Alcoholism is a
chronic disease, progressive and often fatal; 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. In the brain, alcohol interacts with centers
responsible for pleasure and other desirable sensations. After prolonged
exposure to alcohol, the brain adapts to the changes alcohol makes and becomes
dependent on it. For people with alcoholism, drinking becomes the primary
medium through which they can deal with people, work, and life. Alcohol
dominates their thinking, emotions, and actions. The severity of this disease
is influenced by factors such as genetics, psychology, culture, and response
to physical pain.
develop insidiously; often there is no clear line between problem drinking and
alcoholism. The only early indications of alcoholism may be the unpleasant
physical responses to withdrawal that occur during even brief periods of
abstinence. Sometimes people experience long-term depression or anxiety,
insomnia, chronic pain, or personal or work stress that lead to the use of
alcohol for relief, but often no extraordinary events have occurred that
account for the drinking problem.
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.
Alcohol Use and
levels of alcohol use and abuse as follows (with a drink defined as 12 oz of
beer, 6 oz of wine, or 1.5 oz of 90-proof liquor):
Moderate drinking: equal to or less than two drinks a day for men and
equal to or less than one drink a day for women.
At-risk drinking: more than 14 drinks per week or 4 drinks at one
sitting for men and more than seven drinks a week or three drinks at one
sitting for women.
Alcohol abuse: 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; and
continued use in spite of harm being done to social or personal relationships.
o Alcohol dependence: The individual experiences 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; 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.
What Causes Alcoholism?
People have been drinking alcohol for perhaps 15,000
years. Just drinking steadily and consistently over time can cause a sense of
dependence and 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 and
genetics, culture, and psychology.
Brain Chemistry and Genetic Factors
The craving for alcohol during abstinence, the pain
of withdrawal, and the high rate of relapse are due to the brain's adaptation
to and dependence on the changes in its own chemistry caused by long term use
of alcohol. Alcohol causes relaxation and euphoria but also acts as a
depressant on the central nervous system. Even after years of research,
experts still do not know exactly how alcohol affects the brain or how the
brain affects alcoholism. Alcohol appears to have major effects upon the
hippocampus, an area in the brain associated with learning and memory and the
regulation of emotion, sensory processing, appetite, and stress. Alcohol
breaks down into products called fatty acid ethyl esters, which appear to
inhibit important neurotransmitters (chemical messengers in the brain) in the
hippocampus. Of particular importance to researchers of alcoholism are the
neurotransmitters gamma aminobutyric acid (GABA), dopamine, and serotonin,
which are strongly associated with, emotional behavior and cravings. Research
indicates that dopamine transmission, particularly, is strongly associated
with the rewarding properties of alcohol, nicotine, opiates, and cocaine.
Investigators have focused on nerve-cell structures known as dopamine D2
receptors (DRD2), which influence the activity of dopamine. Mice with few of
these receptors show low interest in and even aversion to alcohol.
In people with severe alcoholism, researchers have
located a gene that alters the function of DRD2. This gene is also found in
people with attention deficit disorder, who have an increased risk for
alcoholism, and in people with Tourette’s syndrome and autism. One major
study, however, found no connection at all between the DRD2 gene and
alcoholism. More work in this area is needed. Researchers are also
investigating genes that regulate certain enzymes known as kinases that affect
alcohol uptake in the brain as well as genes that affect serotonin. Even if
genetic factors can be identified, however, they are unlikely to explain all
cases of alcoholism. In fact, lack of genetic protection may play a role in
alcoholism. 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.
Who Becomes an Alcoholic?
General Risks and Age
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 and Ethnicity
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 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.
Irish and Native Americans are at increased risk for
alcoholism; Jewish and Asian Americans are at decreased risk. Overall, there
is no difference in alcoholic prevalence between African Americans, whites,
and Hispanic people. Although the biological causes of such different risks
are not known, certain people in these population groups may be at higher or
lower risk because of the way they metabolize alcohol. One study of Native
Americans, for instance, found that they are less sensitive to the
intoxicating effects of alcohol. This confirms other studies, in which young
men with alcoholic fathers exhibited fewer signs of drunkenness and had lower
levels of stress hormones than those without a family history. In other words,
they "held their liquor" better. Experts suggest such people may
inherit a lack of those warning signals that ordinarily make people stop
drinking. Many Asians, on the other hand, are less likely to become alcoholic
because of a genetic factor that makes them deficient in aldehyde
dehydrogenase, a chemical used by the body to metabolize ethyl alcohol. In its
absence, toxic substances build up after drinking alcohol and rapidly lead to
flushing, dizziness, and nausea. People with this genetic susceptibility,
then, are likely to experience adverse reactions to alcohol and therefore not
become alcoholic. This deficiency is not completely protective against
drinking, however, particularly if there is added social pressure, such as
among college fraternity members. It is important to understand that, whether
it is inherited or not, people with alcoholism are still legally responsible
for their actions.
Severely depressed or anxious people are at high risk
for alcoholism, smoking, and other forms of addiction. Major depression, in
fact, accompanies about one-third of all cases of alcoholism. It is more
common among alcoholic women (and women in general) than men. Interestingly,
one study indicated that depression in alcoholic women may cause them to drink
less than nondepressed alcoholic women, while in alcoholic men, depression has
the opposite effect. 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. It should be noted, however, that in all adults with
alcoholism these mood disorders may be actually caused by alcoholism and often
abate after withdrawal from alcohol.
Studies are finding that alcoholism is strongly
related to impulsive, excitable, and novelty-seeking behavior, and such
patterns are established early on, if not inherited. People with attention
deficit hyperactivity disorder, a condition that shares these behaviors, have
a higher risk for alcoholism. 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 risk for harm. 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 than nonalcoholics. It was once thought that a
family history of passivity and abnormal dependency needs increased the risk
for alcoholism, but studies have not borne out this theory.
It has been long thought that alcoholism is more
prevalent in people with lower educational levels and in those who were
unemployed. A thorough 1996 study, however, reported that the prevalence of
alcoholism among adult welfare recipients was 4.3% to 8.2%, which was
comparable to the 7.4% found in the general population. There was also no
difference in prevalence between poor African Americans and poor whites.
People in low-income groups did display some tendencies that differed from the
general population. For instance, as many women as men were heavy drinkers.
Excessive drinking may 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
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 U.S. 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).
People who crave sugar may also be at higher risk for
alcoholism. In one recent 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. Any protection
that occurs with moderate alcohol intake appears to be confined to adults over
60 who have risks for heart disease. The earlier a person begins drinking
heavily, the greater their chance of developing serious illnesses later on.
Alcoholism can kill in many different ways, and, in general, people who drink
regularly have a higher rate of deaths from injury, violence, and some
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.
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
Domestic violence is a common consequence of alcohol
abuse. 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. 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. Alcoholic households are less cohesive, have more conflicts,
and their members are less independent and expressive than households with
nonalcoholic or recovering alcoholic parents. 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 divorced and for psychiatric
symptoms. One study concluded that the only events with greater psychological
impact on children are sexual and physical abuse.
Alcohol can affect the body in so many ways that
researchers are having a hard time determining exactly what the consequences
are of drinking. It is well known, however, that chronic consumption leads to
many problems, some of them deadly.
Large doses of alcohol can trigger irregular
heartbeats and raise blood pressure even in people with no history of heart
disease. A major study found that those who consumed more than three alcoholic
drinks a day had higher blood pressure than teetotalers. The more alcohol
someone drank, the greater the increase in blood pressure. People who were
binge drinkers had the highest blood pressures. One study found that binge
drinkers (people who have nine or more drinks once or twice a week) had a risk
for a cardiac emergency that was two and a half times that of nondrinkers.
Chronic alcohol abuse can also damage the heart muscle, which leads to heart
failure; women are particularly vulnerable to this disorder. Contrary to many
previous reports, a recent study suggested that moderate to heaving drinking
(more than two bottles of beer or two glasses of wine day) was a greater risk
factor for coronary artery disease than smoking. As in other studies, light
drinking (two to six drinks a week) was protective. More research is needed to
confirm or refute this new study. In any case, moderate drinking does not
appear to offer any heart benefits for people who are at low risk for heart
disease to begin with.
Alcohol may not cause cancer, but it probably does
increase the carcinogenic effects of other substances, such as cigarette
smoke. Daily drinking increases the risk for lung, esophageal, gastric,
pancreatic, colorectal, urinary tract, liver, and brain cancers, lymphoma and
leukemia. About 75% of cancers of the esophagus and 50% of cancers of the
mouth, throat, and larynx are attributed to alcoholism. (Wine appears to pose
less danger for these cancers than beer or hard liquor.) Smoking combined with
drinking enhances risks for most of these cancers dramatically. When women
consume as little as one drink a day, they may increase their chances of
breast cancer by as much as 30%.
The liver is particularly endangered by alcoholism.
About 10% to 35% of heavy drinkers develop alcoholic hepatitis, and 10% to 20%
develop cirrhosis. In the liver, alcohol converts to an even more toxic
substance, acetaldehyde, which can cause substantial damage. Not eating when
drinking and consuming a variety of alcoholic beverages are also factors that
increase the risk for liver damage. People with alcoholism are also at higher
risk for hepatitis B and C, potentially chronic liver diseases than can lead
to cirrhosis and 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.
Alcohol can cause diarrhea and hemorrhoids. Alcohol
can also contribute to serious infections of the pancreas and to ulcers in
people taking the painkillers known as nonsteroidal anti-inflammatory drugs
(such as aspirin or ibuprofen).
Pneumonia and Other Infections
Alcohol suppresses the immune system, so people with
alcoholism are prone to infections. In particularly, 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.
Mental and Neurologic Disorders
Alcohol has widespread effects on the brain. One
study that scanned 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). Habitual use of alcohol, however, eventually produces
depression and confusion. In chronic cases, gray matter is destroyed, possibly
leading to psychosis and mental disturbances. Alcohol can also cause milder
neurologic problems, including insomnia and headache (especially after
drinking red wine). Except in severe cases, neurologic damage is not permanent
and abstinence nearly always leads to recovery of normal mental function.
Alcohol may increase the risk for hemorrhagic stroke (caused by bleeding in
the brain), although it may protect against stroke caused by narrowed
Skin, Muscle, and Bone Disorders
Severe alcoholism is associated with osteoporosis,
wasting away of muscles with swelling and pain, skin sores, and itching. In
addition, alcohol-dependent women seem to face an increased risk for damage to
muscles, including muscles of the heart, from the toxic effects of alcohol.
Alcoholism increases levels of the female hormone
estrogen and reduces levels of the male hormone testosterone, factors that
contribute to impotence in men.
Alcoholics who smoke face 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 more directly tied to excessive drinking.
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
A pint of whiskey provides about half the daily
calories needed by an adult, but it has no nutritional value. In addition to
replacing food, alcohol may also interfere with absorption of proteins,
vitamins, and other nutrients. Of particular concern in alcoholism is a severe
deficiency in the B-vitamin thiamin, 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 deficiency of the B vitamin folic acid, which can cause severe
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 is can by caused by many of the
medical conditions common in chronic alcoholism, including severe infection,
trauma, blood transfusions, pneumonia, and other serious lung conditions.
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. In
other words, taking almost any medication should preclude drinking alcohol.
Pregnancy and Infant Development
Even moderate amounts of alcohol may have damaging
effects on the developing fetus, including low birth weight and an increased
risk for miscarriage. High amounts can cause fetal alcohol syndrome, which can
result in mental and growth retardation. One study indicates a significantly
higher risk for leukemia in infants of women who drink any type of alcohol
Complications in Older People
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.
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 take the first steps toward treatment.
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. It is particularly difficult to diagnose alcoholism 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. 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.
A physician who
suspects alcohol abuse should ask the patient questions about current and past
drinking habits to distinguish moderate from heavy drinking. If alcohol abuse
or dependency is indicated, the physician will usually perform a screening
test. Many are available for diagnosing alcoholism, usually either
standardized questionnaires that the patient can take on their own or that are
conducted by the physician. 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. The quickest test takes
only one minute; it is called the CAGE test, an acronym for the following
questions: (C) attempts to Cut down on drinking; (A) Annoyance with criticisms
about drinking; (G) Guilt about drinking; and (E) use of alcohol as an
Eye-opener in the morning. This test and another called the Self-Administered
Alcoholism Screening Test (SAAST), however, appear to be most useful in
detecting 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. A more effective test for such individuals may be the
Alcohol Use Disorders Identification Test (AUDIT), which asks three questions
about amount and frequency of drinking, three questions about alcohol
dependence, and four questions about problems related to alcohol consumption.
Other short screening tests are the Michigan Alcoholism Screening Test (MAST)
and The Alcohol Dependence Scale (ADS).
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. 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. A test for a
factor known as carbohydrate-deficient transferrin may prove to be fairly
accurate indicator of heavy drinking. A physical examination and other tests
should be performed to uncover any related medical problems. Sometimes the
results of tests that detect other problems, such as blood tests reporting
liver damage or low testosterone levels in men, can persuade alcoholics to
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 lack of confidence in successful therapies, denial of their own
alcoholism, and the social stigma attached to the condition and its treatment.
Studies have found that even a brief intervention (e.g., several
fifteen-minute counseling sessions with a physician and a follow-up by a
nurse) can be very effective in reducing drinking in heavy drinkers who are
not yet dependent. However, the best approaches are group meetings between
people with alcoholism and their friends and family members who have been
affected by the alcoholic behavior. Using this interventional approach, each
person affected offers a compassionate but direct and honest report describing
specifically how he or she has been specifically hurt by their loved one's or
friend's alcoholism. Children may even be involved in this process, depending
on their level of maturity and ability to handle the situation. 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. 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.
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 treatments for other life-threatening
diseases, such as cancer, are, but that it is the only hope for a cure.
What Is the
Treatment for Alcohol Withdrawal?
When a person with
alcoholism 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. About 5% of alcoholic patients experience delirium tremens,
which usually develops two to four days after the last drink. Symptoms include
fever, rapid heart beat, either high or low blood pressure, extremely
aggressive behavior, hallucinations, and other mental disturbances.
Upon entering a
hospital, 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. The immediate goal of
treatment is to calm the patient as quickly as possible. Patients are usually
given one of the anti-anxiety drugs known as benzodiazepines, which relieve
withdrawal symptoms and help prevent progression to delirium tremens. An
injection of the B vitamin thiamine may be given to prevent Wernicke-Korsakoff
syndrome. 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. Older people
with alcoholism are not at higher risk for more severe symptoms than younger
patients, but they may suffer more complications during withdrawal, including
delirium, falls, and a decreased ability to perform normal activities.
Mild to Moderate Withdrawal Symptoms
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.
Delirium Tremens, Seizures, and Other Severe Symptoms
symptoms of delirium tremens must be treated immediately. Untreated delirium
tremens has a fatality rate that can be as high as 20%. They are usually first
given intravenous anti-anxiety medications and their physical condition is
stabilized. It is extremely important that fluids be administered. Restraints
may be necessary to prevent injury to themselves or others.
usually self-limited and treated only 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 whose seizures cannot be
controlled. Because phenytoin may lower blood pressure, the patient's heart
should be monitored during treatment. For hallucinations or extremely
aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol),
may be administered. Lidocaine (Xylocaine) may be given to people with
disturbed heart rhythms.
Drugs Used for
Mild to Moderate Withdrawal Symptoms
are anti-anxiety drugs that inhibit nerve-cell excitability in the brain. They
relieve withdrawal symptoms and make it easier for patients to remain in
treatment. The drugs may be administered intravenously or orally, depending on
the severity of symptoms. For most adults with alcoholism, the longer-acting
drugs, such as diazepam (Valium) or chlordiazepoxide (Librium), are usually
prescribed. To prevent seizures, the physician may give the patient an
initial, or loading, dose of the long-acting drug diazepam with additional
doses given every one to two hours thereafter over the period of withdrawal.
This regimen can cause very heavy sedation. People with serious medical
problems, particularly respiratory disorders, may be given repeated doses of
shorter-acting benzodiazepines, such as lorazepam (Ativan) and oxazepam (Serax);
these drugs can be withdrawn immediately at any sign of trouble. Some
physicians question the use of any anti-anxiety medication for mild withdrawal
symptoms. Others believe that repeated withdrawal episodes, even mild forms,
that are inadequately treated may result in increasingly severe episodes with
seizures and possible brain damage.
are usually not prescribed for more than two weeks or administered for more
than three nights per week. Tolerance to these drugs may develop after as
little as four weeks of daily use. Physical dependence may develop after just
three months of normal dosage. People who discontinue benzodiazepines after
taking them for long periods may experience rebound symptoms -- sleep
disturbance and anxiety -- which can develop within hours or days after
stopping the medication. Some patients experience withdrawal symptoms from the
drugs, including stomach distress, sweating, and insomnia, that can last from
one to three weeks. Common side effects are day-time drowsiness and a
hung-over feeling. Respiratory problems may be exacerbated. Benzodiazepines
are potentially dangerous when used in combination with alcohol. They should
not be used by pregnant women or nursing mothers unless absolutely necessary.
Other Drugs for
Mild to Moderate Withdrawal
such as propranolol (Inderal) and atenolol (Tenormin), may sometimes be used
in combination with a benzodiazepine. This class of drugs is effective in
slowing heart rate and reducing tremor. Other drugs being tested are clonidine
(Catapres) and carbamazepine (Tegretol). When used by themselves, they do not,
however, appear to be effective in reducing seizures or delirium.
Chlormethiazole, a derivative of vitamin B1, is presently used in Europe and
is showing promise in reducing agitation and seizures.
What Are the
Long-Term Treatments for Alcoholism?
The two basic
goals of long-term treatment are total abstinence and replacement of the
addictive patterns with satisfying, time-filling behaviors that can fill the
void in daily activity that occurs when drinking has ceased. Some studies have
reported that some people who are alcohol dependent can eventually learn to
control their drinking and do as well as those who remain abstinent. There is
no way to determine, however, which people can stop after one drink and which
cannot. Alcoholics Anonymous and other alcoholic treatment groups whose goal
is strict abstinence are greatly worried by the publicity surrounding these
studies, since many people with alcoholism are eager for an excuse to start
drinking again. At this time, abstinence is the only safe route.
versus Outpatient Treatment
People with mild
to moderate withdrawal symptoms are usually treated as outpatients and
assigned to support groups, counseling, or both. Inpatient treatment in a
general or psychiatric hospital or in a center dedicated to treatment of
alcohol and other substance abuse is recommended for patients with a
coexisting medical or psychiatric disorder and those who may harm themselves
or others, who have not responded to conservative treatments, or who have a
disruptive home environment. A typical inpatient regimen includes a physical
and psychiatric work-up, detoxification, treatment with psychotherapy or
cognitive-behavioral therapy, and an introduction to Alcoholics Anonymous.
Because of the high cost of inpatient care, its advantages over outpatient
care are currently being questioned. One study compared employed alcoholics
who were either hospitalized, treated as outpatients with compulsory
attendance at AA meetings, or allowed to choose their own treatment option --
including none at all. After two years, everyone experienced fewer job
problems, but those in the inpatient group had significantly fewer
rehospitalizations and remained abstinent longer than people in the other two
groups. Another study analyzing drug and alcohol treatment programs found that
75% of inpatients completed therapy compared to only 18% of outpatients. Other
studies, however, have shown no difference in results between inpatient and
outpatient programs, and in one, the costs for AA were 45% lower than other
outpatient options. Studies have attempted to uncover characteristics that
might make people more likely to drop out of either outpatient or inpatient
programs. One study found that people who drop out of outpatient treatments
are more apt to be female, young, unskilled, or have more than one addiction.
Another reported that those who leave inpatient treatment against medical
advice tend to have jobs, to be college educated, and have a history of
and Cognitive-Behavioral Therapy
The two usual
forms of therapy for alcoholics are cognitive-behavioral and interactional
group psychotherapy based on the Alcoholics Anonymous 12-step program. In one
study, all treatment approaches were, on average, equally effective as long as
the individual program was competently administered. Those with fewer
psychiatric problems, however, 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
did poorly with interactional group therapy but tended to do better with
cognitive-behavioral therapy. This difference in response to the two forms of
treatments held up after two years.
Group Psychotherapy (12-Step Program)
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. 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.
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. For example, 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, this
therapeutic approach achieved 47% abstinence rates after six months compared
to only 13% abstinence in patients who received standard treatments and
Aid in Abstinence
causes distressing symptoms, including 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 one study found
that the total number of drinking days was less in people who took the drug.
The drug may also be more effective in married patients or those with other
family members or caregivers, including AA "buddies", close by and
vigilant to ensure that they take it.
appears to block the pleasurable effects of alcohol and reduce cravings. When
used with counseling or support groups, studies indicate that it may be very
effective for people with low- to medium-risk for alcohol dependency. In one
10-week program, patients who had been abstinent only 37% of the time
increased this rate to 89%, and the average number of drinks consumed when
they did drink dropped from 9.5 to 2.5. 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.
calms the brain and reduces cravings by inhibiting the transmission of the
neurotransmitter gamma aminobutyric acid (GABA). In one European study, 18% of
patients were still abstaining after a year compared to only 7% who did not
take the drug. Acamprosate is fully effective after about a week of treatment.
It may cause occasional diarrhea. At this time it is available only in Europe
but is being tested in America. It should be used along with counseling.
Combination therapy with naltrexone or disulfiram may be possible.
and Anti-anxiety Drugs
common among alcohol-dependent people and can lead to a higher relapse rate.
Antidepressants may be helpful, particularly those that maintain elevated
levels of serotonin in the brain, since alcoholism has been associated with
low serotonin levels. Two studies have reported higher rates of abstinence,
fewer heavy drinking days, and fewer drinks in severe alcoholics who took
fluoxetine (Prozac), the most common antidepressant in a class known as
serotonin reuptake inhibitors (SSRIs). Other SSRIs include sertraline
(Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Another small study
reported that people given the tricyclic antidepressant desipramine (Norpramin,
Pertofrane) -- whether or not they exhibited other symptoms of depression --
had fewer drinking days and a longer period between relapses than those not
taking the drug. A unique anti-anxiety drug, buspirone (BuSpar), may also be
beneficial for alcoholics, particularly if they also suffer from anxiety. The
drug has few side effects and a low potential for abuse. It not only reduces
anxiety, but also appears to have modest effects on alcohol cravings. In one
study, alcoholics who took it had a slow return to alcohol consumption and
fewer drinking days than those not on the drug.
calcium channel blocker, reduced cravings more effectively than naltrexone and
the antidepressant paroxetine (Paxil) -- drugs used to maintain abstinence.
Calcium channel blockers are used to treat high blood pressure and can have
serious side effects, which should be discussed with a physician. Another drug
being investigated for withdrawal and abstinence is gamma-hydroxybutyric acid
(GHB). In one small study, 58% of subjects remained abstinent during a
six-month period. The drug has a number of potentially very serious side
Why Do People
with Alcoholism 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.
One study found that three factors placed a person at high risk for relapse:
frustration and anger, social pressure, and internal temptation. Treatment of
relapses, however, does not always require starting from scratch with
detoxification or hospitalization; often, abstinence can begin the next day.
Self-forgiveness and persistence are behaviors essential for permanent
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 against abstinence are depression and
anxiety (the emotional equivalents of physical pain) that 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 brain will use
all its powers of rationalization to persuade the patient to return to
drinking. 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.
One of the most
difficult problems facing a person with alcoholism is being around 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. 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 to
alcoholics, spouses often build their own self-images on surviving or handling
their mates' difficult behavior and then discover that they are threatened by
abstinence. Friends may not easily accept the sober, perhaps more subdued,
comrade. 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.
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 potential great harm to individuals.
to Test for Alcoholism Risk
shown that a blood test for a substance in the body called beta-endorphin done
after drinking alcohol may indicate who has a genetic risk for developing
alcoholism. The results support a growing body of evidence that when drinking,
alcoholics have enhanced stimulation in certain parts of their brain's
chemical system. The research appears in the March issue of the journal Alcoholism:
Clinical and Experimental Research.
Lead author of the
study, Janice C. Froehlich, PhD, says she is often asked why a person would
want to know if they were at increased risk of alcoholism. "The question
of whether or not you'd want to be tested for alcoholism is the same
essentially as whether you'd want to be tested for any other disease. ... With
alcoholism, the individual actually has a chance to prevent the development of
the disease by staying away from alcohol. ... [Knowing their risk] gives the
individual more freedom and more control over their own destiny than would a
test for diabetes or cancer." Froehlich is professor of medicine at
Indiana University School of Medicine in Indianapolis.
"We know that
a large proportion of the risk for alcoholism is genetic rather than
environmental. The question becomes, 'What do you inherit when you inherit a
predisposition to drink alcohol?'" She explains that researchers
have been trying to determine various bodily responses to alcohol in order to
identify what leads to the development of alcoholism.
that beta-endorphin is released in response to drinking alcohol. It acts like
morphine to produce feelings of well-being and euphoria. "The current
thought is that release of [beta-endorphin] during alcohol drinking may
contribute to the high you get from alcohol, particularly right after you
drink," says Froehlich.
Blood levels of
beta-endorphin were tested in 88 pairs of twins. The results showed that
beta-endorphin levels were strongly inherited. That is, the responses of
identical twin pairs were much more similar than the responses of fraternal
suggest that people run out and get blood tests of their beta-endorphin
response to alcohol yet," says Froehlich. She suggests that it may be
used as part of a battery of tests that could help identify those individuals
at risk for developing alcoholism. "If we could start early intervention
programs and counseling, that might serve to decrease the probability that
those individuals would become addicted to alcohol."
Gianoulakis, PhD, a researcher in this area from McGill University, agrees
that beta-endorphin may prove to be a marker for vulnerability to alcoholism
but also sees it as one of many tests that should be used.
present time, my opinion is that there is not a single marker than can be used
to diagnose people who could develop alcoholism in the future," She
was not involved in the study.
When asked for his
opinion of the Froehlich paper, Gary Wand, MD, a professor of medicine and
psychiatry at the Johns Hopkins School of Medicine in Baltimore, says the
study "comes close to being the last nail in the coffin in testing
whether [this system] really creates a vulnerability to alcoholism and is
involved in heavy alcohol drinking.
"I'm not that
interested in the use of beta-endorphin as a marker. We already know, just by
taking a history, that the children of alcoholics have between a four- and
tenfold risk of developing alcoholism. That's enough of a marker for me to say
we should be counseling children of alcoholics and saying that even if you
carry some genetic baggage for alcoholism, it's not a fait accompli that you
will become alcoholic," says Wand.
Wand believes the
power of the findings concerning beta-endorphin lies in its potential to
increase the understanding the mechanisms behind alcoholism. He says this
study should provoke the government and pharmaceutical companies to pursue
drug development to treat alcoholism through the beta-endorphin pathway.