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Alcohol psychology
Brain animated color nevit

Alcohol use
Alcohol abuse
Alcohol consumption and health
Treatment of alcohol problems

Alcoholism can take on a variety of definitions, depending on the context in which it is being discussed. In common and historical usage, alcoholism typically constitutes any condition that results in the continued consumption of alcoholic beverages, despite negative personal and social consequences. Medical definitions describe alcoholism as a disease influenced by genetic, psychological, and social factors any of which may precipitate on-going difficulty in controlling overall alcohol consumption. More generally, alcoholism may also point to concerns such as a preoccupation with or compulsion toward the consumption of alcohol, and/or an impaired ability to recognize the overall negative effects of excessive alcohol consumption. Although not all of these definitions specify current and on-going use of alcohol as a qualifier, some do, as well as remarking on the long-term effects of consistently heavy alcohol use, including dependence and symptoms of withdrawal.

While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. The degree, quantity, frequency and regularity of alcohol consumption influencing the development of alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, emotional health and genetic predisposition, have been identified. [How to reference and link to summary or text]
King Alcohol and his Prime Minister

"King Alcohol and his Prime Minister" circa 1820

Definitions and Terminology

The definitions of alcoholism and related terminology vary significantly between the medical community, treatment programs, and the general public.

Definitions

In medicine, alcoholism is defined as a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking.[1]

Outside the medical field, alcoholism can also refer to the continued excessive or compulsive consumption of alcoholic beverages.[2]

Terminology

Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The introduction of politics and religion further muddles the issue and exacerbates ambiguity.

Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol.

Misuse, problem use, and heavy use do not have standard definitions, but suggest consumption of alcohol beyond the point where it causes physical, social, or moral harm to the drinker. Social and moral harm are highly subjective and therefore differ from individual to individual.

The term abuse has a variety of possible meanings. Within psychiatry, the DSM-IV has a specific definition involving a set of life circumstances which take place because of substance use. Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescribed medication in excess of the prescribed dosage or to use of a prescription drug without a prescription. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion due to audiences that do not necessarily share a single definition.

Dependence also has multiple definitions, but is not as commonly used as abuse outside of the medical profession. Physical medicine considers dependence to be the body's physical adaptation to the persistent presence of alcohol. Psychological medicine considers dependence to be a person's mental reliance upon something to maintain their mental status quo. These two are occasionally differentiated as physical and psychological dependence. Within the field of psychiatry, alcohol dependence is the term referring to alcoholism. As a result, a diagnosis of alcohol dependence does not necessarily indicate the presence of physical dependence.

The precise definition of addiction is debated, but in general it refers to any condition which causes a person to continue behaviors demonstrated as harmful to that person. For alcoholism, that behavior is the consumption of alcoholic beverages. Some conditions which contribute to alcoholism include physical dependence, neurochemical conditioning, and a person's perception that alcohol benefits them psychologically or socially.

Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. The American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full. Others (most notably Alcoholics Anonymous) use the term recovery to describe those who have completely stopped consumption of alcohol.

Epidemiology

Substance use disorders are a major public health problem facing many countries. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol."[3] In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.[4]

Within the medical community, there is broad consensus regarding alcoholism as a disease state. Outside the medical community, there is considerable debate regarding the Disease Theory of Alcoholism. Proponents argue that any structural or functional disorder having a predictable course, or progression, should be classified as a disease. Opponents cite the inability to pin down the behavioral issues to a physical cause as a reason for avoiding classification.

Identification and diagnosis

Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared to the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify.

Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.

Genetic predisposition testing

Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut indicate that alcoholism does not have a single cause—including genetic—but that genes do play an important role "by affecting processes in the body and brain that interact with one another and with an individual's life experiences to produce protection or susceptibility." They also report that less than a dozen alcoholism-related genes have been identified, but that more likely await discovery.[5]

At least one genetic test[6] exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol.[7] Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.[5]

Some writers posit that alcohol was discovered to be a replacement for polluted drinking water in early urban societies. In these conditions, alcohol's antibacterial properties offset its health risk, and the slow death of cirrhosis of the liver was preferred to an early death from waterborne disease. This caused a selection pressure on the genes of humans who had abandoned the hunter-gatherer lifestyle towards people with genes which were not prone to over consumption and drunkenness. Over generations, the descendants of these first farmers and urban dwellers became dominated by individuals who could drink more beer more often. This theory explains why some groups who continued a predominately hunter-gatherer culture, such as Native Americans or Australian Aborigines, have such high rates of alcoholism today [8].

Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

Main article: Assessment in alcohol psychology
Main article: Alcohol use assessment tools

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents one approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcohol dependence diagnosis is:

...maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

Effects

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging. The secondary damage caused by an inability to control one's drinking manifests in many ways.

It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption are described in Alcohol consumption and health, but may include cirrhosis of the liver, pancreatitis, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources.

Social effects

The social problems arising from alcoholism can be significant. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic's behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

Alcohol withdrawal

Alcohol withdrawal differs significantly from withdrawal from other drugs in that it can be directly fatal. While it is possible for heroin addicts, for instance, to die from other health problems made worse by the strain of withdrawal, an otherwise healthy alcoholic can die from the direct effects of withdrawal if it is not properly managed. Heavy consumption of alcohol reduces the production of GABA, which is a neuroinhibitor. An abrupt stop of alcohol consumption can induce a condition where neither alcohol nor GABA exists in the system in adequate quantities, causing uncontrolled firing of the synapses. This manifests as hallucinations, shakes, convulsions, seizures, and possible heart failure, all of which are collectively referred to as delirium tremens. All of these withdrawal issues can be safely controlled with a medically supervised detox.

Treatments

Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.[3]

Effectiveness

The effectiveness of alcoholism treatments varies widely. When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own.[9] Based on information from Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism, the February 2007 issue of Newsweek reported that "A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed."[10]

Detoxification

Detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to offset the withdrawal symptoms. Benzodiazepines are the most common family of drugs used for this, followed by barbiturates.

Detoxes are performed in multiple ways. The first takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur, which is safe only with relatively mild alcohol users.

Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting. Detoxification may or may not be necessary depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcoholism.

Group therapy and psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service, including Alcoholics Anonymous, LifeRing Secular Recovery, Rational Recovery, Smart Recovery, Al-Anon/Alateen, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs such as Moderation Management do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking.[11]

Harm Reduction

Harm Reduction programs such as those offered by The HAMS Harm Reduction Network may be helpful for people who are unwilling or unable to abstain from alcohol. Data from harm reduction therapists like Patt Denning[12] suggest that harm reduction can be effective for those who are unhelped by more traditional approaches, although there are no empirical studies to support this approach.

Medications

Although not necessary for treatment of alcoholism, a variety of medications may be prescribed as part of treatment. Some may ease the transition to sobriety, while others cause physical hardship to result from the use of alcohol. In most cases, the desired effect is to have an alcoholic abstain from drinking.

  • Antabuse (disulfiram) prevents the elimination of (acetaldehyde), a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hang over symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast acting and long lasting uncomfortable hang over. This discourages an alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on antabuse can cause severe illness and death.
  • Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. It also appears to act on glutamate neurotransmission.[How to reference and link to summary or text] Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction. Naltrexone comes in two forms. Oral naltrexone, originally but no longer available as the brand ReVia, is a pill form and must be taken daily to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.
  • Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse...Campral proved superior to placebo in maintaining abstinence for a short period of time...[13]" While effective alone,[14] it is often paired with other medication treatments like naltrexone with great success.[15] Acamprosate reduces glutamate release. The COMBINE study was unable to determine the presence of efficacy for Acamprosate[How to reference and link to summary or text].
  • Sodium oxybate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in Italy in small amounts under the trade name Alcover.
  • Baclofen has been shown in animal studies and in small human studies to enhance detoxification.This drug acts as a GABA B receptor agonist and this may be beneficial.

Pharmacological extinction

See also: Sinclair Method

Pharmacological extinction is the use of opioid antagonists like naltrexone combined with normal drinking habits to eliminate the craving for alcohol.[16] This technique has had success in Finland,[17] Pennsylvania,[18] and Florida,[19] and is sometimes referred to as the Sinclair Method.

While standard naltrexone treatment uses the drug to curb craving and enforce abstinence, pharmacological extinction targets the endorphin-based neurological conditioning. Our behaviors become conditioned when our neurons are bathed in endorphins following that action. Conversely, we receive negative reinforcement when we perform that action and yet do not get our endorphins. By having the alcoholic go about their normal drinking habits (limited only by safety concerns), and while preventing the endorphins from being released by the alcohol, the pull to drink is eliminated over a period of about three months. This allows an alcoholic to give up drinking as being sensibly unbeneficial. The effects persist after the drug is discontinued, but the addiction can return if the person drinks without first taking the drug. This treatment is also highly unusual in that it works better if the patient does not go through detoxification before starting it. Clinical studies have shown this treatment to allow 78-87% of inductees to reduce their drinking below levels dangerous to health, and allow 25% of inductees to achieve complete abstinence. Follow-up studies indicate an overall 50% relapse rate over five years, and 2% relapse rate for those who continue to take naltrexone before drinking.

There is a lot of professional resistance to this treatment for two reasons. Studies have demonstrated that controlled drinking for alcoholics was not a useful treatment technique.[20] Other studies have also shown naltrexone to be of questionable value in supporting abstinence alone.[21][22][23] The individual failure of these two separate treatments suggests that their use in combination is equally ineffective. This would be the case if the two treatments were merely additive, as for two people pushing a car. Experimental evidence[16] indicates that the presence of naltrexone causes the drinking of alcohol to have a reverse effect on alcoholism, decreasing the alcoholic's attachment to alcohol consumption when they drink instead of increasing it.

Nutritional therapy

Preventative treatment of alcohol complications includes long-term use of a multivitamin as well as such specific vitamins as B12 and folate.

While nutritional therapy is not a treatment of alcoholism itself, it treats the difficulties that can arise after years of heavy alcohol use. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be diminished by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, causing poor treatment outcomes.[24]

Societal impact

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, for example, money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there is also the pain and suffering of the all individuals besides the alcoholic affected. For instance, alcohol consumption by a pregnant woman can lead to Fetal alcohol syndrome,[25] an incurable and damaging condition.[26]

Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six per cent of a country's GDP.[27] One Australian estimate pegged alcohol's social costs at 24 per cent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 per cent.[28]

A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).[29][4]

Stereotypes

Imlauer Ihr zu Fuessen 1883

Depiction of a wino or town drunk

Stereotypes of alcoholics are often found in fiction and popular culture. Common examples include the 'town drunk' or the portrayal of certain nationalities as alcoholics. In modern times, the recovery movement has led to more realistic depictions of problems that stem from heavy alcohol use. Authors such as Charles R. Jackson and Charles Bukowski describe their own alcohol addiction in their writings. Films like Days of Wine and Roses, My Name is Bill W, Arthur, Leaving Las Vegas chronicle similar stories of alcoholism.

Politics and public health

Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

Organizations working with those suffering from alcoholism include:

See also

References

  1. The definition of alcoholism, The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine to Study the Definition and Criteria for the Diagnosis of Alcoholism, The Journal of the American Medical Association, 268(8), August 26, 1992
  2. Merriam-Webster Online Dictionary
  3. 3.0 3.1 Gabbard: "Treatments of Psychiatric Disorders". Published by the American Psychiatric Association: 3rd edition, 2001, ISBN 0-88048-910-3
  4. 4.0 4.1 Cabinet Office Strategy Unit Alcohol misuse: How much does it cost? September 2003
  5. 5.0 5.1 Nurnberger, Jr., John I., and Bierut, Laura Jean. "Seeking the Connections: Alcoholism and our Genes." Scientific American, Apr2007, Vol. 296, Issue 4.
  6. New York Daily News (William Sherman) Test targets addiction gene 11 February 2006
  7. Ulf Berggren, Claudia Fahlke, Erik Aronsson, Aikaterini Karanti, Matts Eriksson, Kaj Blennow, Dag Thelle, Henrik Zetterberg and Jan Balldin The TaqIA DRD2 A1 Allele Is Associated with Alcohol-Dependence although its Effect Size Is Small Alcohol and Alcoholism 2006 41(5):479-485; doi:10.1093/alcalc/agl043
  8. A synopsis of the idea can be found in popular science writer Steven Berlin Johnson's The Ghost Map, Penguin Group (2006) pgs 103-104
  9. Spontaneous Recovery in Alcoholics: A Review and Analysis of the Available Research, by R. G. Smart Drug and Alcohol Dependence, Vol. 1, 1975-1976, p. 284.
  10. Adler, Jerry; Underwood, Anne; Kelley, Raina; Springen, Karen; Breslau, Karen. "Rehab Reality Check" Newsweek, 2/19/2007, Vol. 149 Issue 8, p44-46, 3p, 4c
  11. National Institute on Alcohol Abuse and Alcoholism 2001-2002 Survey Finds That Many Recover From Alcoholism Press release 18 January 2005
  12. Denning, P (2004). Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. New York: Guilford Press. ISBN 1593850964
  13. FDA Approves New Drug for Treatment of Alcoholism. URL accessed on 2006-04-02.
  14. (2006-03-17). Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: The role of patient motivation.. URL accessed on 2006-04-10.
  15. (2006-02-08). COMBINED ACAMPROSATE AND NALTREXONE, WITH COGNITIVE BEHAVIOURAL THERAPY IS SUPERIOR TO EITHER MEDICATION ALONE FOR ALCOHOL ABSTINENCE: A SINGLE CENTRES' EXPERIENCE WITH PHARMACOTHERAPY.. URL accessed on 2006-04-10.
  16. 16.0 16.1 Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism
  17. ContrAl Clinics ContrAl Results
  18. The Sinclair Method
  19. University of Pennsylvania Health System
  20. Pendery et al. Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study. Science 1982 Jul 9;217 (4555):169-75
  21. Renault, P.F. (1978) Treatment of heroin-dependent persons with antagonists: Current status. Bulletin on Narcotics 30: 21-29 ¶ Renault, P.F. (1980) Treatment of heroin dependent persons with antagonists: Current status. In: Naltrexone: Research Monograph 28, Willett, R.E., and Barnett, G., (eds.), Washington, DC: National Institute of Drug Abuse, 11 22.
  22. O'Malley, S.S., Jaffe, A.J., Rode, S., and Rounsaville, B.J. (1996) Experience of a “slip among alcoholics treated with Naltrexone or placebo. American Journal of Psychiatry, 153(2): 281-283.
  23. Maxwell, S., and Shinderman, M.S. (1997) Naltrexone in the treatment of dually-diagnosed patients. Journal of Addictive Diseases 16: A27, 125, 1997 ¶ Maxwell, S., and Shinderman M.S. (2000) Use of Naltrexone in the treatment of alcohol use disorders in patients with concomitant severe mental illness. Journal of Addictive Diseases 19:61-69.
  24. The Hypoglycemic Health Association of Australia
  25. CDC. (2004). Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. Can be downloaded at http://www.cdc.gov/fas/faspub.htm
  26. Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN 1-55766-283-5.
  27. World Health Organization Global Status Report on Alcohol 2004 Global Status Report on Alcohol 2004 accessed 3 January 2007
  28. World Health Organization Global Alcohol Database [1] 3 January 2007 search for Economic cost of alcohol consumption
  29. BBC Q&A: The costs of alcohol 19 September 2003

Further reading

  • Berry, Ralph E.; Boland James P. The Economic Cost of Alcohol Abuse The Free Press, New York, 1977 ISBN 0-02-903080-3
  • Royce, James E. and Scratchley, David Alcoholism and Other Drug Problems Free Press, March 1996 ISBN-10: 0-684-82314-4 ISBN-13: 978-0-684-82314-0
  • Valliant, George E., The Natural History of Alcoholism (Revisited), Harvard University Press, May 1995 ISBN-10: 0-674-60378-8 ISBN-13: 978-0-674-60378-3
  • Pence, Gregory, "Kant on Whether Alcoholism is a Disease," Ch. 2, The Elements of Bioethics, McGraw-Hill Books, 2007 ISBN-10: 0-073-13277-2.
  • Milam, Dr. James R. and Ketcham, Katherine Under The Influence: A Guide to the Myths and Realities of Alcoholism. Bantam, 1983, ISBN 0-553-27487-2

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