Alcoholism

The continuous or excessive use of alcohol (ethanol) with associated pathologic results. Alcoholism is characterized by constant or periodic intoxication, although the pattern of consumption varies markedly. Individuals admitted for the first time to an alcoholism treatment center typically have been consuming approximately 3–4 oz (80–100 g) of pure alcohol per day, corresponding to about seven to nine drinks or bottles of beer or glasses of wine. Studies have shown that problem drinking in these populations starts at about 2 oz/day (60 g/day), that is, four to five drinks per day, and that these are consumed in rapid succession, leading to intoxication on three or more days per week. Individuals who consume these levels of alcohol have also a greater than average risk of developing alcoholic liver cirrhosis. However, the levels should not be taken as absolute, since they can vary greatly in different individuals, according to body weight and other factors.

The symptoms and consequences associated with severe alcohol consumption also vary greatly; that is, in some individuals only a few may be present. These may consist of the development of physical dependence manifested as a state of physical discomfort or hyperexcitability (tremors or shakes) that are reduced by continued consumption; the development of tolerance to the effects of alcohol, which leads individuals to increase their consumption; accidents while intoxicated; blackouts, characterized by loss of memory of events while intoxicated; work problems, including dismissal; loss of friends and family association; marital problems, including divorce; financial losses, including bankruptcy or continual unemployment. Medical problems can include gastric ulcers, pancreatitis, liver disease, and brain atrophy. The last is often associated with cognitive deficiencies, as shown by the inability to comprehend relatively simple instructions or to memorize a series of numbers. See also Cognition.

Almost without exception, individuals seeking an early treatment for their alcohol problems have very good probabilities of recovery. The lesser the number of presenting problems described above, the better the chances of favorable outcome, and so an early identification of problem drinking by family, friends, employers, or physicians becomes very important. The types of intervention vary greatly, progressing from self-monitoring techniques to intensive outpatient and inpatient programs to Alcoholics Anonymous groups.

The exact mechanisms of the pharmacological actions of alcohol are not known. Alcohol can act as a stimulant at lower doses and as a depressant at higher doses. Even at very low doses alcohol can impair the sensitivity to odors and taste. Also, low doses are known to alter motor coordination and time and space perception, important aspects of car driving. Some effects are already seen at levels of 0.05%. Pain sensitivity is diminished with moderate doses. In some individuals, alcohol is known to diminish feelings of self-criticism and to inhibit fear and anxiety, effects which are probably related to an alcohol-induced sociability. These effects act, no doubt, as psychological reinforcers for the use of alcoholic beverages.

It is generally accepted that alcohol affects the nerve cell by preventing the production and propagation of electric impulses along a network consisting of axons and synapses. A major finding in the mid-1980s was that some of the neurologic effects of alcohol can be quickly reversed by new experimental drugs. Studies have shown that alcohol enhances the actions of an inhibitory brain neurotransmitter referred to as gamma-aminobutyric acid (GABA). Benzodiazepines, such as diazepam, are anxiety-reducing and sedative drugs which also enhance the effects of GABA. These effects can be reduced by experimental antagonist molecules, which interact in the brain in the same regions where GABA is found. See also Synaptic transmission.

The liver is responsible for about 80% of the metabolism of alcohol. In the liver, alcohol is first oxidized to acetaldehyde and then to acetate, which is metabolized in many tissues, including the brain, heart, and muscles. A 150-lb (68-kg) person metabolizes approximately 0.4 oz (10 g) of pure alcohol per hour (about 1 oz of a distilled beverage per hour) or, if alcohol is continuously present in the bloodstream, about 8–10 oz (190–240 g) of pure alcohol per day, equivalent to 1300–1600 calories per day. Since alcoholic beverages contain negligible levels of essential nutrients, these calories are called “empty calories.” Many alcoholics show malnutrition due to the fact that an important part of their caloric intake is alcohol. Alcohol also impairs the absorption and the metabolism of some essential nutrients. In the presence of alcohol, about 80% of oxygen consumed by the liver is devoted to the metabolism of alcohol; as a consequence, other substances such as fats, normally oxidized by the liver, are not metabolized, leading to fat accumulation in the liver. See also Liver; Malnutrition.

Alcoholic liver disease is characterized by two conditions: failure of the liver to detoxify noxious substances and to produce essential products; and increased resistance to blood flow through the liver. Alcoholic liver disease and liver cirrhosis rank among the 10 leading causes of mortality in the United States and Canada. See also Cirrhosis.

There is abundant evidence that tendency to alcoholism can be of familial origin, due to environmental, cultural, and genetic factors. A Swedish study demonstrated that identical twins are twice as likely to have a common alcoholic problem as fraternal twins. In an American-Danish study, it was shown that children of alcoholic parents are more likely to develop alcoholism (18%) than children of nonalcoholic parents (4%) when both groups of children were adopted by nonrelatives within 6 weeks of birth. See also Behavior genetics; Behavioral toxicology.

Pharmacotherapy for alcohol rehabilitation has been gaining wider acceptance. Specific pharmacotherapies which have received the most research attention utilize naltrexone and disulfiram. Other promising pharmacological interventions are acamprosate and buspirone. Naltrexone is an opiate receptor antagonist which blocks the effects of endogenous opioids in the brain. Research from animal studies suggests that alcohol activates endogenous opioid systems and, thereby, may contribute to the pleasurable effects produced by alcohol consumption. Consequently, naltrexone might reduce the reinforcing effects of alcohol consumed by people and decrease their incentive to drink. Disulfiram is a drug which causes an inhibition of the enzyme aldehyde dehydrogenase, leading to an increase in acetaldehyde blood levels. This rise will produce nausea, vomiting, tachycardia, difficulty in breathing, and changes in blood pressure leading to hypotension. Acamprosate may function to reduce alcohol-induced euphoria related to the effects of excitatory neurotransmitters such as N-methyl-D-aspartate and have some blocking effects on opiate receptors. Buspirone, a nonbenzodiazepine antianxiety agent, may decrease anxiety symptoms associated with a protracted alcohol withdrawal syndrome, thus reducing alcohol relapse potential. Both of these medications require further investigation to determine their effectiveness as a pharmacotherapeutic agent in the treatment of alcoholism.

Description

The effects of alcoholism are quite far-reaching. Alcohol affects every body system, causing a wide range of health problems. Some such problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, muscle weakness (including the heart), heart rhythm disturbances, anemia, clotting disorders, decreased immunity to infections, gastrointestinal inflammation and irritation, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, and weakened bones.

On a personal level, alcoholism results in marital and other relationship difficulties, depression, unemployment, child abuse, and general family dysfunction.

Alcoholism causes or contributes to a variety of severe social problems including homelessness, murder, suicide, injury, and violent crime. Alcohol is a contributing factor in at least 50% of all deaths from motor vehicle accidents. In fact, about 100, 000 deaths occur each year due to the effects of alcohol, of which 50% are due to injuries of some sort. According to a recent special report prepared for the U.S. Congress by the National Institute on Alcohol Abuse and Alcoholism, the impact of alcohol on society, including violence, traffic accidents, lost work productivity, and premature death, costs our nation an estimated $185 billion annually. In addition, it is estimated that approximately one in four children (19 million children or 29 percent of children up to 17 years of age) is exposed at some time to familial alcohol abuse, alcohol dependence, or both. Furthermore, it has been estimated that approximately 18 percent of adults experience an episode of alcohol abuse or dependence a some time during their lives.

Causes and symptoms

There are probably a number of factors that work together to cause a person to become an alcoholic. Recent genetic studies have demonstrated that close relatives of an alcoholic are four times more likely to become alcoholics themselves. Furthermore, this risk holds true even for children who were adopted away from their biological families at birth and raised in a non-alcoholic adoptive family, with no knowledge of their biological family's difficulties with alcohol. More research is being conducted to determine if genetic factors could account for differences in alcohol metabolism that may increase the risk of an individual becoming an alcoholic.

The symptoms of alcoholism can be broken down into two major categories: symptoms of acute alcohol use and symptoms of long-term alcohol use.

Alcohol exerts a depressive effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain alcohol level will quickly become equivalent to the blood alcohol level. Alcohol's depressive effects result in difficulty walking, poor balance, slurring of speech, and generally poor coordination (accounting in part for the increased likelihood of injury). The affected person may also have impairment of periperal vision. At higher alcohol levels, a person's breathing and heart rates will be slowed, and vomiting may occur (with a high risk of the vomit being breathed into the lungs, resulting in severe problems, including the possibility of pneumonia). Still higher alcohol levels may result in coma and death.

Long-term use of alcohol affects virtually every organ system of the body:

• Nervous system. An estimated 30-40% of all men in their teens and twenties have experienced alcoholic blackout, which occurs when drinking a large quantity of alcohol results in the loss of memory of the time surrounding the episode of drinking. Alcohol is well-known to cause sleep disturbances, so that overall sleep quality is affected. Numbness and tingling may occur in the arms and legs. Two syndromes, which can occur together or separately, are known as Wernicke's and Korsakoff's syndromes. Both are due to the low thiamine (a form of vitamin B complex) levels found in alcoholics. Wernicke's syndrome results in disordered eye movements, very poor balance and difficulty walking, while Korsakoff's syndrome severely affects one's memory, preventing new learning from taking place.
• Gastrointestinal system. Alcohol causes loosening of the muscular ring that prevents the stomach's contents from re-entering the esophagus. Therefore, the acid from the stomach flows backwards into the esophagus, burning those tissues, and causing pain and bleeding. Inflammation of the stomach can also result in bleeding and pain, and decreased desire to eat. A major cause of severe, uncontrollable bleeding (hemorrhage) in an alcoholic is the development of enlarged (dilated) blood vessels within the esophagus, which are called esophageal varices. These varices are actually developed in response to liver disease, and are extremely prone to bursting and hemorrhaging. Diarrhea is a common symptom, due to alcohol's effect on the pancreas. In addition, inflammation of the pancreas (pancreatitis) is a serious and painful problem in alcoholics. Throughout the intestinal tract, alcohol interferes with the absorption of nutrients, creating a malnourished state. Because alcohol is broken down (metabolized) within the liver, that organ is severely affected by constant levels of alcohol. Alcohol interferes with a number of important chemical processes that also occur in the liver. The liver begins to enlarge and fill with fat (fatty liver), fibrous scar tissue interferes with the liver's normal structure and function (cirrhosis), and the liver may become inflamed (hepatitis).
• Blood. Alcohol can cause changes to all the types of blood cells. Red blood cells become abnormally large. White blood cells (important for fighting infections) decrease in number, resulting in a weakened immune system. This places alcoholics at increased risk for infections, and is thought to account in part for the increased risk of cancer faced by alcoholics (ten times increased over normal). Platelets and blood clotting factors are affected, causing an increased risk of bleeding.
• Heart. Small amounts of alcohol cause a drop in blood pressure, but with increased use, alcohol begins to increase blood pressure into a dangerous range. High levels of fats circulating in the bloodstream increase the risk of heart disease. Heavy drinking results in an increase in heart size, weakening of the heart muscle, abnormal heart rhythms, a risk of blood clots forming within the chambers of the heart, and a greatly increased risk of stroke (due to a blood clot from the heart entering the circulatory system, going to the brain, and blocking a brain blood vessel).
• Reproductive system. Heavy drinking has a negative effect on fertility in both men and women, by decreasing testicle and ovary size, and interfering with both sperm and egg production. When pregnancy is achieved in an alcoholic woman, the baby has a great risk of being born with fetal alcohol syndrome, which causes distinctive facial defects, lowered IQ, and behavioral problems.

Diagnosis

Two different types of alcohol-related difficulties have been identified. The first is called alcohol dependence, which refers to a person who literally depends on the use of alcohol. Three of the following traits must be present to diagnose alcohol dependence:

• tolerance, meaning that a person becomes accustomed to a particular dose of alcohol, and must increase the dose in order to obtain the desired effect
• withdrawal, meaning that a person experiences unpleasant physical and psychological symptoms when he or she does not drink alcohol
• the tendency to drink more alcohol than one intends (once an alcoholic starts to drink, he or she finds it difficult to stop)
• being unable to avoid drinking or stop drinking once started

Symptoms Of Co-Alcohol Dependence

Psychological distress manifested in symptoms such as anxiety, aggression, anorexia nervosa, bulimia, depression, insomnia, hyperactivity, and suicidal tendency Psychosomatic illness (ailments that have no biological basis and clear up after the co-alcoholism clears up)

Family violence or neglect

Alcoholism or other drug abuse

• having large blocks of time taken up by alcohol use
• choosing to drink at the expense of other important tasks or activities
• drinking despite evidence of negative effects on one's health, relationships, education, or job

Alcohol abuse requires that one of the following four criteria is met. Because of drinking, a person repeatedly:

• fails to live up to his or her most important responsibilities
• physically endangers him or herself, or others (for example, by drinking when driving)
• gets into trouble with the law
• experiences difficulties in relationships or jobs

Diagnosis is sometimes brought about when family members call an alcoholic's difficulties to the attention of a physician. A clinician may begin to be suspicious when a patient suffers repeated injuries or begins to experience medical problems related to the use of alcohol. In fact, some estimates suggest that about 20% of a physician's patients will be alcoholics.

Diagnosis is aided by administering specific psychological assessments that try to determine what aspects of a person's life may be affected by his or her use of alcohol. Determining the exact quantity of alcohol that a person drinks is of much less importance than determining how his or her drinking affects relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body breaks down and processes alcohol) is so individual, the quantity of alcohol consumed is not part of the criteria list for diagnosing either alcohol dependence or alcohol abuse.

One very simple tool for beginning the diagnosis of alcoholism is called the CAGE questionnaire. It consists of four questions, with the first letters of each key word spelling out the word CAGE:

• Have you ever tried to Cut down on your drinking?
• Have you ever been Annoyed by anyone's comments about your drinking?
• Have you ever felt Guilty about your drinking?
• Do you ever need an Eye-opener (a morning drink of alcohol) to start the day)?

Other, longer lists of questions exist to help determine the severity and effects of a person's alcohol use. Given the recent research pointing to a genetic basis for alcoholism, it is important to ascertain whether anyone else in the person's family has ever suffered from alcoholism.

Physical examination may reveal signs suggestive of alcoholism: evidence of old injuries; a visible network of enlarged veins just under the skin around the navel (called caput medusae); fluid in the abdomen (ascites); yellowish-tone to the skin; decreased testicular size in men; and poor nutritional status. Lab work may reveal an increase in the size of the red blood cells; abnormalities in the white blood cells (cells responsible for fighting infection) and platelets (particles responsible for clotting); and an increase in certain liver enzymes.

Treatment

Treatment of alcoholism has two parts. The first step in the treatment of alcoholism, called detoxification, involves helping the person stop drinking and ridding his or her body of the harmful (toxic) effects of alcohol. Because the person's body has become accustomed to alcohol, the person will need to be supported through withdrawal. Withdrawal will be different for different patients, depending on the severity of the alcoholism, as measured by the quantity of alcohol ingested daily and the length of time the patient has been an alcoholic. Withdrawal symptoms can range from mild to life-threatening. Mild withdrawal symptoms include nausea, achiness, diarrhea, difficulty sleeping, sweatiness, anxiety, and trembling. This phase is usually over in about three to five days. More severe effects of withdrawal can include hallucinations (in which a patient sees, hears, or feels something that is not actually real), seizures, an unbearable craving for more alcohol, confusion, fever, fast heart rate, high blood pressure, and delirium (a fluctuating level of consciousness). Patients at highest risk for the most severe symptoms of withdrawal (referred to as delirium tremens) are those with other medical problems, including malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begin about three to five days after the patient's last drink, progressing from the more mild symptoms to the more severe, and may last a number of days.

Patients going through only mild withdrawal are simply monitored carefully to make sure that more severe symptoms do not develop. No medications are necessary, however. Treatment of a patient suffering the more severe effects of withdrawal may require the use of sedative medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Drugs called benzodiazapines are helpful in those patients suffering from hallucinations. Because of the patient's nausea, fluids may need to be given through a vein (intravenously), along with some necessary sugars and salts. It is crucial that thiamine be included in the fluids, because thiamine is usually quite low in alcoholic patients, and deficiency of thiamine is responsible for the Wernicke-Korsakoff syndrome.

After cessation of drinking has been accomplished, the next steps involve helping the patient avoid ever taking another drink. This phase of treatment is referred to as rehabilitation. The best programs incorporate the family into the therapy, because the family has undoubtedly been severely affected by the patient's drinking. Some therapists believe that family members, in an effort to deal with their loved one's drinking problem, sometimes develop patterns of behavior that accidentally support or "enable" the patient's drinking. This situation is referred to as "co-dependence, " and must be addressed in order to successfully treat a person's alcoholism.

Sessions led by peers, where recovering alcoholics meet regularly and provide support for each other's recoveries, are considered some of the best methods of preventing a return to drinking (relapse). Perhaps the most well-known such group is called Alcoholics Anonymous, which uses a "12-step" model to help people avoid drinking. These steps involve recognizing the destructive power that alcohol has held over the alcoholic's life, looking to a higher power for help in over-coming the problem, and reflecting on the ways in which the use of alcohol has hurt others and, if possible, making amends to those people. According to a recent study reported by the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined.

There are also medications that may help an alcoholic avoid returning to drinking. These have been used with variable success. Disulfiram (Antabuse) is a drug which, when mixed with alcohol, causes unpleasant reactions including nausea, vomiting, diarrhea, and trembling. Naltrexone, along with a similar compound, Nalmefene, can be helpful in limiting the effects of a relapse. Acamprosate is helpful in preventing relapse. None of these medications would be helpful unless the patient was also willing to work very hard to change his or her behavior.

Alternative treatment

Alternative treatments can be a helpful adjunct for the alcoholic patient, once the medical danger of withdrawal has passed. Because many alcoholics have very stressful lives (whether because of or leading to the alcoholism is sometimes a matter of debate), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. The malnutrition of long-term alcohol use is addressed by nutrition-oriented practitioners with careful attention to a healthy diet and the use of nutritional supplements such as vitamins A, B complex, and C, as well as certain fatty acids, amino acids, zinc, magnesium, and selenium. Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs are thought to be helpful for the patient suffering through withdrawal. Some of these include lavender (Lavandula officinalis), skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), peppermint (Mentha piperita) yarrow (Achillea millefolium), and valerian (Valeriana officinalis). Acupuncture is believed to both decrease withdrawal symptoms and to help improve a patient's chances for continued recovery from alcoholism.

Prognosis

Recovery from alcoholism is a life-long process. In fact, people who have suffered from alcoholism are encouraged to refer to themselves ever after as "a recovering alcoholic, " never a recovered alcoholic. This is because most researchers in the field believe that since the potential for alcoholism is still part of the individual's biological and psychological makeup, one can never fully recover from alcoholism. The potential for relapse (returning to illness) is always there, and must be acknowledged and respected. Statistics suggest that, among middle-class alcoholics in stable financial and family situations who have undergone treatment, 60% or more can be successful at an attempt to stop drinking for at least a year, and many for a lifetime.

Prevention

Prevention must begin at a relatively young age since the first instance of intoxication (drunkenness) usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholism—those with a family history of alcoholism, an early or frequent use of alcohol, a tendency to drink to drunkenness, alcohol use that interferes with school work, a poor family environment, or a history of domestic violence—receive education about alcohol and its long-term effects. How this is best achieved, without irritating the youngsters and thus losing their attention, is the subject of continuing debate and study.