Alcoholism

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Alcoholism is a powerful craving for alcohol which often results in the compulsive consumption of alcohol otherwise known as an addiction. The cause of this craving is heavily debated, but the most popular beliefs are that it is (1) a chemical or nutritional imbalance, (2) a genetic predisposition, (3) a neurological effect caused by runaway learning mechanisms, or (4) an inability to curb one's own desire for enjoyment. As a result, the etiology and nature of alcoholism are both currently being debated within the medical and scientific communities and the very definition of alcoholism is a part of that debate.

Some believe that alcoholism is a biological disease, but the inability to tie it to a specific biological cause means that this is not a debate over the medical details of the problem and its treatment so much as the semantic and political categorization of it. People are more willing to accept that the problem has a biological basis (as opposed to just being a problem of weak willpower or poor moral character) if the word disease is attached. Those who oppose the term disease don't necessarily believe that the problem is a willpower issue because there are many physical conditions (broken bones, blood clots, and embolisms, for example) that are not disease related.

Terminology

There are many terms, such as use, misuse, heavy use, addiction, abuse and dependence, all of which have different and sometimes non-standard meanings. 'Use' refers to simple use of a substance.

An individual who drinks a beer once a day uses alcohol. Misuse and 'heavy use' do not have standard definitions in the field. It has been determined that the human system can tolerate up to 14 two-ounce "doses" of alcohol per week before they begin to show signs of long-term cellular damage ^{[How to reference and link to summary or text]}.

Addiction refers to any single or group of conditions which cause a user of a substance to continue using a substance in spite of any negative effects that that use may cause. Negative effects are highly varied, but include those that are psychological, physical, social or monetary.

Alcohol addiction has been identified as having many components.

Psychological addiction involves those things which convince a person that they gain benefit from the use of the substance. For instance, if they feel that they are more socially adept while drunk or that it allows them to better handle stress, then they might feel that any problems caused were worth the benefits.

Physical addiction (a.k.a., dependence) involves the physical adaptation of a person's biological systems to the continuous presence of alcohol. The person's systems become more comfortable with the typical level of alcohol and higher doses are required to maintain an equivalent effect. A decrease in the level of alcohol causes reverse imbalances resulting in withdrawal symptoms, which for alcohol can be deadly.

Neurochemical addiction involves the hijacking of existing learning mechanisms in order to convince the system that an addictive behavior is good for it, despite all evidence to the contrary. Endorphin is the body's way of telling the mind that a behavior is good for it. We release endorphin into the blood stream during sex, exercise and consumption of some foods for instance, and this is responsible for "runner's high" and "afterglow". This is more than just a good feeling, it is teaching our brain that these are the behaviors that it should repeat. It has been demonstrated in various clinical tests that mammals with more active endorphin systems are more prone to alcohol addiction. This is because alcohol triggers the release of endorphins into our system, and we learn that alcohol drinking is a behavior that we should repeat. This effect is also visible in the use of opiates, and in various risk-taking behaviors such as skydiving and gambling.

Psychological versus Physical Addiction

One of the primary components of alcohol addiction is the person's belief that alcohol provides value to them. This value can come from any of a large selection of sources, including:

belief that it improves their ability to socialize
belief that it helps them handle pressure
desire for a state of calm and well-being brought on by alcohol consumption
peer pressure, or fear of alienation if the person does not drink
desire to conform
sense of superiority from ability to handle extreme intoxication
sense of superiority from knowledge of alcoholic drinks

These effects all contribute to a person's impression of the beneficial effects of alcohol in his/her life, and may result in a denial of the negative effects. It is important to recognize that many of these benefits can be real, not imagined. For instance, some people really are more enjoyable to be around when they're intoxicated, and alcohol really does help some people handle stress better. Alcoholism becomes a problem when the negative effects exceed the positive ones, although for a typical alcoholic this point is reached very quickly.

Psychological addiction factors are often responsible for encouraging potential alcoholics to drink in quantities which result in other forms of addiction to alcohol, and they are also responsible for maintaining alcoholism in the absence of other forms of addiction. The person must be convinced of the net negative value of alcohol in their lives before any treatment can have meaningful lasting effects. An inability to stop drinking despite a clear understanding of alcohol's negative balance of effects on his or her life is a primary indicator that a person suffers from alcoholism.

A person's "social dependence" is defined by the Prevention Research Institute from Kentucky as a condition that a person experiences and re-experiences in a social setting. It reflects the habitual experiences one has as they enjoy "partying" with the same people.

Effects

Alcoholism can have severe negative effects on a person's physical, mental, emotional and social well-being. In addition to the physical effects caused by the continued consumption of alcohol, the person's regular debilitation can result in a loss of employment, social and marital connections, property, and physical health via mechanisms like auto crashes and falls down stairs.

Alcohol addiction can be harder to break and significantly more damaging than addiction to most other substances. The physical symptoms of withdrawal from alcohol can be quite severe and dangerous, with death reported in extreme cases.

The alcoholic personality can exhibit a radical change when they drink, from passive when sober to aggressive when drunk, though the reverse can also be true.

Long-term

The long-term effects of high quantity alcohol use can include:

death
pancreatitis, or inflammation of the pancreas (both the acute and chronic form)
heart disease, including dilated cardiomyopathy
polyneuropathy, or damage to the nerves leading to poor sensation or pain
cirrhosis of the liver, a chronic disease characterized by destruction of liver cells and loss of liver function, and its numerous complications, including bleeding from esophageal varices
depression, insomnia, anxiety, and suicide
increased incidence of many types of cancer, including breast cancer, head and neck cancer, esophageal cancer and colorectal cancer
nutritional deficiency of folic acid, thiamine (vitamin B1) and several others
Wernicke-Korsakoff syndrome, a neuropsychiatric disorder caused by thiamine deficiency that results from poor nutrition in alcoholics
personality changes toward others, especially those who are close
significant damage to occupational, social, and interpersonal areas, including sexual dysfunction
gait ataxia due to damage to the superior vermis

Social Effects

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

Alcohol Withdrawal

There are several distinct but not mutually exclusive clinical alcohol withdrawal syndromes caused by alcohol withdrawal:

Tremulousness - "the shakes"
Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure.
Seizures - acute grand mal seizures can occur in alcohol withdrawal in patients who have no history of seizure or any structural brain disease.
Hallucinations - usually visual or tactile in alcoholics
Delirium tremens - can be severe and often fatal.

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

Diagnosis

Although there is no specific diagnosis for alcoholism, there have been many efforts at diagnostic approaches to alcohol dependence, abuse and complications associated with chronic alcohol consumption.

In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

The DSM IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism, one more closely based on specifics than the 1992 JAMA article. In part this is to assist in the development of research protocols in which findings can be compared with one another, but the DSM definition is the one in general use from a diagnostic standpoint. That definition is: maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Note that many sedative agents are cross-tolerant with alcohol (meaning that these agents can be taken instead of alcohol to relieve withdrawal symptoms or to maintain the level of sedation provided by alcohol). A more general diagnosis than alcohol dependence is that of sedative dependence. Whether an individual uses alcohol or another sedative, if they meet the criteria above, the process is likely the same.

Screening

Several tools may be used to detect the habitual abuse of alcohol. The CAGE questionnaire, developed by Dr. John Ewing and named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

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

The Alcohol Dependence Data Questionnaire [1] is a more sensitive diagnostic test than the CAGE test. The Alcohol Dependence Data Questionnaire serves to distinguish a diagnosis of alcohol dependence from one of alcohol abuse.

Blood tests

Although there is no blood test specific for alcohol abuse or alcohol dependence (alcoholism), prolonged heavy alcohol consumption may lead to several abnormalities, including:

Macrocytosis (enlarged MCV)¹
Elevated GGT²
Moderate elevation of AST and ALT and an AST:ALT ratio of 2:1.
High carbohydrate-deficient transferrin²

The disease model

The disease model of alcoholism was first proposed by Dr. Benjamin Rush of Philadelphia. Prior to Benjamin Rush, drunkenness was viewed as a moral lapse and a sinful choice.

Whether or not alcoholism is a systemic problem that can be legitimately described as a disease remains a controversial subject in the medical field. However the consequences of chronic alcoholism have a clearly defined course of physical debilitation that can end in death. The controversy over the disease hypothesis exists partly because of these various characterizations and uses of the words "alcoholism" and "disease", and not all participants in the debate are without self-interest. For example, if alcoholism is not considered a disease, third-party payments to physicians and hospitals for its treatment might cease. Programs such as Rational Recovery also reject the "disease model" for a variety of reasons, one claim being that there is no medical procedure to determine if one has alcoholism as a disease. Many "alcoholism as a disease model" critics such as Stanton Peele, PhD also reject the notion that excessive drinking is rooted in a biological disease. Herbert Fingarette, PhD, has written extensively on the subject including Heavy Drinking: The Myth Of Alcoholism as a Disease.

The American Society of Addiction Medicine and the American Medical Association both maintain extensive policy regarding alcoholism. The American Psychiatric Association recognizes the existence of "alcoholism" as the equivalent of alcohol dependence. With the publication of the DSM-III in 1980, two separate syndromes of alcohol dependence and alcohol abuse replaced the earlier category of alcoholism. The World Health Organization dropped the diagnostic category "alcoholism" in 1979, replacing it with the diagnostic categories "alcohol dependence" and "harmful use" (ICD-9, ICD-10)[2]. The American Hospital Association, the American Public Health Association, the National Association of Social Workers, and the American College of Physicians classify "alcoholism" as a disease.

The causes for alcohol abuse and dependence cannot be easily explained. However, the belief that the roots are from moral or ethical weakness on the part of the sufferer has been largely superseded.

In contrast, in a 1988 U.S. Supreme Court decision on whether alcohol dependence is a condition for which the U.S. Veterans Administration should provide benefits (Traynor v. Turnage)[3], Justice Byron R. White agrees with the U.S. District Court that there exists "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility." ^{[How to reference and link to summary or text]}

Although many people and medical organizations define alcoholism as a disease (with organic, biological and even genetic roots), there is currently no test or procedure to determine or diagnose alcoholism. In view of this medical professionals diagnose proveable alcohol related conditions such as alcohol dependence, alcohol abuse and alcohol withdrawal.

Treatments

Rationing

Some programs attempt to help problem drinkers before they become dependents. These programs focus on harm-reduction and reducing alcohol intake as opposed to cold-turkey approaches. Since one of the effects of alcohol is to reduce a person's judgment faculties, each drink makes it more difficult to decide that the next drink is a bad idea. As a result, rationing or other attempts to control use are increasingly ineffective as pathological attachment to the drug develops. Use may continue despite serious adverse health, personal, legal, work-related, and financial consequences.

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

Detoxification

Treatments for alcohol dependence include detoxification programs run by medical institutions. These may involve stays for three or more weeks in specialized hospital wards; often, however, patients are hospitalized for only a few days. Some insurance providers limit detox stays to 5-6 days or less. Drugs may be used to avoid withdrawal symptoms, which in severe cases may lead to death. To that point, even a simple detox can involve seizures, if not properly monitored. In many cases, the physical effects of rapid detox can result in neurological damage.

Most other forms of treatment require detoxification before they can be effective because they rely upon the maintenance of abstinence. For these treatments, the elimination of the physical dependence is an important first step that allows the treatment of the underlying psychological or neurochemical addictions. With the exception of pharmacological extinction, any treatment that doesn't rely on detox has questionable effectiveness because it allows the patient continued access to the substance to which they are addicted.

Group Therapy and Psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues leading to alcohol dependence, and also to provide the recovering addict with relapse prevention skills. Aversion therapies may be supported by drugs like Disulfiram, which causes a strong and prompt sensitivity reaction whenever alcohol is consumed. Naltrexone or Acamprosate may improve compliance with abstinence planning by treating the physical aspects of cravings to drink. The standard pharmacopoeia of antidepressants, anxiolytics, and other psychotropic drugs treat underlying mood disorders, neuroses, and psychoses associated with alcoholic symptoms.

In the mid-1930s, the mutual-help group-counseling approach to treatment began and has become very popular. Alcoholics Anonymous is the best-known example of this movement. Other groups that provide similar treatment without AA's religious bias include LifeRing Secular Recovery and SMART Recovery.

Medications

The classical use of medications for alcoholism is to supplement a person's willpower and encourage abstinence. Antabuse (a.k.a. disulfiram), for instance, prevents the elimination of chemicals which cause severe discomfort when alcohol is ingested, effectively preventing the alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on ant abuse can result in severe illness and death. Naltrexone has also been used because it helps curb cravings for alcohol while the person is on it. Both of these, however, have been demonstrated to cause a rebound effect when the user stops taking them. These do allow a person to resist psychological addictions to alcohol, but they do not treat the neurochemical addiction.

Pharmacological Extinction

In more recent studies it has been demonstrated that the use of endorphin antagonists [e.g. naltrexone] while the alcoholic continues to drink can result in extinction of the neurochemical addiction. Over a period of roughly three months the patient, while continuing to drink, loses interest in drinking alcohol and can eventually just give it up as being sensibly unbeneficial. This technique is used to good effect inFinland, Florida, and Pennsylvania.

There is a lot of professional bias against this treatment for two reasons. The first is the long-standing bias against any treatment that doesn't involve detoxification and abstinence. The second is due to a large body of research which has been done using naltrexone to encourage abstience, for which it is poorly suited. Naltrexone use during abstinence fails to treat the neurochemical addiction, and can result in a rebound effect when the patient stops taking it, and these results have been falsely assumed to reflect its effectiveness as a treatment when coupled with continued drinking. This particular form of treatment is sometimes referred to as the Sinclair Method.

Nutritional therapy

Another treatment program is based on nutritional therapy. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be treated by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, resulting in poor treatment outcomes. See: [4]

Return to normal drinking

Although it has long been argued that alcoholic dependents cannot learn to drink in moderation, research by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that about 18% of such individuals in the US whose dependence began more than one year earlier are now drinking in moderation. In contrast, roughly 78% of those who undergo pharmacological extinction are capable of normal drinking habits, although this does involve the use of naltrexone an hour before any drinking occurs in order to maintain this.

Societal Impact

Today, alcohol abuse and alcohol dependence are major public health problems in North America, costing the region's inhabitants, by some estimates, as much as US$170 billion annually. Alcohol abuse and alcohol dependence sometimes cause death, particularly through liver, pancreatic, or kidney disease, internal bleeding, brain deterioration, alcohol poisoning, and suicide. Heavy alcohol consumption by a pregnant mother can also lead to fetal alcohol syndrome, an incurable and damaging condition.

Additionally, alcohol abuse and alcohol dependence are major contributing factors for head injuries, motor vehicle accidents (MVA), violence and assaults, neurological, and other medical problems (cirrhosis, etc.).

Of the one half of the North American population who consume alcohol, it has been estimated by some that 10% are alcohol abusers and alcohol dependents, and 6% consume more than half of all alcohol.

Stereotypes of alcohol abusers and alcohol dependents are often found in fiction and popular culture: for example the "town drunk," or the stereotype of Russians and the Irish as alcoholics. In modern times, the recovery movement has led to more realistic portraits of abusers and dependents and their problems, such as in Charles R. Jackson's The Lost Weekend, or the films Days of Wine and Roses, and My Name is Bill W or the extreme Leaving Las Vegas. Charles Bukowski describes honestly his alcohol addiction in the movie Barfly and in his other writings.

Politics and public health

Because alcohol abuse affects 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.

Organisations working with alcohol abusers include:

Alcoholics Anonymous (AA)
International Organisation of Good Templars (IOGT)
LifeRing Secular Recovery (LifeRing)
Men For Sobriety (MFS)
Moderation Management (MM)
Rational Recovery (RR)
Secular Organizations for Sobriety (SOS)
Self-Management and Recovery Training (SMART)
Women For Sobriety (WFS)

External links

References

Tonnesen H, Hejberg L, Frobenius S, Andersen JR. Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics. Acta Med Scand. 1986;219(5):515-8. (Medline abstract)
Schwan R, Albuisson E, Malet L, Loiseaux MN, Reynaud M, Schellenberg F, Brousse G, Llorca PM. The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach. Drug Alcohol Depend. 11 June 2004 ;74(3):273-9. (Medline abstract)
Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984
U.S Supreme Court, Traynor v Turnage, 485 U.S 353 (1988) at 535-550
McKelvey v. Turnage, 792 F.2d 194 (D.C. Cir. 1986) and Traynor v. Walters, 791 F.2d 226 (2d. Cir. 1986)

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