Alcohol Dependence Research Paper

Outline

1. Who Becomes Alcoholic?
2. Other Drug Use Associated with Alcohol Dependence
3. Dependence Syndrome and Screening Instruments
4. Alcoholism Treatment: Pharmacological Approaches
5. Psychiatric and Medical Complications
6. Alcoholism Treatment: Behavioral Approaches
7. Long-Term Recovery from Alcoholism
8. Beneficial Versus Harmful Effects of Alcohol
9. Prevention of Alcohol Use and Problems

1. Who Becomes Alcoholic?

The best predictor of who will become an alcoholic is a positive  family history  of alcoholism.  Family history studies of alcoholism show that alcoholism is common among families of alcoholics and that a given alcoholic is likely to have a family history for alcoholism. Moreover,  family history,  rather  than  environmental factors, is associated with the development of alcoholism. Contrary to popular belief, histories of deprivation and poverty do not predict alcoholism nearly as well as do  biological  factors.  Furthermore, although  mental illness is commonly associated with alcoholism, most alcoholics  do not  have a mental  illness beyond  their alcoholism.

Adoption  studies  reveal that  the  biological parents, and not the adoptive parents, predict alcoholism in the offspring. Thus, it is the relationship of sons and daughters  to  parents  through  blood  linkage,  and  not  who raised  them  or  their  environment,   that  predicts  the onset  of alcoholism.  In addition,  identical  twins who share the same genes (DNA) have a greater prevalence of alcoholism than do fraternal twins who share half of the same genes (DNA), again implicating the biological origin of alcoholism. Importantly,  although  the prevalence of alcohol dependence  typically has been greater in males, studies have shown that the biological risk for developing alcohol dependence is the same among women as among men.

When  children  are  asked  for reasons  for initiating alcohol (and  drug)  use, peer influences and exposure to alcohol are the best predictors.  Those children  who associate with other children who consume alcohol are more likely to try alcohol and use it more often. Other factors, such as poverty and social deprivation,  do not predict  alcohol use; in fact, certain  racial populations such as black males are negatively correlated with onset of alcohol  dependence  (i.e.,  they have lower  rates  of alcoholism).  Thus,  we  can  predict  alcohol  use  and onset of dependence with a family history and exposure to alcohol,  particularly  if an individual  is biologically related and exposed to alcohol by peers. Physicians can do well in assessing the risk for onset of alcohol dependence, and who might actually be alcoholic, by inquiring about patients’ family histories of alcoholism and patients’ association with other drinkers.

2. Other Drug Use Associated With Alcohol Dependence

Other  drug use is commonly  associated with alcohol use  and  dependence.   For  instance,  more  than  half of those identified  as alcoholic will have at least one other drug dependence.  This is somewhat age dependent;  younger  alcoholics are more likely to have another drug dependence.  At least 80% of alcoholics are dependent  on nicotine, with the vast majority smoking cigarettes. Conversely, 30% of those with nicotine dependence are dependent on alcohol. Cannabis (marijuana)  dependence is probably the next most common drug dependence  among alcoholics, particularly among younger alcoholics. Most cocaine addicts use alcohol, and many qualify for alcohol dependence, as do most heroin addicts.

Longitudinal studies tend to demonstrate alcohol as a gateway drug, followed by nicotine, for those who go on to develop other  drug addictions  such as cocaine and heroin.  Surveys of high school-age students  show that 80 to 90% of students  have consumed  alcohol during the past year and that 5 to 10% drink  daily. Also, the mean age of onset of alcoholism in the U.S. population is 21 years in males and 24 years in females, indicating that  alcoholism  is a youthful  disorder  that  begins to be  prevalent  during  the  teenage  years.  Initiation   of other drug use also occurs during these vulnerable developmental  years,  when  biological  and  especially peer factors are operative.

3. Dependence Syndrome And Screening Instruments

3.1.  Syndromes

The dependence  syndrome, as described in the fourth edition  (text  revised) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), defines  a maladaptive pattern of alcohol use leading to clinically significant  impairment  or  distress,  as manifested  by three  or more of the following occurring  at any time during the same 12-month period:

• Tolerance (need for increase in dose or loss of effect)
• Withdrawal (typical of alcohol withdrawal: anxiety, dysphonic mood, muscle aches, insomnia, nausea, vomiting)
• Use of larger amounts for longer periods of time than intended
• Persistent desire or unsuccessful attempts to cut down or control alcohol use
• Preoccupation with acquiring alcohol (e.g., frequently in the presence of alcohol; giving up or reducing important social, occupational, or recreational activities due to alcohol use)
• Alcohol use despite knowledge of adverse physical or psychological problems caused or exacerbated by alcohol (e.g., depression; anxiety; restricted options in daily living; pursuit of drugs to the exclusion of social, occupational, and normal interpersonal relationships;  poor motivation to solve pain problems through  evaluation and treatment; resistance to alternative resolutions to life problems)

Pervasive to these criteria is a loss of control over the use of alcohol, whether an inability to resist initiating alcohol  use  or  an  inability  to  modulate  the  amount used during  a given episode of alcohol consumption. Accordingly, the dependence syndrome mirrors the following basic definition of behavioral addiction:

• Preoccupation with acquiring alcohol
• Compulsive use of alcohol (continued use despite adverse consequences)
• Pattern of relapse to alcohol use despite adverse consequence

The neuropharmacological  basis for behavioral addiction  or dependence  on alcohol lies in the phylogenetically ancient  portion  of the brain in the limbic system, which is responsible for instinctual drive states and emotions. The brain center responsible for behavioral addictive use (and dependence)  lies in the mesolimbic pathway, which extends from the ventral tegmentum in the midbrain to the nucleus accumbens in  the  limbic  forebrain.  Scientific studies  show  that stimulation  of the  mesolimbic  pathway  with  alcohol and other  drugs reinforces compulsive use of alcohol that closely resembles the out-of-control  addictive use seen in patients.

3.2.  The CAGE and MAST

As screening  instruments,  the  CAGE (Cutting  down, Annoyance by criticism, Guilty feeling, and Eyeopeners)   and   MAST (Michigan   Alcohol  Screening Test) are useful in identifying problematic use of alcohol and probable alcohol dependence in individuals. In the CAGE, individuals are asked whether  they find it hard to cut down, whether others are annoyed by their alcohol use, whether  they feel guilty about  drinking, and whether  they use alcohol as an eye-opener in the morning or early in the day to relieve distress (usually symptoms  of  withdrawal  from  alcohol).  A positive answer to one question  means a possible diagnosis of alcohol dependence, and a positive answer to two questions  means  a probable  diagnosis.  However, the CAGE is a screening  instrument  that  requires  a follow-up clinical assessment for a revised DSM (DSM-IV-R) or  similar  objective  diagnostic  scheme  for definitive diagnosis.

The MAST is a self-administered questionnaire  that comes in various lengths (e.g., brief, standard), depending  on  the  number  of questions  indicating  a diagnosable alcohol dependence according to the number of positive answers. As with the CAGE, the MAST requires a follow-up clinical interview to confirm the diagnosis of alcohol dependence.

4. Alcoholism Treatment: Pharmacological Approaches

We know well that pharmacological treatment of withdrawal from alcohol or medical detoxification reduces morbidity and mortality from chronic alcohol use. The mortality from untreated delirium tremens ranges between  20  and  50%,  and  untreated   alcohol  withdrawal can complicate other conditions associated with alcohol  withdrawal  such  as  cardiovascular  problems (e.g., abnormal heart rhythm, hypertension).

The reliable and commonly used medications to treat alcohol withdrawal  are from the benzodiazepine  class and    include    diazepam    (Valium)    and    lorazepam (Ativan).  Benzodiazepines   share  cross-tolerance   and dependence  with alcohol and are effective in suppressing signs and symptoms of withdrawal from alcohol in the  brain  at  the  gamma  amino  butyric  acid  (GABA) receptors on nerve cells. These are particularly effective medications to treat withdrawal when used in the short term under clinical supervision for alcohol withdrawal. Moreover, pharmacological  management  of alcohol withdrawal   improves   compliance   with   behavioral approaches to alcohol dependence in promoting abstinence from alcohol. Alleviation of the noxious symptoms   of  withdrawal,   such   as  anxiety,   depression, malaise,  and  intense  cravings for more  alcohol,  will reduce  the  risk  for continuous  alcohol  consumption and   provide   a   transition    to   the   abstinent   state. Behavioral management  is  typically  not  effective in the setting of active alcohol use due to the poor insight and  judgment   and  the  reduced   motivation   in  the intoxicated and withdrawal states from alcohol use.

5. Psychiatric And Medical Complications

Alcohol regularly induces or causes a plethora of psychiatric  symptoms  in  varying  degrees  of severity. Depression  and  anxiety  can  be expected  to  occur  in virtually any chronic drinker (e.g., daily or weekly consumption). Correspondingly, these symptoms usually subside within a few days following cessation and during abstinence  from alcohol. Predictably, chronic  drinkers experience sadness, loss of energy, anhedonia, hopelessness, and helplessness that reaches degrees equivalent to those of major depression. In addition, suicidal thinking is common among drinkers; alcoholism is the most common  diagnosis  among those  attempting  or  completing suicide.  Moreover,  25% of alcoholics  commit  suicide. Often,  these  suicidal  thoughts  subside  within  days of abstinence from alcohol.

Anxiety  is  a  prominent   state  during  alcohol  withdrawal, and most chronic  drinkers  spend some portion of the day in withdrawal as the blood alcohol level drops. Also, tolerance to alcohol diminishes with chronic intake, such  that  greater  symptoms  of anxiety and  depression reflect increasing dependence on alcohol. Usually, anxiety and depression subside with abstinence within a few days. Occasionally, visual and auditory hallucinations,  as well as delusions (mostly paranoid in type), can occur in  chronic   drinkers.   Typically,  these  subside  with abstinence,  although  short-term  treatment  with  antipsychotic medications may be required.

Importantly,  50% of those with significant psychiatric diagnoses will use alcohol and often qualify for an alcohol dependence diagnosis. Although a presumptive dual diagnosis can be made on the basis of history and mental  status  examination,  abstinence  from  alcohol over time is often required  to make a definitive diagnosis to exclude the alcohol-induced  effects on mood and thought.

6. Alcoholism Treatment: Behavioral Approaches

Although there are many studies on a variety of behavioral approaches  for alcohol problems, these methods are  not  designed  for  ‘‘typical’’  alcoholics  as  defined in  the  DSM-IV-R. Consequently,  brief  interventions do not work well in individuals who have actual alcohol dependence  with the concomitant  loss of control over alcohol use. Moreover, studies of behavioral management  approaches  typically  do  not  provide  long-term  follow-up  of  their  effectiveness beyond  a  few months.  These  approaches  have a variety  of names, such as relapse prevention  and motivational enhancement, but most are derived from cognitive behavioral techniques.  However, one  approach  termed  ‘‘12-step facilitation’’ shows  long-term  positive  results  principally   due   to   referral   to   12-step   groups   such   as Alcoholics Anonymous (AA).

An approach  called ‘‘controlled drinking’’ is a misnomer  and  has caused substantial  confusion,  and ultimately harm, to those who suffer from alcohol dependence.  In studies on controlled  drinking,  abstinence was the best predictor of those who experienced the  fewest  adverse  consequences   from  alcohol  use following  controlled   drinking   exercises.  Moreover, the  mortality  from these  controlled  drinking  techniques during follow-up was high among the study participants.   Carefully  constructed   studies  of actual alcoholics revealed that once loss of control over alcohol use manifested itself, the return to controlled drinking was not possible. Thus, abstinence is required to prevent adverse consequences from alcohol once alcohol dependence is established in individuals.

Importantly, behavioral approaches that employ the 12-step  approach  to the  treatment  of alcohol  dependence show significant abstinence rates from alcohol. These approaches incorporate cognitive behavioral management  with a focus on alcoholism  as an independent disease that responds to treatment  and recovery methods over time. Typically, treatment of alcoholism occurs in inpatient  and outpatient  settings following detoxification from alcohol and concentrates on  increasing  the  individual’s ability to refrain  from relapse to alcohol and to maintain the abstinent state.

Outcome  studies  show  that  following a treatment experience in a structured  inpatient or outpatient treatment program,  60% of patients  achieve abstinence  at 1 year no matter what follow-up care they may receive. However,  they  achieve  abstinence   rates  of  70%  if they attend continuing  care in the treatment  program (20–30%) or attend 12-step groups regularly (50% attended  at least one AA meeting per week). In addition, they improve their abstinence rates to 80% if they both receive continuing  care and attend AA meetings.

7. Long-Term Recovery From Alcoholism

Although   spontaneous    recovery   from   alcoholism occurs, the only assurance of long-term abstinence supported  by empirical data and clinical experience is continuous  attendance  in AA. Surveys of its members reveal an 83% probability  of abstinence  for the  next year if an individual is abstinent between 1 and 5 years with regular attendance of at least one AA meeting per week and a 91% probability of an additional year if the individual is abstinent in AA for more than 5 years.

Clinical experience shows that relapse to alcohol use is very uncommon  for someone who attends AA meetings regularly, particularly  after being abstinent in AA for more than a year. However, for those who relapse, their attendance  at AA meetings had ceased for a substantial  period  prior  to  the  relapse,  typically  years before the actual relapse to alcohol use. Also, use of other addicting drugs, such as cocaine, cannabis, heroin, and nicotine, and/or use of addicting medications, such as opiate analgesics and benzodiazepines,  render continuous abstinence difficult and reliably predict relapse to alcohol.

8. Beneficial Versus Harmful Effects Of Alcohol

Some studies  have  indicated  a  modest  but  positive effect of reducing the risk of cardiovascular disease or heart  attacks in those who regularly consume  one to two drinks  of alcohol per day. These studies are featured in influential medical journals, implicating alcohol as a therapeutic  agent. Despite the overwhelming evidence of the  harmful  effects of alcohol  on health, these studies advocate the use of alcohol without instructing  individuals  about its untoward  or adverse effects.

For instance, studies show that the same amount of alcohol that is described to be beneficial (one or two drinks  per  day) will significantly reduce  intelligence quotients (IQs), resulting in poor attention,  poor concentration,  and impaired  short-term  memory. Studies of alcoholics show that chronic alcohol use causes reduced  cognitive capacities that tend to reverse with abstinence from alcohol. Importantly, the reduced IQs correlated   with  the  age  of  the  drinker;   thus,   the intended  audience  for putative  efficacy on  incidence of heart  disease is those who are at high risk for the dementing properties of alcohol—namely older adults.

9. Prevention Of Alcohol Use And Problems

Currently,  our  public  health  policy and  controls  for alcohol consumption  are archaic and counterproductive.  The  example  of  advocating  alcohol  to  reduce heart  disease  in  high-risk  populations   is  indicative. Thus, alcohol abuse is not commonly thought  of as a health issue but rather is regarded as a legal and moral issue. The policies usually do not  support  educating young people and adults on the responsible use and the potential  pitfalls and risks of alcohol use, particularly by those at high risk. Most discussions  focus on the legal age for drinking  and the legal limit of intoxication.  Not  well discussed  are  that  80% of homicides occur  in the  setting  of alcohol  and  that  alcohol  use and dependence  is the leading risk factor for suicide at any age.

Despite these well-established adverse consequences and  firm  knowledge  that  onset  of  alcohol  use  and alcohol problems occur at young ages, there is blatant advertising clearly and convincingly targeted  to these high-risk  populations.  Our controls  over exposure  to alcohol for vulnerable populations,  and our education in elementary, middle, and high schools, are woefully lacking if we are to protect these vulnerable and at-risk populations.  Currently,  we do not hold  producers  of alcohol accountable for the high rate of alcohol-related consequences  (in  the  billions  of dollars)  due  to our lack  of policy  to  protect  the  public  against  adverse consequences from alcohol use.

Bibliography:

1. Grant, B. F. (1997). Prevalence and correlates of alcohol use and DSM-IV alcohol  dependence  in  the  United  States: Results  of  the  National  Longitudinal   Alcohol Epidemiologic  Journal of Studies in Alcohol, 58, 464–473.
2. McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance,  and outcomes evaluation.  Journal of the American Medical Association, 284, 1689–1695.
3. Miller, N. S., & Goldsmith, R. J. (2001). Craving for alcohol and drugs in animals and humans: Biology and behavior. Journal of Addictive Diseases, 20, 87–104.

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