Alcoholism

Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to the extent that this behavior interferes with the drinker's normal personal, family, social, or work life, and may lead to physical, or mental harm. The resulting chronic use can result in many 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.

The biological mechanism of alcoholism is unknown. While alcohol use is required to trigger alcoholism, the majority of the population can drink alcoholic beverages with no danger of suffering from it. One of several 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. An alcoholic can develop several forms of addiction to alcohol simultaneously (psychological, metabolic, and neurochemical) and they all must be treated in order to effectively treat the condition.

Terminology

Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all in common use, but are not always used with an understanding of the associated medical conditions and therefore have acquired highly variable and sometimes non-standard meanings.

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 as a result 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. The term can therefore cause confusion due to the possibility that an audience doesn't share a single definition.

Dependence also has a variety of definitions. The standard psychiatric diagnosis of dependence is defined in the DSM-IV-TR, but here the terminology is being reconsidered for DSM-V due in part to the many working definitions for dependence.

The precise definition of addiction is debated, but in general it refers to any condition which results in the continuation of 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.

Epidemiology

Substance use disorders are the major public health problem facing many countries. In the United States today, more than 15 million Americans estimated to suffer from alcoholism. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol."Gabbard: "Treatments of Psychiatric Disorders". Published by the American Psychiatric Association: 3rd edition, 2001, ISBN 0880489103 In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.Cabinet Office Strategy Unit Alcohol misuse: How much does it cost? September 2003

Satal, Kosten, and Schuckit noted in 1993 that it is likely that individuals will not reach an optimal level of function until substance free for three to six months. Sleep may not return to normal for up to twelve months after cessation of all sedative use.

Those with the condition are classified by the American Psychiatric Association as either actively using alcohol, or being in early or sustained remission. The latter two groups may be further identified as being partial or full depending upon the patient's symptom profile. Remission states refer not to the quantity of alcohol being used but rather to the decrease in physical or mental symptoms resulting from such use.

There is considerable debate regarding the Disease Theory of Alcoholism. Proponents argue that any structural or functional disorder 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. As a result, identification involves an objective assessment regarding the damage that the consumption of alcohol does to the drinker's life compared to the perceived subjective benefits that the drinker perceives from that consumption. 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.

Screening

Several tools may be used to detect the loss of control of alcohol use. The CAGE questionnaire, developed by Dr. John Ewing and 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:# Have you ever felt you needed to Cut down on your drinking?# Have people Annoyed you by criticizing your drinking?# Have you ever felt Guilty about drinking?# 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?Ewing, John A. "Detecting Alcoholism: The CAGE Questionnaire" JAMA 252: 1905-1907, 1984CAGE Questionnaire (PDF)

Another screening questionnaire is the Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization.

The Alcohol Dependence Data QuestionnaireAlcohol Dependence Data Questionnaire (SADD) is a more sensitive diagnostic test than the CAGE test. The Alcohol Dependence Data Questionnaire serves to distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.

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

Diagnosis

In 1992, a joint committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine was formed to establish a definition of alcoholism that could be used in a clinical setting. That committee defined the condition as a "primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal...characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic."

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism, one more closely based on specifics than the 1992 committee definition. In part this is to assist in the development of research protocols in which findings can be compared with one another, but the DSM definition is the one currently in general use from a diagnostic standpoint. That definition 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.

Blood tests

Although there is no blood test specific for heavy alcohol use or alcohol addiction (alcoholism), prolonged heavy alcohol consumption may lead to several abnormalities, including:
*Macrocytosis (enlarged MCV)¹*Elevated GGT²*Moderate elevation of AST and ALT and an AST:ALT ratio of 2:1.
*High carbohydrate-deficient transferrin²

Effects

Long term physical health effects

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
* pancreatitis, or inflammation of the pancreas (both the acute and chronic form)
* heart disease, including dilated cardiomyopathy
* polyneuropathy, or damage to the nerves leading to poor sensation of pain and impaired mobility
* cirrhosis of the liver, a chronic disease characterized by destruction of liver cells and loss of liver function, and its numerous complications, including bleeding from esophageal varices
* depression, insomnia, anxiety, and suicide
* increased incidence of many types of cancer, including breast cancer, head and neck cancer, esophageal cancer and colorectal cancer
* nutritional deficiency of folic acid, thiamine (vitamin B1) and several others
* Wernicke-Korsakoff syndrome, a neuropsychiatric disorder caused by thiamine deficiency that results from poor nutrition in some alcoholics
* sexual dysfunction

Social effects

The social problems arising from alcoholism can include loss of employment, financial problems, marital conflict and divorce, convictions for crimes such as drunk driving or public disorder, loss of accommodation, and loss of respect from others who may see the problem as self-inflicted and easily avoided. Alcohol dependence affects not only the addicted but can profoundly impact the family members around them. Children of alcohol dependents can be affected even after they are grown; the behaviors commonly exhibited by such children are a topic of research. Adult Children of Alcoholics (ACoA) World Service provides support for such individuals.

A study quantified the cost to the UK of all forms of alcohol misuse as Â£18.5â€"20 billion annually (2001 figures).

Alcohol withdrawal

There are several distinct but not mutually exclusive alcohol withdrawal syndromes caused by alcohol withdrawal:
* Tremulousness - "the shakes"
* Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure.
* Seizures - acute grand mal seizures can occur in alcohol withdrawal in patients who have no history of seizure or any structural brain disease.
* Hallucinations - usually visual or tactile in alcoholics
* Delirium tremens - can be severe and often fatal.

Unlike withdrawal from opioids such as heroin, which can be unpleasant but never fatal (Lowinson), alcohol withdrawal can kill (by uncontrolled convulsions or delirium tremens) if it is not properly managed. The pharmacological management of alcohol withdrawal is based on the fact that alcohol, barbiturates, and benzodiazepines have remarkably similar effects on the brain and can be substituted for each other. Since benzodiazepines are the safest of the three classes of drugs, alcohol consumption is terminated and a long-acting benzodiazepine is substituted to block the alcohol withdrawal syndrome. The benzodiazepine dosage is then tapered slowly over a period of days or weeks.

Treatments

Treatments for alcoholism are quite varied in keeping with the multiple perspectives regarding the condition itself. Those approaching the condition as a medical disease recommend differing treatment processes and goals than, for instance, those approaching the condition as one of social choice. Most treatments focus on helping people discontinue their alcohol and sedative intake, then providing life training and/or social support in order to help them resist a return to sedative use. Since alcoholism involves multiple factors which encourage a person to continue drinking (psychological/social, physical, and neurochemical), all of these factors must be addressed in order to successfully prevent a return to active alcohol use.

The most common approach to 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 approach, though some promote the harm-reduction approach generally used for opioid dependence.

The effectiveness of alcoholism treatments vary from good to counterproductive. When considering the effectiveness of treatment options it is important to consider the percentage of those who enter a program, not just those who complete it. Most programs can boast a high cure rate for those who complete it because most people only complete a program if it works for them. It is also important to consider not just the rate of those reaching sobriety but the rate of those relapsing.

Detoxification

Detoxification (a.k.a. "detox") is the process of eliminating alcohol drinking and giving the drinker's system time to re-adjust to the absence of alcohol. Drugs that have similar effects are used to ease the withdrawal symptoms, which can be deadly in extreme cases if left untreated. Often used drugs are sedative-hypnotics, such as diazepam or clonazepam or, less frequently, barbiturates such as phenobarbital. Many weeks thereafter individuals may still suffer from milder withdrawal symptoms; sleep is generally the last function to return to normal.

Sedatives are used with possible approaches:

a) Sedative-loading is a process through which patients are gradually given increasing doses of the taper medication to determine the level of tolerance already present as a result of ongoing alcohol use. Once the level is determined, the medication is gradually tapered from that point.

b) Patients are given doses of the taper medication depending upon the level of withdrawal symptoms present. Patients then are monitored for withdrawal symptoms and medicated as needed over the course of several days.

Detoxification is not a treatment for alcoholism, but is simply a treatment of the physiologic effects of ongoing use of alcohol. It provides an initial path for an alcoholic to stop drinking in the first place. Detoxification without supplemental treatments to help the patient continue abstinence have a very high rate of relapse.

Detoxification often takes place within an inpatient environment, but several programs offer outpatient detoxification.

Group therapy and psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues leading to alcohol dependence, and also to provide the recovering addict with relapse prevention skills.

In the mid-1930s, the mutual-help group-counseling approach to treatment began and has become very popular. Alcoholics Anonymous is the best-known example of the support group movement. Other groups that provide similar self-help and support without AA's spiritual focus include LifeRing Secular Recovery, Smart Recovery, Women For Sobriety, and Rational Recovery.

Rationing

Some programs attempt to help problem drinkers before they become dependents. These programs focus on harm reduction and reducing alcohol intake as opposed to abstinence-based approaches. Since one of the effects of alcohol is to reduce a person's judgement faculties, each drink makes it more difficult to decide that the next drink is a bad idea. As a result, rationing or other attempts to control use are increasingly ineffective if pathological attachment to the drug develops.

Nonetheless, this form of treatment is initially effective for some people, and it may avoid the physical, financial, and social costs that other treatments result in, particularly in the early phase of recovery. Professional help can be sought for this form of treatment from programs such as Moderation Management.

Medications

Medications for alcoholism are most often used to supplement a person's willpower and encourage abstinence.

Antabuse (disulfiram), for instance, prevents the elimination of a chemical (acetaldehyde) which cause severe discomfort when alcohol is ingested, effectively preventing the alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on Antabuse can result in severe illness and death.

Naltrexone has also been used because it helps curb cravings for alcohol while the person is on it. Both Antabuse and Naltrexone used to encourage abstinence, however, have been demonstrated to cause a rebound effect when the user stops taking them.

Naltrexone, nalphamene, and other endorphin antagonists are also used in a process called pharmacological extinction, which is an attempt to reverse the conditioning which results in alcoholism. No rebound effect is demonstrated from pharmacological extinction.

Sodium oxibate, the sodium salt of gamma-hydroxybutyric acid (50 to 100 milligrams per kilogram per day, in 3 or more divided doses) is used in Italy, under the trade name Alcover, both for acute alcohol withdrawal and medium to long term detoxification.

Naltrexone or Acamprosate may improve compliance with abstinence planning by treating the physical aspects of cravings to drink. The standard pharmacopoeia of antidepressants, anxiolytics, and other psychotropic drugs treat underlying mood disorders, neuroses, and psychoses associated with alcoholic symptoms.

Pharmacological extinction

In recent studiesContrAl Clinics Links and Resources, it has been demonstrated that the use of endorphin antagonists [e.g. naltrexone] combined with normal drinking habits can result in long term elimination of the craving to consume alcoholEvidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Over a period of roughly three months the alcoholic, while continuing to drink, loses interest in drinking alcohol and can eventually just give it up as being sensibly unbeneficial. This technique is used to good effect in FinlandContrAl Clinics ContrAl Results, PennsylvaniaThe Sinclair Method, and FloridaUniversity of Pennsylvania Health System. This particular form of treatment is sometimes referred to as the Sinclair Method.

There is a lot of professional bias against this treatment for two reasons. Pendery et al in 1982Pendery et al. Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study. Science. 1982 Jul 9;217 (4555):169-75 demonstrated that controlled drinking by alcoholics was clearly not a useful treatment technique. Many studies have also been done which demonstrate naltrexone to be of questionable value in supporting abstinence. For those who don't understand the mechanism involved, these results have been falsely assumed to reflect the effectiveness of the two treatments in combination.

The Finn study indicated, "Naltrexone was not better than placebo in the supportive groups, but it had a significant effect in the coping groups: 27% of the coping/naltrexone patients had no relapses to heavy drinking throughout the 32 weeks, compared with only 3% of the coping/placebo patients. The authors' data confirm the original finding of the efficacy of naltrexone in conjunction with coping skills therapy. In addition, their data show that detoxification is not required and that targeted medication taken only when craving occurs is effective in maintaining the reduction in heavy drinking."Heinala, Pekka; Alho, Hannu; Kiianmaa, Kalervo; Lonnqvist, Jouko; Kuoppasalmi, Kimmo; Sinclair, John Targeted Use of Naltrexone Without Prior Detoxification in the Treatment of Alcohol Dependence: A Factorial Double-Blind, Placebo-Controlled Trial J Clin Psychopharmacol 21(3):287-292, June 2001

Nutritional therapy

Not a treatment of alcoholism itself, but rather a treatment of 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 treated 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, resulting in poor treatment outcomes.The Hypoglycemic Health Association of Australia

Return to normal drinking

It has long been argued that alcoholics cannot learn to drink in moderation. The literature is heavy with research that has demonstrated the long-term failure of programs with such goals; despite this, research by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that nearly 18% of such individuals in the US whose dependence began more than one year earlier are now drinking in moderation.National Institute on Alcohol Abuse and Alcoholism 2001-2002 Survey Finds That Many Recover From Alcoholism Press release 18 January 2005

Societal impact

The various health problems associated with long-term alcohol consumption (discussed above) are generally perceived as costing society money due to lost labor-hours, medical costs, and secondary treatment costs, as well as the pain and suffering of the indivuals affected. Additionally, alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Heavy alcohol consumption by a pregnant mother can also lead to fetal alcohol syndrome, an incurable and damaging condition.

Today, alcohol use and alcohol dependence are major public health problems in North America, costing the region's inhabitants, by some estimates, as much as US$170 billion 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.

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 result from heavy alcohol use, such as in Charles R. Jackson's The Lost Weekend, or the films Days of Wine and Roses, My Name is Bill W, and Leaving Las Vegas. Author Charles Bukowski describes his own alcohol addiction in the movie Barfly and in his other writings.

Politics and public health

Because alcohol use disorders impact 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)
* Men For Sobriety (MFS)
* 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.

External links

* National Institute on Alcohol Abuse and Alcoholism (NIAAA)
* Stanton Peele Addiction Website A web site dedicated to exploring popular myths and controversies regarding alcoholism and addiction treatment, prevention and research.
* Baldwin Research Institute Independent Research on Alcoholism and Drug Addiction
* Alcoholics Anonymous
* Online Screening Test for Alcohol Abuse
* Psych Forums: Alcohol Addiction Forum
* Alcohol Tolerance May Be Genetic health.dailynewscentral.com
* Alcoholism Drug Addiction Forums:Help and Information
* Articles and information pertaining to alcohol and drug rehabilitation
* Drink Too Much? by David J. Hanson
* Alcoholics can Drink in Moderation
* Invited Interview from the Oxford Journal of Medicine on the use of Naltrexone to treat alcoholism
* Alcoholism news page - Alcohol and Drugs History Society

Alcoholism: Encyclopedia BETA

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