What-Is-Alcoholism?

WHAT IS ALCOHOLISM?

Alcoholism is a chronic, progressive, and often fatal disease. It is a primary disorder and not a symptom of other diseases or emotional problems. The chemistry of alcohol allows it to affect nearly every type of cell in the body, including those in the central nervous system. After prolonged exposure to alcohol, the brain adapts to the changes alcohol makes and becomes dependent on it. The severity of this disease is influenced by factors such as genetics, psychology, culture, and response to physical pain.

Signs of alcoholism or alcohol dependence include the following:

The only indication of early alcoholism may be the unpleasant physical responses to withdrawal that occur during even brief periods of abstinence.

Alcoholics have little or no control over the quantity they drink or the duration or frequency of their drinking.

They are preoccupied with drinking, deny their own addiction, and continue to drink even though they are aware of the dangers.

Over time, some people become tolerant to the effects of drinking and require more alcohol to become intoxicated, creating the illusion that they can "hold their liquor."

They have blackouts after drinking and frequent hangovers that cause them to miss work and other normal activities.

Alcoholics might drink alone and start early in the day.

They periodically quit drinking or switch from hard liquor to beer or wine, but these periods rarely last.

Severe alcoholics often have a history of accidents, marital and work instability, and alcohol-related health problems.

Episodic violent and abusive incidents involving spouses and children and a history of unexplained or frequent accidents are often signs of drug or alcohol abuse.
Alcoholism can develop insidiously, and often there is no clear line between problem drinking and alcoholism. Eventually alcohol dominates thinking, emotions, and actions and becomes the primary means through which a person can deal with people, work, and life. [ See Box Definition of Alcohol Use and Abuse.]

DEFINITION OF ALCOHOL USE AND ABUSE

In addition to alcohol dependence, experts are now defining alcohol use by levels of harm that it may be causing. This information is useful to determine possible interventions at earlier stages. The following categories of alcohol use and abuse use a definition of one drink as 12-oz of beer, 5 oz of wine, or 1.5 oz (a jigger) of 90-proof liquor.

Moderate Drinking. Moderate drinking, particularly red wine, appears to offer health benefits. Moderate drinking is defined as equal to or less than two drinks a day for men and equal to or less than one drink a day for women.

Hazardous (Heavy) Drinking. Hazardous drinking puts people at risk for adverse health events. People who are heavy drinkers consume the following:

More than 14 drinks per week or 4 to 5 drinks at one sitting for men.

More than seven drinks a week or three drinks at one sitting for women.

Frequent intoxication in either gender.

Harmful Drinking. Drinking is considered harmful when alcohol consumption has actually caused physical or psychologic harm. This is determined by the following:

There is clear evidence that alcohol is responsible for such harm.

The nature of that harm can be identified.

Alcohol consumption has persisted for at least a month or has occurred repeatedly for the past year.

The individual is not alcohol dependent.
Alcohol Abuse. People with alcohol abuse have one or more of the following alcohol-related problems over a period of one year:

Failure to fulfill work or personal obligations.

Recurrent use in potentially dangerous situations.

Problems with the law.

Continued use in spite of harm being done to social or personal relationships.

a 2001 study, 55% patients continued to meet this criteria after five years but only 3.5% developed dependency, the next stage.
Alcohol Dependence. People who are alcohol dependent have three or more of the following alcohol-related problems over a period of one year:

Increased amounts of alcohol needed to produce an effect.

Withdrawal symptoms or drinking alcohol to avoid these symptoms.

Drinking more over a given period than intended.

Unsuccessful attempts to quit or cut down.

Giving up significant leisure or work activities.

Continuing drinking in spite of the knowledge of its physical or psychological harm to oneself or others.

one long-term study, two-thirds of these individuals continued to be dependent on alcohol after five years.

WHAT CAUSES ALCOHOLISM?

People have been drinking alcohol for perhaps 15,000 years. Just drinking steadily and consistently over time can produce dependence and cause withdrawal symptoms during periods of abstinence; this physical dependence, however, is not the sole cause of alcoholism. To develop alcoholism, other factors usually come into play, including biology, genetics, culture, and psychology.

Genetic Factors

Genetic factors play a significant role in alcoholism and may account for about half of the total risk for alcoholism, although alcoholism is so complex that it is unlikely that any single gene will ever be identified as a major culprit.

Researchers are investigating a number of inherited traits that make particular individuals susceptible to this disorder. Some examples are the following:

One 2001 study found that the amygdala is smaller in subjects with family histories of alcoholism, suggesting that inherited differences in brain structure may affect risk. The amygdala is an area of the brain thought to play a role in the emotional aspects of craving, which can lead to addiction.

Because alcohol is not found easily in nature, genetic mechanisms to protect against excessive consumption may not have evolved in humans as they frequently have for protection against natural threats. Some evidence, then, suggests that a natural lack of genetic protection plays a major role in alcoholism. Such studies have found that people with a family history of alcoholism tend to "hold their liquor" better than those without such history. Experts suggest some people may inherit a lack of those warning signals that ordinarily make people stop drinking. Research suggests this factor may contribute to between 40% and 60% of alcoholism cases related to genetic factors. (Even in the absence of genetic factors, repeated exposure to alcohol increases the ability to tolerate larger amounts before experiencing behavioral impairment.)

Genes that regulate certain chemical byproducts of alcohol are under intense scrutiny. Alcohol is metabolized in a two-stage process: it is first converted to acetaldehyde (AcH), which is then converted into acetate. AcH is being researched because it plays a role in most actions of alcohol, including damaging effects on the liver and upper airway. It also may be protective. For example, some people, particularly in Asian and possibly Jewish populations may be less likely to become alcoholic because of a genetic deficiency in AcH, which produces a build-up of acetate after drinking alcohol. Acetate is toxic and in high amounts causes to flushing, dizziness, and nausea. Individuals with this genetic factor, then, are less likely to become alcoholic. (This deficiency is not completely protective against drinking, however, particularly if there is social pressure, such as among college fraternity members.)

Some people with alcoholism may have inherited dysfunction in the transmission of serotonin. This is an important brain chemical known as a neurotransmitter that is important for well-being and associated behaviors (eating, relaxation, sleep). Abnormal serotonin levels are associated with high levels of tolerance for alcohol. They are also linked to impulsive and aggressive behaviors, which can predispose people to drink and also increase the risk for dangerous behaviors and suicide in alcoholics. (Serotonin abnormalities can also develop from environmental pressures as well, such as early loss in childhood.)
Even if genetic factors can be identified, however, they are unlikely to explain all cases of alcoholism. It is important to understand that, whether they inherit the disorder or not, people with alcoholism are still legally responsible for their actions. Inheriting genetic traits does not doom a child to an alcoholic future. Environment, personality, and emotional factors also play a strong role. [ See Who Becomes an Alcoholic?, Below.]

Dependency Caused by Brain Chemical Imbalances after Long-Term Alcohol Use

Alcohol has widespread effects on the brain and can affect neurons (nerve cells), brain chemistry, and blood flow within the front lobes of the brain.

Some research is focusing on the way the brain's chemistry changes after long-term alcohol use in order to adapt to the cravings and pain of withdrawal. Such chemical changes may employ two effects that lead to dependency or relapse after quitting:

The need to reduce agitation, and

The desire to restore pleasurable feelings.
Reducing Agitation. When a person who is dependent on alcohol stops drinking, the following chemical responses create an overexcited nervous system and agitation:

A drop in gamma-aminobutyric acid, a brain chemical that inhibits impulsivity.

An increase in glutamate, a brain chemical that excites nerve cells.

An increase norepinephrine and corticotropin releasing factor, hormones that produce stress.
This hyperactivity in the brain produces an intense need to calm down with the use of yet more alcohol. One recent study suggested that agitation may be the more important factor in causing a relapse than restoring mood.

Restoring Pleasure. Alcohol releases the following neurotransmitters (chemical messengers in the brain) and other chemicals that produce pleasurable feelings:

Dopamine. Produces euphoria and a sensation of being rewarded. Repeated alcohol use increases sensitivity to dopamine.

Serotonin. Produces feelings of well-being.

Opioid peptides. Important for well-being.
Over time, however, heavy alcohol use appears to deplete the stores of dopamine and serotonin. Persistent drinking therefore eventually fails to restore mood, but by then the drinker has been conditioned to believe that alcohol will improve spirits (even though it doesn't).

Social and Emotional Causes of Alcoholic Relapse

Between 80% and 90% of people treated for alcoholism relapse, even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. According to one study, three factors placed a person at high risk for relapse:

Frustration and anger.

Social pressure.

Internal temptation.
(Another study suggests that impaired sleep is also an important predictor of relapse.)

Mental and Emotional Stress. Alcohol blocks out emotional pain and is often perceived as a loyal friend when human relationships fail. It is also associated with freedom and a loss of inhibition that offsets the tedium of daily routines. When the alcoholic tries to quit drinking, the brain seeks to restore what it perceives to be its equilibrium. The brain's best weapons to achieve this are depression, anxiety, and stress (the emotional equivalents of physical pain), which are produced by brain chemical imbalances. These negative moods continue to tempt alcoholics to return to drinking long after physical withdrawal symptoms have abated.

Even intelligence is no ally in this process, for the over-agitated brain will use all its powers of rationalization to persuade the patient to return to drinking. According to a 1999 study having a high or low IQ has little effect on quitting. However, according to this study, a high verbal ability may aid the alcoholic in remaining sober.

It is important to realize that any life change may cause temporary grief and anxiety, even changes for the better. With time and the substitution of healthier pleasures, this emotional turmoil weakens and can be overcome.

Codependency. Many aspects of the ex-drinker's relationships change when drinking stops, making it difficult to remain abstinent:

One of the most difficult problems is being around other people who are able to drink socially without danger of addiction. A sense of isolation, a loss of enjoyment, and the ex-drinker's belief that pity, not respect, is guiding a friend's attitude can lead to loneliness, low self-esteem, and a strong desire to drink again.

Friends may not easily accept the sober, perhaps more subdued, comrade. Close friends and even intimate partners may have difficulty in changing their responses to this newly sober person and, even worse, may encourage a return to drinking.

To preserve marriages, spouses of alcoholics often build their own self-images on surviving or handling their mates' difficult behavior and then discover that they are threatened by abstinence.
In such cases, separation from these "enablers" may be necessary for survival. It is no wonder that, when faced with such losses, even if they are temporary, a person returns to drinking. The best course in these cases is to encourage close friends and family members to seek help as well. Fortunately, groups such as Al-Anon exist for this purpose.

Social and Cultural Pressures. The media portrays the pleasures of drinking in advertising and programming. The medical benefits of light to moderate drinking are frequently publicized, giving ex-drinkers the spurious excuse of returning to alcohol for their health. These messages must be categorically ignored and acknowledged for what they are: an industry's attempt to profit from potentially great harm to individuals.

WHO BECOMES AN ALCOHOLIC?

General Risk Factors

An estimated 90% of American adults drink alcohol, and up to half of American men have problems that are caused by alcohol. Between 10% and 20% of men and between 3% and 10% of women either abuse or become dependent on alcohol, and some studies indicate that every day, more than 700,000 Americans are being treated for alcoholism.

Age

Drinking in Adolescence. Currently 1.9 million young people between the ages of 12 and 20 are considered heavy drinkers and 4.4 million are binge drinkers. Anyone who begins drinking in adolescence is at risk for developing alcoholism. Young people at highest risk for early drinking are those with a history of abuse, family violence, depression, and stressful life events. People with a family history of alcoholism are also more likely to begin drinking before the age of 20 and to become alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges or driving after drinking, than young drinkers without a family history of alcoholism.

Drinking in the Elderly Population. Although alcoholism usually develops in early adulthood, the elderly are not exempt. A survey of 5,000 adults over 60 reported that 15% of men and 12% of women were hazardous drinkers, and 9% of men and 3% of women were alcohol dependent. In another study, the prevalence of problem drinking was as high as 49% among nursing home patients. Alcohol also affects the older body differently; people who maintain the same drinking patterns as they age can easily develop alcohol dependency without realizing it. Physicians may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process.

Gender

Most alcoholics are men, but the incidence of alcoholism in women has been increasing over the past 30 years. About 9.3% of men and 1.9% of women are heavy drinkers, and 22.8% of men are binge drinkers compared to 8.7% of women. In general, young women problem drinkers follow the drinking patterns of their partners, although they tend to engage in heavier drinking during the premenstrual period. Women tend to become alcoholic later in life than men, and it is estimated that 1.8 million older women suffer from alcohol addiction. Even though heavy drinking in women usually occurs later in life, the medical problems women develop because of the disorder occur at about the same age as men, suggesting that women are more susceptible to the physical toxicity of alcohol.

Family History

The risk for alcoholism in sons of alcoholic fathers is 25%. The familial link is weaker for women, but genetic factors contribute to this disease in both genders. In one study, women with alcoholism tended to have parents who drank. Women who came from families with a history of emotional disorders, rejecting parents, or early family disruption had no higher risk for drinking than women without such backgrounds. A stable family and psychological health, however, were not protective in people with a genetic risk. Unfortunately, there is no way to predict which members of alcoholic families are most at risk for alcoholism.

Ethnicity

Overall, there is no difference in alcoholic prevalence among African Americans, Caucasians, and Hispanic people. Some population groups, however, such as Irish and Native Americans, have an increased incidence in alcoholism while others, such as Jewish and Asian Americans, have a lower risk. Although the biological or cultural causes of such different risks are not known, certain people in these population groups may have a genetic susceptibility or invulnerability to alcoholism because of the way they metabolize alcohol. [ See Genetic Factors under What Causes Alcoholism?, above .]

Emotional and Behavioral Disorders

Depression and Anxiety. Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. According to one 2000 study, for example, the risk for heavy drinking in women who are depressed was 2.6 times greater than the risk in women who are not depressed.

Depression and anxiety may play a major role in the development of alcoholism in the elderly, who are often subject to dramatic life changes, such as retirement, the loss of a spouse or friends, and medical problems. Problem drinking in these cases may be due to self-medication of the anxiety or depression. Major depression, in fact, accompanies about one-third of all cases of alcoholism.

Evidence suggests that 20% of people with a form of anxiety called social phobia abuse alcohol. Social phobia causes an intense fear of being publicly scrutinized and humiliated. Such individuals may use alcohol as a way to become less inhibited in public situations.

It should be noted, however, that long-term alcoholism itself causes chemical changes that produce anxiety and depression. In fact, a study on elderly people with depression reported that when even moderate drinkers reduced consumption, their mood improved. It is not always clear, then, whether people with emotional disorders are self-medicating with alcohol or whether alcohol itself is producing mood swings.

Behavioral Disorders and Lack of Impulse Control. Studies are also finding that alcoholism is strongly related to impulsive, excitable, and novelty-seeking behavior, and such patterns are established early on. In a test of mental functioning, alcoholics (mostly women) did not show any deficits in thinking but they were less able to inhibit their responses. Children who later become alcoholics or who abuse drugs are more likely to have less fear of new situations than others, even if there is a greater risk for harm than in nonalcoholics. People with attention deficit hyperactivity disorder, a condition that shares these behaviors, have a higher risk for alcoholism.

Socioeconomic Factors

Alcoholism is not restricted to any social or economic levels. For example, one small 2000 study found that 22% of resident physicians (physicians undergoing postgraduate training) who took a test for alcoholism had scores that were at least suggestive of alcoholism and 35% reported experiences of alcohol misuse. Additionally, a thorough 1996 study reported that no higher prevalence of alcoholism among adult welfare recipients than in the general population (about 7%). There was also no difference in prevalence between poor African Americans and poor Caucasians.

On the other hand, people in low-income groups who drank did display some tendencies that differed from the general population of drinkers. For instance, as many women as men were heavy drinkers in lower income groups. Excessive drinking may also be more dangerous in lower income groups; one study found that it was a major factor in the higher death rate of people, particularly men, in lower socioeconomic groups compared with those in higher groups.

Geographic Factors

Although 54% of urban adults use alcohol at least once a month compared to 42% in nonurban areas, living in the city or the country does not affect the risks for bingeing or heavy alcohol use. One study reported that people in the north central US are at highest risk for heavy drinking (6.4% heavy use and 19% binge drinking), and those in the Northeast have the lowest risk (4.5% heavy use and 13% binge drinking).

Sugar Cravings

People who crave sugar may also be at higher risk for alcoholism. In one study, 62% of male alcoholics enjoyed a sweet sugar solution compared with only 21% of those without a drinking problem. It is not known, however, whether having a "sweet tooth" can be an early predictor of alcoholism or whether alcohol abusers simply develop a taste for sweetness as a result of their chronic alcohol abuse.

HOW SERIOUS IS ALCOHOLISM?

About 100,000 deaths a year can be wholly or partially attributed to drinking, and alcoholism reduces life expectancy by 10 to 12 years. Next to smoking, it is the most common preventable cause of death in America. Although studies indicate that adults who drink moderately (about one drink a day) have a lower mortality rate than their non-drinking peers, their risk for untimely death increases with heavier drinking. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Once one becomes dependent on alcohol, it is very difficult to quit. In one study, after five years, two-thirds of people with alcoholism were still dependent.

General Effects on the Body

Alcohol can affect the body in so many ways that researchers are having a hard time determining exactly what the consequences are from drinking. It is well known, however, that chronic consumption leads to many problems, some of them deadly.

Alcoholism can kill in many different ways, and, in general, people who drink regularly have a higher rate of death from injury, violence, and some cancers.

Frequent, heavy drinking is associated with a higher risk for alcohol-related medical disorders (pancreatitis, upper gastrointestinal bleeding, nerve damage, and impotence) than is episodic drinking or continuous drinking without intoxication.

As people age, it takes fewer drinks to become intoxicated, and organs can be damaged by smaller amounts of alcohol than in younger people. Also, up to one-half of the 100 most prescribed drugs for older people react adversely with alcohol.

Alcohol abusers who require surgery also have an increased risk of postoperative complications, including infections, bleeding, insufficient heart and lung functions, and problems with wound healing. Alcohol withdrawal symptoms after surgery may impose further stress on the patient and hinder recuperation.
The Effects of Hangover

Although not traditionally thought of as a medical problem, a 2000 review of studies found that hangovers have significant consequences that include changes in liver function, hormonal balance, and mental functioning and an increased risk for depression and cardiac events. Hangovers can impair job performance, increasing the risk for mistakes and accidents. Interestingly, hangovers are generally more common in light to moderate drinkers than heavy and chronic drinkers, suggesting that binge drinking can be as threatening as chronic drinking. Any man who drinks more than five drinks or any woman who has over three drinks is at risk for a hangover.

Overdose

Alcohol overdose can lead to death. This is a particular danger for adolescents who may want to impress their friends with their ability to drink alcohol but cannot yet gauge its effects. It is important to note that alcohol overdose doesn't only occur from any one heavy drinking incident, but may also occur from a constant infusion of alcohol in the blood stream.

Accidents, Suicide, and Murder

Alcohol plays a major role in more than half of all automobile fatalities. Less than two drinks can impair the ability to drive. Alcohol also increases the risk of accidental injuries from many other causes. One study of emergency room patients found that having had more than one drink doubled the risk of injury, and more than four drinks increased the risk eleven times. Another study reported that among emergency room patients who were admitted for injuries, 47% tested positive for alcohol and 35% were intoxicated. Of those who were intoxicated, 75% showed evidence of chronic alcoholism. This disease is the primary diagnosis in one quarter of all people who commit suicide, and alcohol is implicated in 67% of all murders.

Domestic Violence and Effects on Family

Alcoholic households are less cohesive, have more conflicts, and their members are less independent and expressive than households with nonalcoholic or recovering alcoholic parents. Domestic violence is a common consequence of alcohol abuse.

Effect on Women. Research suggests that for women, the most serious risk factor for injury from domestic violence may be a history of alcohol abuse in her male partner.

Effect on Children. Alcoholism in parents also increases the risk for violent behavior and abuse toward their children. Children of alcoholics tend to do worse academically than others, have a higher incidence of depression, anxiety, and stress and lower self-esteem than their peers. One study found that children who were diagnosed with major depression between the ages of six and 12 were more likely to have alcoholic parents or relatives than were children who were not depressed. In addition to their own inherited risk for later alcoholism, one study found that 41% of children of alcoholics have serious coping problems that may be life long.

Adult children of alcoholic parents are at higher risk for divorce and for psychiatric symptoms. One study concluded that the only events with greater psychological impact on children are sexual and physical abuse.

Increased Risk for Other Addictions

Researchers are finding common genetic factors in alcohol and nicotine addiction, which may explain, in part, why alcoholics are often smokers. Alcoholics who smoke compound their health problems. More alcoholics die from tobacco-related illnesses, such as heart disease or cancer, than from chronic liver disease, cirrhosis, or other conditions that are more directly tied to excessive drinking.

The Effect on Mental Functioning

Effect of Recent Alcohol Use. Drinking too much alcohol can cause mild neurologic problems in anyone, including insomnia and headache. In a 1999 study, loss of verbal memory and slower reaction times were associated with a higher incidence of recent alcohol use (ie, within the last 3 months). One study that used imaging techniques to scan the brains of inebriated subjects suggested that while alcohol stimulates those parts of the brain related to reward and induces euphoria, it does not appear to impair cognitive performance (the ability to think and reason).

Long-Term Alcohol Use. Long-term alcohol use may physically affect the brain. Studies have reported less blood flow in the front lobes of the brain, which may reflect links to deeper levels.

Researchers are particularly interested in the effects on the hippocampus. This region in the brain is associated with learning and memory and the regulation of emotion, sensory processing, appetite, and stress. One 2000 study suggests that during adolescence the hippocampus is particularly vulnerable to the adverse effects of alcohol.

Brain scans of people with long-term alcoholism have shown atrophy in different parts of the brain and reduced brain activity. Fortunately, this seems to be reversible with continued abstinence. A history of lifetime mild to moderate alcoholism, in any case, does not seem to impair mental functioning. Except in severe cases, any neurologic damage is not permanent and abstinence nearly always leads to recovery of normal mental function. Severely alcoholic patients, however, often have co-existing psychiatric or neurologic problems, and habitual use of alcohol eventually produces depression and confusion.

Liver Disorders

Alcohol is absorbed in the small intestine and passes directly into the liver, where it becomes the preferred energy source. The liver, then, is particularly endangered by alcoholism. In the liver, alcohol converts to toxic chemicals, notably acetaldehyde, which trigger the production of immune factors called cytokines. In large amounts, these agents cause inflammation and tissue injury and are proving to be major culprits in the destructive process in the liver, which leads to cirrhosis.

only 10% of heavy drinks develop advanced liver disease. Not eating when drinking and consuming a variety of alcoholic beverages are factors that increase the risk for liver damage. Still, the amount of alcohol consumed and the patterns of drinking are only weak predictions of risk. Other risk factors have been identified that may increase the danger to the liver:

Obesity is a major factor for all stages of liver disease.

Women develop liver disease at lower quantities of alcohol intake than men.

Genetic factors that regulate the immune responses also play role.
Alcoholic Hepatitis. About 10% to 35% of heavy drinkers develop alcoholic hepatitis (damaging inflammation in the liver). And, between 10% to 20% of these individuals develop cirrhosis, a progressive scarring of the liver that can eventually be fatal.

Viral Hepatitis B and C. People with alcoholism tend to have lifestyles that put them at higher risk for hepatitis B and C, which are caused by viruses. These potentially chronic liver diseases than can also lead to cirrhosis and pose a risk for liver cancer. People with alcoholism should be immunized against hepatitis B; they may need a higher-than-normal dose of the vaccine for it to be effective. There is no vaccine for hepatitis C [ See also Well-Connected, Report #59, Hepatitis.]

Gastrointestinal Problems

Alcoholism can cause many problems in the gastrointestinal tract. Violent vomiting can produce tears in the junction between the stomach and esophagus. Alcoholism poses a high risk for diarrhea, hemorrhoids, and increases the risk for ulcers, particularly in people taking the painkillers known as nonsteroidal anti-inflammatory drugs (such as aspirin or ibuprofen). Alcohol can contribute to serious and chronic inflammation of the pancreas (pancreatitis) in people who are susceptible to this condition. It can also cause inflammation of the esophagus (esophagitis), which can lead to bleeding in heavy drinkers.

Effect on Heart Disease and Stroke

Benefits of Moderate Drinking. The effects of alcohol on heart disease and stroke vary depending on consumption. Evidence strongly suggests that light to moderate alcohol consumption (one or two drinks a day, especially of red wine) protects the heart and helps prevent stroke. The benefits are strongest in people at high risk for heart disease and may be fairly small in those at low risk. Wine drinkers, according to a Danish study, tend to enjoy a higher social status than non-wine drinkers, which suggests they have better general health and may account for heart protection. Nevertheless, other studies, including one in 2001, have found direct benefits on factors that affect blood flow and the heart, particularly with red wine.

Adverse Effects of Heavy Drinking. On the other hand, cardiovascular disease is the leading cause of death in alcoholics. The following are negative effects on the heart and circulation from high alcohol consumption.

Evidence suggests that people who consume more than three drinks a day have abnormal blood clotting factors.

Heavy alcohol consumption can raise blood pressure even in people with no history of heart disease. The more alcohol someone drank, the greater the increase in blood pressure, with binge drinkers (people who have nine or more drinks once or twice a week) being at greatest risk. One study found that binge drinkers had a risk for a cardiac emergency that was two and a half times that of nondrinkers.

Heavy drinking, and particularly binge drinking, may also increase the risk for hemorrhagic stroke (caused by bleeding in the brain).

Large doses of alcohol can trigger irregular heartbeats, which can be dangerous in people with existing heart disease.

Alcohol abuse has also been associated with and may actually be one cause of idiopathic dilated cardiomyopathy, a condition in which the heart enlarges and its muscles weaken, putting the patient at risk for heart failure.
Cancer

As with heart disease, light to moderate consumption of alcohol, particularly red wine, may protect against cancer. Cancer, however, is the second leading cause of death in alcoholics (after cardiovascular disease), and alcoholics have a rate of carcinoma 10 times higher than that of the general population. Alcohol is probably not the direct cause of cancer, but evidence suggests that it increase the effects of factors that can contribute to certain cancers. The following are some examples:

Alcohol produces various enzymes in saliva that may be carcinogenic and increase the risk of upper digestive cancers in certain individuals.

Studies suggest that alcohol, in combination with tobacco smoke, causes genetic damage that is associated with the development of cancer in the upper airways, the esophagus, and liver.

Moderate use of alcohol has also been associated with a higher risk for breast cancer, possibly because of increased estrogen levels or because the liver overproduces certain carcinogenic growth factors in response to alcohol.

Alcoholism is also highly associated with invasive cervical and vaginal cancers. This high risk, however, may be due to behaviors associated with both alcoholism and these cancers (smoking, promiscuity, use of hormonal contraception, and dietary deficiencies).
Effects on the Lung

Pneumonia. Acute alcoholism is strongly associated with very serious pneumonia. One study on laboratory animals suggests that alcohol specifically damages the bacteria-fighting capability of lung cells. (Chronic alcoholism also causes changes in the immune system, although in people without any existing medical problems these changes do not appear to be significant.)

Acute Respiratory Distress Syndrome. One study indicated that intensive care patients with a history of alcohol abuse have a significantly higher risk for developing acute respiratory distress syndrome (ARDS) during hospitalization. ARDS is a form of lung failure that can be fatal. It can be caused by many of the medical conditions common in chronic alcoholism, including severe infection, trauma, blood transfusions, pneumonia, and other serious lung conditions.

Skin, Muscle, and Bone Disorders

Severe alcoholism is associated with osteoporosis (loss of bone density), muscular deterioration, skin sores, and itching. Alcohol-dependent women seem to face a higher risk than men for damage to muscles, including muscles of the heart, from the toxic effects of alcohol. Peripheral neuropathy, damage to the nerves in the limbs, occurs in 5% to 15% of people with alcoholism. Such injuries cause tingling, pain, and numbness in the hands, feet, arms and legs.

Hormonal Effects on Men and Women

Alcoholism increases levels of the female hormone estrogen and reduces levels of the male hormone testosterone, factors that possibly contribute to impotence in men and infertility in women. Increased estrogen levels in women may also play a role in the higher rates of breast cancer observed in women who even drink moderately. Drinking also increases the loss of melatonin, a hormone associated with sleep regulation.

Pregnancy and Infant Development

Even moderate amounts of alcohol can have damaging effects on the developing fetus, including low birth weight and an increased risk for miscarriage. High amounts can cause fetal alcohol syndrome, a condition that can cause mental and growth retardation. One study indicated a significantly higher risk for leukemia in infants of women who drank any type of alcohol during pregnancy.

Effect on People with Diabetes

Moderate alcohol consumption may help protect the hearts of adults with adult-onset, also called type 2, diabetes. It should be noted, however, that alcohol can cause hypoglycemia, a drop in blood sugar, which is especially dangerous for people with diabetes who are taking insulin. Intoxicated diabetics may not be able to recognize symptoms of hypoglycemia, a particularly hazardous condition.

Malnutrition and Wernicke-Korsakoff Syndrome

People with alcoholism should be sure to take vitamin supplements. Even apparently well-nourished people with alcoholism may be deficient in important vitamins, such as the following:

Of particular concern in alcoholism is a severe deficiency in thiamin (vitamin B1), which can cause a serious condition called Wernicke-Korsakoff syndrome. Symptoms of this syndrome include severe loss of balance, confusion, and memory loss. Eventually, it can result in permanent brain damage and death.

Another serious nutritional problem among alcoholics is B vitamin folic acid deficiency, which can cause severe anemia.

Deficiencies in potassium, magnesium, calcium, zinc, and phosphorus can also develop. Such deficiencies also cause widespread health problems.

There is some indication that magnesium and vitamin E supplements may help prevent alcohol-induced injuries in the brain.

the syndrome develops, oral supplements have no effect, and only adequate and rapid intravenous vitamin B1 can treat this serious condition.
Drug Interactions

The effects of many medications are strengthened by alcohol, while others are inhibited. Of particular importance is its reinforcing effect on antianxiety drugs, sedatives, antidepressants, and antipsychotic medications. Alcohol also interacts with many drugs used by diabetics. It interferes with drugs that prevent seizures or blood clotting. It increases the risk for gastrointestinal bleeding in people taking aspirin or other nonsteroidal inflammatory drugs including ibuprofen and naproxen. Chronic alcohol abusers have a particularly high risk for adverse side effects from consuming alcohol while taking certain antibiotics. These side effects include flushing, headache, nausea, and vomiting. In other words, taking almost any medication should preclude drinking alcohol.

At a Glance: Effects of Alcohol

Medical Problem

Light-Moderate Drinking

Binge Drinking and Hangovers

Heavy Chronic Drinking

Liver Disorders

Changes in liver function.

Alcoholic Hepatitis, Cirrhosis.

Gastrointestinal Problems

Diarrhea.

Diarrhea. Hemorrhoids. Pancreatitis. Bleeding in the intestines and stomach. Tears in the esophagus from violent vomiting.

Heart Disease

Beneficial. May help reduce risk for heart disease caused by blockage of arteries.

High Blood Pressure. Increased heart rate. Heart rhythm disturbances.

High Blood Pressure. Weakened heart muscles leading to failure.

Stroke

Beneficial: May help reduce risk for ischemic stroke (strokes caused by blockage in the arteries to the brain.)

Hemorrhagic Stroke.

Hemorrhagic Stroke.

Cancer

Associated with higher risk for breast cancer in women.

Cancers in the head and neck, esophagus, stomach, liver, pancreas, and cervix and vagina (in women). (Effect of heavy drinking on breast cancer is unclear.)

Neurologic or Mental Disorders

Insomnia. Headache.

Memory impairment and problems in thinking and concentration.

Nerve damage from severe vitamin deficiencies. Impairment in mental functioning and memory. Emotional disorders, psychosis.

Genital and Reproductive Problems.

Increase sexual drive (although even modest drinking can cause impotence in men). Even moderate drinking during pregnancy increases risk for birth defects.

Any drinking during pregnancy increases risk for birth defects.

Impotence in Men. Menstrual disorders and infertility in women. Drinking during pregnancy increases risk for birth defects.

Immune System

Increased susceptibility to infections.

Skin, Muscle, and Bone Disorders

Osteoporosis. Muscular Deterioration. Skin Sores. Itching.

Peripheral neuropathy.

Diabetes

Possibly beneficial, though associated with hypoglycemia.

Hypoglycemia.

Hypoglycemia.

Lung Disorders

Acute respiratory distress syndrome. Pneumonia.

HOW IS ALCOHOLISM DIAGNOSED?

Barriers to a Diagnosis

Even when people with alcoholism experience withdrawal symptoms, they nearly always deny the problem, leaving it up to coworkers, friends, or relatives to recognize the symptoms and to take the first steps toward encouraging treatment. Denial, in fact, may be an important warning signal for alcoholism.

Family members cannot always rely on a physician to make an initial diagnosis. Although 15% to 30% of people who are hospitalized suffer from alcoholism or alcohol dependence, physicians often fail to screen for the problem. In addition, doctors themselves often cannot recognize the symptoms. In one study, alcohol problems were detected by the physician in less than half of patients who had them. Even when physicians identify an alcohol problem, however, they are frequently reluctant to confront the patient with a diagnosis that might lead to treatment for addiction.

Screening Tests for Alcoholism

A physician who suspects alcohol abuse should ask the patient questions about current and past drinking habits to distinguish moderate from heavy, or hazardous, drinking. [ See Box Definition of Alcohol Use and Abuse.]

A physician who suspects alcohol abuse or dependency have a number of short screening tests available, which a person can even take on his or her own. Because people with alcoholism often deny their problem or otherwise attempt to hide it, the tests are designed to elicit answers related to problems associated with drinking rather than the amount of liquor consumed or other specific drinking habits.

CAGE Test. The CAGE test is an acronym for the following questions and is the quickest test:

Attempts to CUT (C) down on drinking.

ANNOYANCE (A) with criticisms about drinking.

GUILT (G) about drinking.

Use of alcohol as an EYE-OPENER (E) in the morning.
This test and another called the Self-Administered Alcoholism Screening Test (SAAST), appear to be most useful in detecting possible alcoholism in white middle-aged males. They are not very accurate for identifying alcohol abuse in older people, white women, and African- and Mexican-Americans.

T-ACE Test. The T-ACE test is a four-question test that appears to be quite accurate in identifying alcoholism in both men and women. It asks the following questions:

Does it TAKE (T) more than three drinks to make you feel high?

Have you ever been ANNOYED (A) by people's criticism of your drinking?

Are you trying to CUT DOWN (C) on drinking?

Have you ever used alcohol as an EYE OPENER (E) in the morning?
A positive response to two of these four questions is considered to indicate possible alcohol abuse or dependence.

AUDIT Test. A more effective and important test for most people may be the Alcohol Use Disorders Identification Test (AUDIT), which is the only test specifically designed to identify hazardous or harmful drinking. It asks three questions about amount and frequency of drinking, three questions about alcohol dependence, and four questions about problems related to alcohol consumption.

A Single-Question. One simple question may be as sensitive as the CAGE or Audit test: "When was the last time you had more than five drinks (for men) or four drinks (for women) in one day?" An answer of "within three months" accurately identified about half of people who were problem drinkers. Problem drinking is defined as hazardous drinking within the last month or some alcohol-use disorder during the past year. [ See Box Definition of Alcohol Use and Abuse.]

Other Screening Tests. Other short screening tests are the Michigan Alcoholism Screening Test (MAST) and The Alcohol Dependence Scale (ADS).

Ruling Out Other Problems

Some symptoms of alcoholism may be attributed to other disorders, particularly in the elderly, where symptoms of confusion, memory loss, or falling may be attributed to the aging process alone. Heavy drinkers may be more likely to complain to their doctors about so-called somatization symptoms, which are vague ailments such as joint pain, intestinal problems, or general weakness, that have no identifiable physical cause. Such complaints should signal the physician to follow-up with screening tests for alcoholism.

Alcoholism is particularly less likely to be recognized in elderly women. In fact, only 1% of older women who need treatment for alcoholism are diagnosed accurately and treated appropriately. Instead, they are often diagnosed with depression and may even be prescribed anti-anxiety drugs or antidepressants that can have dangerous interactions with alcohol.

Tests for Related Medical Problems

A physical examination and other tests should be performed to uncover any related medical problems.

Tests for alcohol levels in the blood are not useful for diagnosing alcoholism because they reflect consumption at only one point in time and not long-term usage. Certain blood tests, however may provide biologic markers that suggest medical problems associated with alcoholism or indications of alcohol abuse:

A test for a factor known as carbohydrate-deficient transferrin (CDT) has been approved as a marker for heavy drinking. It can be helpful in monitoring patients for progress towards abstinence and may also be an indicator for a higher risk for suicide in people with alcoholism.

Gamma-glutamyltransferase (GGT). This liver enzyme is very sensitive to alcohol and can be elevated after moderate alcohol intake and in chronic alcoholism.

Aspartate and alanine aminotransaminases (AST,ALT) are tests for enzymes and factors that can help identify liver damage.

Tests of testosterone levels in men with alcoholism may be low. (This result sometimes persuades men with alcoholism to seek help.)

A mean corpuscular volume (MCV) blood test is sometimes used to measure the size of red blood cells, which increase with alcohol use over time.
WHAT ARE THE GENERAL GUIDELINES FOR TREATING ALCOHOLISM?

Getting the Patient to Seek Treatment

Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. One study reported that the main reasons alcoholics do not seek treatment are the following:

Lack of confidence in successful therapies.

Denial of their own alcoholism.

Social stigma attached to the condition and its treatment.
The alcoholic patient and everyone involved should fully understand that alcoholism is a disease and that the responses to this disease (need, craving, fear of withdrawal) , are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as are treatments for other life-threatening diseases, such as cancer, but that it is the only hope for a cure.

Personal Intervention. The best approaches for motivating a patient to seek treatment are interventional group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this approach, each person affected offers a compassionate but direct and honest report describing specifically how he or she has been hurt by their loved one's or friend's alcoholism.

The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and consistently demand that the patient seek treatment. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation.

Employer Intervention. Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if he or she does not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers.

Overall Treatment Goals

The ideal goals of long-term treatment by many physicians and organizations such as AA are total abstinence and replacement of the addictive patterns with satisfying, time-filling behaviors that can fill the void in daily activity which occurs when drinking has ceased. Patients who secure total abstinence have better survival rates, mental health, and marriages, and they are more responsible parents and employees than those who continue to drink or relapse.

Because abstinence is so difficult to attain, however, many professionals choose to treat alcoholism as a chronic disease. In other words, patients should expect and accept relapse but should aim for as long a remission period as possible. Even reducing alcohol intake can lower the risk for alcohol-related medical problems.

Alcoholics Anonymous and other alcoholic treatment groups are greatly worried by treatment approaches that do not aim for strict abstinence, however. Many people with alcoholism are eager for any excuse to start drinking again. There is also no way to determine which people can stop after one drink and which ones cannot. At this time, seeking total abstinence is the only safe route.

Inpatient Versus Outpatient Treatment

A number of treatment options now exist for alcoholism. It is first important to determine if in- or outpatient care would best benefit the individual. Inpatient care is performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. It is recommended for the following people:

Those with a coexisting medical or psychiatric disorder.

Those who may harm themselves or others.

Those who have not responded to conservative treatments.

Those who have a disruptive home environment.
Many studies have reported better success rates with inpatient treatment of patients with alcoholism. Examples are the following:

In one 1999 study, patients were hospitalized and treated for four weeks and compared to patients treated as outpatients for six weeks. At three months after treatment, inpatients had fewer complications and were less likely to return to drinking than outpatients. After six months to a year the differences were smaller.

In another study, those in an inpatient group had significantly fewer rehospitalizations and remained abstinent longer than people in two other outpatient groups (compulsory attendance at AA meetings or allowed to choose their own treatment option, including none at all).
Other studies, however, have shown no difference in results between inpatient and outpatient programs. Given the ambiguity in results and high expense of inpatient treatment, then, most care providers do not choose inpatient treatment for alcoholics who are not a threat to others or themselves.

Inpatient Treatment Options. A typical inpatient regimen may include the following stages:

A physical and psychiatric work-up for any physical or mental disorders.

Detoxification.

Treatment with medications.

Psychotherapy or cognitive-behavioral therapy.

An introduction to Alcoholics Anonymous (AA).
Outpatient Treatment Options. People with mild to moderate withdrawal symptoms are usually treated as outpatients. Treatments are similar to those in inpatient situations and include the following:

Psychotherapy or counseling.

Medications that target brain chemicals involved in addiction.

Social support groups such as Alcoholics Anonymous.

Studies are suggesting that cognitive therapies may be very effective for selected people.

Even brief intervention by a family doctor can be helpful for reducing alcohol intake in many heavy drinkers.

Because people with alcoholism are very likely to also be smokers, one study suggested that quitting smoking at the same time might even promote alcohol abstinence.

After-care employs services that help alcoholics maintain sobriety. For example, in some cities, sober-living houses provide residences for people who are trying to stay sober. They do not offer formal treatment services, but the people living there offer each other support and maintain an abstinent environment.
Factors that Predict Success or Failure after Treatment

A 2001 analysis of studies reported that 25% of people were continuously abstinent following treatment, and another 10% used alcohol moderately and without problems. And even among the remaining group, alcohol consumption was reduced by an average of 87%. Most studies strongly suggest that intensive and prolonged treatment is important for successful recovery, whether the patient is treated within or outside a treatment center. Certain factors play a role in success or failure:

Patients from low-income groups tend to have worse results in general. Their difficulties are often intensified by lack of insurance, low self-esteem, and minimal social support.
In patients who have private insurance the factors predicting success differ from lower-income groups and appear to be gender related:

The factors that tended to keep more women in treatment were unemployment, marriage, and higher incomes. Women who dropped out tended to have more severe psychiatric problems. African American women were also less likely to stay in treatment than non-African Americans.

Factors that kept men in treatment were older age, pressure from the employer, and abstinence as a goal. Dropping out was associated with the opposite factors.
Treating People with Alcoholism and Health Problems

Severe alcoholism is often complicated by the presence of serious medical illnesses.

A program called integrated outpatient treatment (IOT) has been designed specifically for medically ill alcoholics:

The patient visits a clinic once a month for both intensive alcohol treatment and a physical check-up, which includes tracking factors, such as liver function, that are affected by drinking.

Patients are motivated through discussions of benefits and costs of drinking and by reporting any barriers to changing their habits and learning strategies to overcome them.
One study showed that IOT significantly increased abstinence and the number of treatment visits. IOT may even improve survival rates. Interestingly, however, drinking also significantly decreased in a comparison group of patients who were treated only for their medical conditions.

Treating People with Alcoholism and Mental Illness

Treatment for patients with both alcoholism and mental illness is particularly difficult. The greater the psychiatric distress a person is experiencing, the more he or she is tempted to drink, particularly in negative situations.

It has not been clear if self-help programs, such as alcoholics anonymous (AA), are effective for patients with a dual diagnoses of mental illness and alcoholism, because the focus of the organization is on addiction, not psychiatric problems. A 1999 study found no difference in regular attendance between people with or without schizophrenia, and some experts believe AA is underused by patients with both alcoholism and mental illness. There have been some unfortunate reports that AA members have encouraged patients with dual disorders to go off their medications. In one study of 125 AA contact people, however, 93% indicated that such people should continue their medications. And, in fact, newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), are proving to be very useful complements to AA or counseling sessions.

Anti-anxiety medications are also available for people with anxiety. Social phobia is an anxiety disorder highly linked with alcoholism. In one interesting study, such individuals achieved better abstinence rates after being treated only for alcoholism compared to patients treated for both disorders at the same time. (Cognitive-behavioral therapy was used for both groups.)

People with alcoholism and more severe problems, such as schizophrenia or severe bipolar disorder, probably need more intense help.

WHAT IS THE TREATMENT FOR ALCOHOL WITHDRAWAL?

Symptoms of Withdrawal

When an alcoholic stops drinking, withdrawal symptoms begin within six to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are over-produced and the central nervous system becomes over-excited. Depending on severity, withdrawal symptoms may include the following:

Fever.

Rapid heart beat.

Changes in blood pressure either higher or lower.

Extremely aggressive behavior.

Hallucinations and other mental disturbances.

Seizures occur in about 10% of adults during withdrawal, and in about 60% of these patients, the seizures are multiple. The time between the first and last seizure is usually six hours or less.

About 5% of alcoholic patients experience delirium tremens, which usually develops two to four days after the last drink.
Although it is not clear if older people with alcoholism are at higher risk for more severe symptoms than younger patients, several studies have indicated that they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Initial Assessment

Upon entering a hospital due to alcohol withdrawal, patients should be given a physical examination for any injuries or medical conditions and should be treated for any potentially serious problems, such as high blood pressure or irregular heartbeat. Patients should be observed for at least two hours to determine the severity of withdrawal symptoms. Physicians may use assessment tests, such as the Clinical Institute Withdrawal Assessment Scale (CIWA), to help determine treatment and whether the symptoms will progress in severity.

Treatment for Withdrawal Symptoms

The immediate goal of treatment is to calm the patient as quickly as possible.

About 95% of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15% to 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients can nearly always be treated as outpatients. After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms become severe. If possible, a family member or friend should support the patient through the next few days of withdrawal.

Benzodiazepines. Patients are usually given one of the anti-anxiety drugs known as benzodiazepines, which inhibit nerve-cell excitability in the brain. They are used to relieve withdrawal symptoms, help prevent progression to delirium tremens, and reduce the risk for seizures. The agents used include diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), midazolam (Versed), and oxazepam (Serax). Benzodiazepines may be administered intravenously or orally, depending on the severity of symptoms. These drugs vary in how long they are effective.

Diazepam has a longer duration of action than lorazepam or midazolam. Typically, the physician may give the patient an initial (or loading) intravenous dose of diazepam with additional doses given every one to two hours thereafter over the period of withdrawal. This regimen can cause very heavy sedation.

Lorazepam and oxazepam are easier for the liver to metabolize than other benzodiazepines and often prove useful for treating alcoholic patients. One study reported that when a single, intravenous dose of lorazepam was given within several hours of a first alcohol-related seizure, it reduced the risk for subsequent ones.
Assessing withdrawal symptoms frequently and administering benzodiazepine doses in response to symptoms (compared to a fixed dose at regular intervals) has proven to reduce the incidence of withdrawal symptoms and other adverse events, including delirium, seizures, and transfer to the intensive care unit.

Some physicians question the use of any anti-anxiety medication for mild withdrawal symptoms, since these agents are subject to abuse. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe and frequent seizures with possible brain damage. In any case, benzodiazepines are usually not prescribed for more than two weeks or administered for more than three nights per week. Problems with benzodiazepines include the following:

Side Effects. Common side effects of benzodiazepines are daytime drowsiness and a hung-over feeling. In rare cases, they actually cause agitation. Respiratory problems may be exacerbated. The drugs appear to stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet), antihistamines, and oral contraceptives. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although very rarely fatal. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. Benzodiazepines are associated with birth defects, and should not be used by pregnant women or nursing mothers.

Loss of Effectiveness and Dependence. The primary problem with these drugs is their loss of effectiveness over time with continued use at the same dosage. As a result, patients may increase their dosage level to prevent anxiety. Patients then can become dependent. In fact, some evidence suggests that people with alcoholism, or even a family history of alcoholism, may be more susceptible to benzodiazepine abuse than nonalcoholics. This is a common danger and can occur after as short a time as three months. (These agents do not cause euphoria, a so-called "high," so such agents are not addictive in the same way as narcotics.)

Withdrawal Symptoms. People who discontinue benzodiazepines after taking them for even four weeks can experience mild rebound symptoms. The longer the agents are taken and the higher the dose the more severe the symptoms. They include sleep disturbance and anxiety, which can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms, including stomach distress, sweating, and insomnia, that can last from one to three weeks. Sleep changes, in fact, can persist or months or years after quitting and may be a major factor in relapse.
Other Drugs for Mild to Moderate Withdrawal. The following agents may also be given:

Beta-blockers. Beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), slow heart rate and reduce tremor. They are sometimes used in combination with benzodiazepines.

Anti-Seizure Medications. Anti-seizure agents, such as carbamazepine (Tegretol) or divalproex sodium (Depakote) may be useful for reducing the requirements of a benzodiazepine. When used by themselves, however, they do not appear to be effective in reducing seizures or delirium.
Specific Treatment for Severe Symptoms

Treating Delirium Tremens. People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. Symptomatic patients are usually given intravenous anti-anxiety medications. Lidocaine (Xylocaine) may be given to people with disturbed heart rhythms. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to themselves or others.

Treating Seizures. Seizures are usually self-limited and treated with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or in those whose seizures cannot be controlled. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe in reducing agitation and seizures.

Psychosis. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Korsakoff's psychosis (Wernicke-Korsakoff-Syndrome) is very difficult to treat. It is caused by severe vitamin B1 (thiamine) deficiencies, which cannot be replaced orally. Rapid and immediate injection of the B vitamin thiamin is necessary. One study reported benefits from a combination of fluvoxamine (Prozac) and clonidine (Catapres), an agent used for Tourettes syndrome.

WHAT ARE THE PSYCHOTHERAPY TREATMENTS FOR ALCOHOLISM?

Choose a Psychotherapeutic Approach

The two standard forms of therapy for alcoholism are the following:

Cognitive-behavioral therapy

Interactional group psychotherapy based on the Alcoholics Anonymous (AA) 12-step program.
In one study, all treatment approaches were, on average, equally effective as long as the individual program was competently administered. One 2001 study reported that, in general, AA had a better abstinence rate than cognitive-behavioral therapy; AA was also less expensive.

Specific people, however, may do better with one program than another:

In one study, people with fewer psychiatric problem did best with the AA approach. This confirms an earlier study in which researchers categorized alcoholics as either Type A or Type B. Type A individuals became alcoholic at a later age, had less severe symptoms or fewer psychiatric problems, and had a better outlook on life than those with Type B. The people in the Type A group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy.

Type B people became alcoholic at an early age, had a high family risk for alcoholism, more severe symptoms, and a negative outlook on life. This group tended to do better with cognitive-behavioral therapy.
This difference in response to the two forms of treatments held up after two years.

Interactional Group Psychotherapy (Alcoholics Anonymous)

Alcoholics Anonymous (AA), founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well-known program for helping people with alcoholism. It offers a very strong support network using group meetings open seven days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation.

AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. [ See Box The 12 Steps of Alcoholics Anonymous.] Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends.

The 12 Steps of Alcoholics Anonymous

We admit we were powerless over alcohol - that our lives have become unmanageable.

We have come to believe that a Power greater than ourselves could restore us to sanity.

We have made a decision to turn our will and our lives over to the care of God, as we understand what this Power is.

We have made a searching and fearless moral inventory of ourselves.

We have admitted to God, to ourselves and to another human being the exact nature of our wrongs.

We are entirely ready to have God remove all these defects of character.

We have humbly asked God to remove our shortcomings.

We have made a list of all persons we had harmed and have become willing to make amends to them all.

We have made direct amends to such people wherever possible, except when to do so would injure them or others.

We have continued to take personal inventory and when we were wrong promptly admitted it.

We have sought through prayer and meditation to improve our conscious contact with God as we understand what this higher Power is, praying only for knowledge of God's will for us and the power to carry that out.

Having had a spiritual awakening as the result of these steps, we have tried to carry this message to alcoholics and to practice these principles in all our affairs.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy uses a structured teaching approach and may be better than AA for severe alcoholism. People with alcoholism are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. The following are examples of approaches:

Patients might write a history of their drinking experiences and describe what they consider to be risky situations.

They are then assigned activities to help them cope when exposed to "cues," places or circumstances that trigger their desire to drink.

Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team; this gave them the opportunity to practice coping skills, develop supportive relationships, and engage in healthy alternative activities.
In one study of patients with both depression and alcoholism, cognitive therapy achieved 47% abstinence rates after six months compared to only 13% abstinence in patients who received standard treatments and relaxation techniques. It may be especially effective when used in combination with opioid antagonists, such as naltrexone.

WHAT MEASURES OR DRUGS ARE USED TO PREVENT RELAPSE?

Opioid Antagonists

Opioid antagonists are drugs that reduce the intoxicating effects of alcohol and the urge to drink. The two currently most used are naltrexone and nalmefene. These agents are useful for helping people who are still drinking although they have no effect for people who are already abstinent.

Naltrexone. Naltrexone (ReVia) is approved for the treatment of alcoholism. It may be quite effective in preventing relapse for people with low- to moderate alcohol dependency when used with cognitive behavioral therapy. In one 1999 study, for example, 62% of patients taking naltrexone and undergoing such therapy did not relapse into heavy drinking compared with 40% of patients taking a placebo (a "dummy" pill). Nevertheless, evidence on their long-term benefits are still lacking, and a 2001 study did not find any advantages for men with chronic, severe alcohol dependence.

Taking the drug consistently as prescribed by the doctor is very important for its success. One study suggested that it may be safe and most effective when naltrexone is administered as follows:

Psychotherapeutic treatments should be given concurrently.

Only patients who are still drinking should take naltrexone. (The drug is not useful in patients who are already abstinent.)

Sober patients should take naltrexone only when they anticipate a drinking relapse.

However, some experts recommend that it is safe and effective to use naltrexone indefinitely.
The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.

Nalmefene. Nalmefene, an oral form, is also proving to be effective in preventing relapse in heavy drinkers. Nalmefene blocks more opioid receptors than naltrexone does and may have less of an adverse effect on the liver. One 1999 study comparing the two agents found that outpatients taking nalmefene were significantly less likely to relapse to heavy drinking (34% vs. 59%) and consumed fewer drinks per day (average of 4 vs. 5). Like naltrexone, nalmefene does not seem to improve abstinence rates.

Aversion Medications (Disulfiram)

Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and last from half an hour to two hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for one to two weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. Studies have not shown the use of disulfiram to have any effect on staying abstinent, although it does reduce the frequency of drinking. One study indicated that the drug may be more effective in patients with spouses or other family members or caregivers, including AA "buddies," who are close by and vigilant to ensure that they take it. (Such support, however, probably improves the effectiveness of any treatment.) Another aversion drug, calcium carbimide, was withdrawn from the market.

Acamprosate

Acamprosate (Campral) calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies in Europe indicate that it reduces the frequency of drinking. Although it is not clear whether it can improve abstinence, one study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use it cautiously. Combination therapy with naltrexone or disulfiram may be possible.

Antidepressants

Depression is common among alcohol-dependent people and can lead to a higher relapse rate. Antidepressants may be helpful, particularly for patients who suffer from both depression and alcoholism. Studies suggest they may help reduce drinking but do not appear to have any effect on alcohol dependence itself.

SSRIs. Because of their effect on serotonin, the antidepressants selective serotonin reuptake inhibitors (SSRIs) may be of particular value. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox). Studies indicate that they may reduce cravings and desire for alcohol, even in selected people who are not depressed. Studies report reductions in alcohol ranging from 10% to 70% in people with alcoholism who take SSRIs. Research is underway to determine which individuals with alcoholism might best respond to SSRIs. For example, one study suggested that they may be more effective for men than women.

Designer Antidepressants. A number of drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron). Some research suggests they may have some benefits for treating alcoholism.

Treating Sleep Disturbances

Nearly all patients who are alcohol dependent suffer from insomnia and sleep problems, including having less sleep, taking longer to fall asleep, and experiencing less deep sleep. Such problems can last months to years after abstinence. There is some evidence that they are important factors in relapse. Medications for inducing sleep are not recommended in people with alcoholism. Available therapies include sleep hygiene, bright light therapy, meditation, relaxation methods, and other nondrug approaches. [For more information, see Well-Connected Report #27 Insomnia.]

Other Drugs

Ondansetron. Ondansetron (Zofran) is a drug that is ordinarily used to prevent nausea and vomiting due to chemotherapy. It also has actions that affect serotonin in the brain, a neurotransmitter that helps regulate alcohol's effects. In one study, subjects who took ondansetron significantly reduced their drinking compared to those taking a placebo (dummy pill).

Tiapride. Tiapride blocks dopamine, the neurotransmitter (chemical messenger in the brain) that produces a sense of reward after drinking. It has shown some modest benefits in small European studies.