Alcoholism

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Alcoholism is a multifactorial condition widely believed to be based upon both genetic (Lowinson JH, Ruiz P, Millman RB, Langrod JG. Substance Abuse, A Comprehensive Textbook, 4th Ed. 2005) and environmental factors which is best explained as a continued use of alcohol or other sedatives despite ones best interest. The condition is thought to be lifelong (Diagnostic and Statistal Manual of Mental Disorders, 4th Ed, APA, 2004) and can be treated through ongoing therapy, medication, and/or accompanied by attendance at self-help meetings. Although medication has been developed to assist in the treatment of alcoholism, the research has not yet demonstrated long term efficacy. Alcoholics do not typically experience craving, unlike individuals afflicted with opioid dependence. Of importance is that frequency and quantity of alcohol use are not related to the presence of the condition (definition, as per 1992 JAMA article cited below); that is, individuals can drink a great deal without necessarily being alcoholic, and alcoholics may drink minimally and/or infrequently. Alcohol is cross-tolerant with other sedatives such as Valium, Phenobarbital, and Soma. These other sedative agents are therefore generally not prescribed to individuals with alcoholism.

Biological mechanism

The biological mechanism of alcoholism is unknown, although the biologic mechanism of alcohol metabolism and alcohol-induced behavioral change is well-described in the literature. Alcohol itself is not a factor in the development of this condition, however, or one would be able to turn a non-alcoholic into an alcoholic through the provision of alcohol (the literature has demonstrated that this is impossible).

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)[1]. 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.

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."

File:Stop drinking.jpg

Polish propaganda poster saying: "Stop drinking! Come with us and build a happy tomorrow."

The causes for alcohol abuse and dependence cannot be easily explained. However, the prejudice that the roots are from moral or ethical weakness on the part of the sufferer has been largely altered. A 1995 Gallup Poll found that 90% of Americans currently believe that "alcoholism" is a disease.

In contrast, in a 1988 U.S. Supreme Court decision on whether alcoholism is a condition for which the U.S. Veterans Administration should provide benefits, 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." [4][5]

In spite of the popularity of the "disease concept", alcohol disease model critics such as Herbert Fingarette, PhD and Stanton Peele, PhD have stated no such disease or genetic link[2] has ever been scientifically proven (Peele 1999, Fingarette 1988). Furthermore, the Baldwin Research Institute has pointed out

In a recent Gallup poll, 90 percent of people surveyed believe that alcoholism is a disease. Most argue that because the American Medical Association (AMA) has proclaimed alcoholism a disease, the idea is without reproach. But, the fact is that the AMA made this determination in the absence of empirical evidence. After reviewing the history of the decision, it would not be unreasonable to suggest that the AMA has been pursuing its own agenda in the face of evidence negating the validity of alcoholism....The promulgation of the disease concept, in conjunction with AMA approval, has created a multi-billion dollar treatment industry that contributes billions to the health care industry....The promulgation of the disease concept, in conjunction with AMA approval, has created a multi-billion dollar treatment industry that contributes billions to the health care industry.[3]

Terminology

There are many terms which are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, addiction, abuse and dependence are all commonly in use, but are not always used with an understanding of the associated medical conditions and therefore have acquired highly varying and sometimes non-standard meanings.

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

Misuse, abuse, and heavy use do not have standard definitions, but generally refer to the 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 have no clinical definition. Studies in mammals reveal long-term changes (though not necessarily harmful changes) after even brief initial exposure to alcohol (Gitlow SE, Bentkover SH, Dziedzic SW, Khazan N. Persistence of Abnormal REM Sleep Response to EtOH as a Result of Previous EtOH Ingestion. Psychopharmacologia 33, 135-140. 1973).

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 by some 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.

File:King alcohol.jpg

"King Alcohol and his Prime Minister" circa 1820

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

Main article: Effects of alcohol on the body

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 so-called 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. Research has yet to identify an alcoholic personality.

Long term physical health effects

The long term health effects caused by the consumption of large amounts of alcohol, or of continually having alcohol in one's system include:

death from many sources, primarily alcohol toxemia
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 of pain and impaired mobility
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
sexual dysfunction

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.

The DSM IV classification is not without controversy. In the article Alcoholism: A disease of speculation[4] one research organization observed,

Then there is the DSM IV criterion for diagnosing alcohol abuse. It also does not include physically measurable symptoms. It only requires social and/or legal problems. The DSM IV criterion for diagnosing alcohol dependence requires only one physical symptom that is a result of drinking too much, which is alcohol withdrawal. Following this logic, if a person smokes cigarettes they do not have a problem, but, when they stop smoking and go through nicotine withdrawal, they are then diseased. Yet, most treatment professionals seem oblivious to these blatant contradictions. (Keep in mind that cigarette smoking is not a disease according to DSM IV, although it causes far more health problems than does the use of alcohol and all other drugs combined.)

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 [5] 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.

There is currently no valid test to determine if one has a disease called alcoholism.

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 in the early 1800's, who also defined being African-American as a disease. Prior to Benjamin Rush, drunkenness was viewed as a moral lapse and a sinful choice. In the present day 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)[6]. The American Hospital Association, the American Public Health Association[7], the National Association of Social Workers, and the American College of Physicians classify "alcoholism" as a disease.

Whether or not alcoholism is a biological disease remains a controversial subject 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. 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), Justice Byron R. White agreed 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." [8]

Programs such as Rational Recovery reject the "disease model" and Stanton Peele has devoted a significant portion of his web site to disputing many assertions made by the alcoholism treatment community including the AMA, APA and NIAAA[9].

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 the support group movement. Other groups that provide similar self-help and support without AA's spiritual focus include LifeRing Secular Recovery, Smart Recovery, Women For Sobriety, and Rational Recovery.

Medications

The use of medications for alcoholism is to supplement a person's willpower and encourage abstinence. Antabuse (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 Antabuse 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[10] it has been demonstrated that the use of endorphin antagonists [e.g. naltrexone] combined with normal drinking habits 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 in Finland[11], Pennsylvania[12], and Florida[13].

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: [14]

Return to normal drinking

It has long been argued that alcoholics cannot learn to drink in moderation; despite this, 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.

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 use disorders impact 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 alcohol use disorders include:

Journals

Quarterly Journal of Studies on Alcohol

Bibliography

Key Texts – Books

Additional material – Books

Fingarette, H. (1988)Heavy Drinking: The Myth Of Alcoholism As a Disease PhD (University of California Press,
Peele, S. (1999)The Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control PhD (Jossey-Bass,
Kissin,B. and Begleiter,H. (1972)(eds) The Biology of Alcoholism, vol. 2 Physiology and Behaviour, New York: Plenum Press.

Key Texts – Papers

Overton, D.A. (1972) State dependent learning produced by alcohol and its relevance to alcoholism. In: B. Kissin and H. Begleiter (eds) The Biology of Alcoholism, vol. 2 Physiology and Behaviour, New York: Plenum Press.

Additional material - Papers

Google Scholar

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)

Roe, A. (1945) The adult adjustment of children of alcoholic parents raised in foster homes, Quarterly Journal of Studies on Alcohol 5: 12-15.
Goodwin, D.W., Powell, B., Bremer, B., Home, H. and Stern, J. (1969) Alcohol and recall: state dependent effects in man, Science 16.3: 1358-60.

External links

National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Stanton Peele Addiction Website A web site dedicated to exploring popular myths and controversies regarding alcoholism and addiction treatment, prevention and research.
Baldwin Research Institute Independent Research on Alcoholism and Drug Addiction
Alcoholics Anonymous
Online Screening Test for Alcohol Abuse
Psych Forums: Alcohol Addiction Forum
Alcohol Tolerance May Be Genetic health.dailynewscentral.com
CAGE Questionnaire (PDF)
Drink Too Much? by David J. Hanson
Alcoholics can Drink in Moderation
Invited Interview from the Oxford Journal of Medicine on the use of Naltrexone to treat alcoholism
List of alcohol journals

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