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Alcoholism (health article)

Definition

Alcoholism is an illness marked by drinking alcoholic beverages at a level that interferes with physical health, mental health, and social, family, or occupational responsibilities.

Alcoholism is divided into 2 categories: dependence and abuse.

People with alcohol dependence, the most severe alcohol disorder, usually experience tolerance and withdrawal. Tolerance is a need for markedly increased amounts of alcohol to achieve intoxication or the desired effect. Withdrawal occurs when alcohol is discontinued or intake is decreased. Alcohol dependents spend a great deal of time drinking alcohol, and obtaining it.

Alcohol abusers may have legal problems such as drinking and driving. They may also have problems with binge drinking (drinking 6 or more drinks at one sitting).

People who are dependent on or abuse alcohol continue to drink it despite evidence of physical or psychological problems. Those with dependence have more severe problems and a greater compulsion to drink.

 

Alternative Names

Alcohol dependence; Alcohol abuse

Causes, incidence, and risk factors

Alcoholism is a type of drug addiction. There is both physical and psychological dependence with this addiction. Physical dependence reveals itself by withdrawal symptoms when alcohol intake is interrupted, tolerance to the effects of alcohol, and evidence of alcohol-associated illnesses.

Alcohol affects the central nervous system as a depressant, resulting in a decrease of activity, anxiety, tension, and inhibitions. Even a few drinks can result in behavioral changes, a slowing in motor performance, and a decrease in the ability to think clearly. Concentration and judgment become impaired. In excessive amounts, intoxication may result.

Alcohol also affects other body systems. Irritation of the gastrointestinal tract can occur with erosion of the lining of the esophagus and stomach causing nausea and vomiting, and possibly bleeding. Vitamins are not absorbed properly, which can lead to nutritional deficiencies with the long-term use of alcohol. Liver disease, called alcoholic hepatitis, may also develop and can progress to cirrhosis. The heart muscle may be affected. Sexual dysfunction may also occur, causing problems with erections in men and cessation of menstruation in women.

Alcohol affects the nervous system and can result in nerve damage and severe memory loss. Chronic alcohol use also increases the risk of cancer of the larynx, esophagus, liver, and colon. Alcohol consumption during pregnancy can cause severe birth defects. The most serious is fetal alcohol syndrome, which may result in mental retardation and behavior problems. A milder form of the condition which can still cause lifelong impairment is called fetal alcohol affects.

The social consequences of problem drinking and alcohol dependence can be as serious as the medical problems. People who abuse or are dependent on alcohol have a higher incidence of unemployment, domestic violence, and problems with the law. About half of all traffic deaths are related to alcohol use.

The development of dependence on alcohol may occur over a period of years, following a relatively consistent pattern. At first, a tolerance of alcohol develops. This results in a person being able to consume a greater quantity of alcohol before its adverse effects are noticed. Memory lapses (black-outs) relating to drinking episodes may follow tolerance. Then, people may lose control over drinking and find it difficult or impossible to stop if they try. The most severe drinking behavior includes prolonged binges of drinking with associated mental or physical complications. Some people are able to gain control over their dependence in earlier phases before a total lack of control occurs. The problem is, no one knows which heavy drinkers will be able to regain control and which will not.

Withdrawal develops because the brain has physically adapted to the presence of alcohol and cannot function adequately in the absence of the drug. Symptoms of withdrawal may include elevated temperature, increased blood pressure, rapid heart rate, restlessness, anxiety, psychosis, seizures, and rarely even death.

There is no known common cause of alcoholism. However, several factors may play a role in its development. A person who has an alcoholic parent is more likely to become an alcoholic than a person without alcoholism in the immediate family. Research suggests that certain genes may increase the risk of alcoholism but which genes or how they exert their influence is controversial. Psychological factors may include a need for relief of anxiety, ongoing depression, unresolved conflict within relationships, or low self-esteem. Social factors include availability of alcohol, social acceptance of the use of alcohol, peer pressure, and stressful lifestyles.

The incidence of alcohol intake and related problems is increasing. Data from many sources indicate that about 15% of the population in the United States are problem drinkers, and approximately 5% to 10% of male drinkers and 3% to 5% of female drinkers could be diagnosed as alcohol dependent (12.5 million people).

Symptoms

Men who consume 15 or more drinks a week, women who consume 12 or more drinks a week, or anyone who consumes 5 or more drinks per occasion at least once a week are all at risk for developing alcoholism. (One drink is defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1 1/2-ounce shot of liquor).

The following questions are used by the National Institute on Alcohol Abuse and Alcoholism to screen for alcohol abuse or dependence:

  • Have you felt that you should cut down on your drinking?
  • Do you ever drive when you have been drinking?
  • Is someone in your family concerned about your drinking?
  • Have you ever had any blackouts after drinking?
  • Have you ever been absent from work or lost a job because of drinking?
  • Do you have to drink more than before to achieve intoxication or the desired effect?

Some of the symptoms associated with alcoholism include:

  • Drinking alone
  • Making excuses to drink
  • Need for daily or frequent use of alcohol for adequate function
  • Lack of control over drinking, with inability to discontinue or reduce alcohol intake
  • Episodes of violence associated with drinking
  • Secretive behavior to hide alcohol related behavior
  • Hostility when confronted about drinking
  • Neglect of food intake
  • Neglect of physical appearance
  • Nausea and vomiting
  • Shaking in the morning
  • Abdominal pain
  • Numbness and tingling
  • Confusion

Alcohol withdrawal symptoms vary from mild to severe and may include:

  • Rapid heart rate and sweating
  • Restlessness or agitation
  • Loss of appetite, nausea, or vomiting
  • Confusion or hallucinations
  • Tremors and seizures

 

Signs and tests

All physicians should ask their patients about their drinking. A history may be obtained from family if the affected person is unwilling or unable to answer questions. A physical examination is performed to identify physical problems related to alcohol use.

  • A toxicology screen or blood alcohol level confirms recent alcohol ingestion, which does not necessarily confirm alcoholism.
  • Liver function tests can be elevated. GGPT (glutaryl transaminase) is often elevated more than other liver function tests.
  • CBC (complete blood count) - MCV can be elevated (mean corpuscular volume or size of the red blood cells).
  • Serum magnesium, uric acid, total protein, and folate tests may be abnormal.

 

Treatment

Many people with alcohol problems don't recognize when their drinking gets out of hand. In the past, treatment providers believed that alcoholics should be confronted about denial of their drinking problems, but now research has shown that compassionate and empathetic counseling is more effective.

Three general steps are involved in treating the alcoholic once the disorder has been diagnosed: intervention, detoxification, and rehabilitation. Research finds that the traditional confrontational intervention - where the employer or family members surprise the alcoholic and threaten consequences if treatment is not begun - is NOT effective. Studies find that more people enter treatment if their family members or employers are honest with them about their concerns, and try to help them to see that drinking is preventing them from reaching their goals.

Once the problem has been recognized, total abstinence from alcohol is required for those who are dependent; for those who are problem drinkers, moderation may be successful. Since many alcoholics initially refuse to believe that their drinking is out of control, a trial of moderation can often be an effective way to deal with the problem. If it succeeds, the problem is solved. If not, the person is usually ready to try abstinence. Because alcoholism affects the people closely related to the alcoholic person, treatment for family members through counseling is often necessary.

Detoxification is the first phase of treatment. Withdrawal from alcohol is done in a controlled, supervised setting in which medications relieve symptoms. Detoxification usually takes 4 to 7 days. Examination for other medical problems is necessary. For example, liver and blood clotting problems are common. A balanced diet with vitamin supplements is important. Complications associated with the acute withdrawal of alcohol may occur, such as delirium tremens (DT's), which could be fatal. Depression or other underlying mood disorders should be evaluated and treated. Often, alcohol abuse develops from efforts to self-treat an illness.

Alcohol recovery or rehabilitation programs support the affected person after detoxification to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centers are recovering alcoholics who serve as role models. Programs can be either inpatient, with the patient residing in the facility during the treatment, or outpatient, with the patient attending the program while they live at home.

Medications are sometimes prescribed to prevent relapses.

  • Naltrexone (Vivitrol) is an opioid antagonist that decreases alcohol cravings. In April 2006, the U.S. Food and Drug Administration approved an injected form of the drug.
  • Disulfiram (Antabuse) works by producing very unpleasant side effects if even a small amount of alcohol is ingested within 2 weeks after taking the drug.
  • Acomprosate is a new drug that has been shown to lower relapse rates in those who are alcohol dependent.

These medications are not given during pregnancy or if the person has certain medical conditions. Long-term treatment with counseling or support groups is often necessary. The effectiveness of medication and counseling varies.

Alcoholics Anonymous is a self-help group of recovering alcoholics that offers emotional support and an effective model of abstinence for people recovering from alcohol dependence. There are more than 1 million members worldwide, and local chapters are found throughout the United States.

For those who don't like the 12-step approach, there are several other support groups available. It is important that people dealing with alcohol problems know about these other groups because in the past, those who did not find AA helpful or were troubled by its requirement of submission to a "Higher Power" had no alternatives.

SMART recovery uses research-based cognitive techniques to help alcoholics recover. LifeRing recovery and SOS are two other secular programs. Women For Sobriety is a self-help group just for women - many female alcoholics have different concerns than men. Moderation Management is a program for problem drinkers seeking to moderate their drinking - it recommends abstinence for those who fail at such attempts.

Support Groups

Members of AA have help available 24 hours a day, associate with a sober peer group, learn that it is possible to participate in social functions without drinking, and are given a model of recovery by observing the accomplishments of sober members of the group. Other support groups are smaller, but growing, and all have an online presence which provides support even at home late at night.

 

Expectations (prognosis)

Alcoholism is a major social, economic, and public health problem. Alcohol is involved in more than half of all accidental deaths and almost half of all traffic deaths. A high percentage of suicides involve the use of alcohol in combination with other substances. Additional deaths are related to the long-term medical complications associated with the disease. Only 15% of those with alcohol dependence seek treatment for this disease. Relapse after treatment is common, so it is important to maintain support systems in order to cope with any slips and ensure that they don't turn into complete reversals. Treatment programs have varying success rates, but many people with alcohol dependency have a full recovery.

 

Complications

  • Pancreatitis
  • Heart muscle damage
  • Nerve damage
  • Esophageal bleeding
  • Brain degeneration
  • Cirrhosis of the liver
  • Delirium tremens (DTs)
  • Depression
  • Erectile dysfunction
  • Fetal alcohol syndrome in the offspring of alcoholic women
  • High blood pressure
  • Increased incidence of cancer
  • Insomnia
  • Nutritional deficiencies
  • Suicide
  • Wernicke-Korsakoff syndrome

 

Calling your health care provider

If severe confusion, seizures, bleeding, or other health problems develop in a person known or who is suspected to have alcohol dependence take the person to the emergency room or call the local emergency number such as 911.

 

Prevention

Educational programs and medical advice about alcohol abuse have been successful in decreasing alcohol abuse and its associated problems. Alcohol dependency requires more intensive management.

The National Institute on Alcohol Abuse and Alcoholism recommends that women have no more than 1 drink per day and men no more than 2 drinks per day. One drink is defined as a 12-ounce bottle of beer, a 5-ounce glass of wine, or a 1 1/2-ounce shot of liquor.

 

References

Noble J. Textbook of Primary Care Medicine. 3rd ed. St. Louis, Mo: Mosby; 2001:428-439.

Goldman L, Ausiello D. Cecil Textbook of Medicine. 22nd ed. Philadelphia, Pa: WB Saunders; 2004:79-80.

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