drunk' or the portrayal of certain nationalities as alcoholics. In modern times, the recovery movement has led to more realistic depictions of problems that stem from heavy alcohol use. Authors such as Charles R. Jackson and Charles Bukowski describe their own alcohol addiction in their writings. Films like Days of Wine and Roses, My Name is Bill W, Leaving Las Vegas and Clean and Sober chronicle similar stories of alcoholism.

Politics and public health

Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

Organizations working with those suffering from alcoholism include:

• Alcoholics Anonymous (AA)
• International Organisation of Good Templars (IOGT)
• LifeRing Secular Recovery (LifeRing)
• Moderation Management (MM)
• Rational Recovery (RR)
• Secular Organizations for Sobriety (SOS)
• Smart Recovery (Self Management And Recovery Training - SMART)
• Women For Sobriety (WFS)
• Narcotics Anonymous (NA), Alcohol is a drug, although not a narcotic.

See also

• Alcohol-related traffic crashes
• Alcohol tolerance
• Drunkenness
• List of famous deaths through alcohol
• List of fictional alcoholics
• List of famous alcoholics
• List of iconic drinkers
• Substance abuse
• Wernicke-Korsakoff syndrome
• Medical diagnostics to test for alcohol use: liver function tests, full blood count, blood alcohol content

References

Further reading

• Berry, Ralph E.; Boland James P. The Economic Cost of Alcohol Abuse The Free Press, New York, 1977 ISBN 0-02-903080-3
• Royce, James E. and Scratchley, David Alcoholism and Other Drug Problems Free Press, March 1996 ISBN-10: 0-684-82314-4 ISBN-13: 978-0-684-82314-0

External links

• Alcoholics Anonymous
• Baldwin Research Institute Independent Research on Alcoholism and Drug Addiction
• Drink Too Much? by David J. Hanson
• Invited Interview from the Oxford Journal of Medicine on the use of Naltrexone to treat alcoholism
• Moderation Management
• National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• Michigan Alcohol Screening Test (MAST), Revised and Online
• Rational Recovery