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Practically everyone has consumed alcohol in his or her lifetime. Fully 90% of the U.S. population has had at least one alcohol-containing beverage. In addition, 30% of the population drinks regularly with adverse consequences (15% develops alcohol dependence and another 15% drinks heavily). Costs due to problems from alcohol use and dependence reach $100 billion annually in the United States. Despite the available knowledge about the etiology and course of alcohol consumption, the costs from adverse consequences continue to rise each year for a wide range of age groups (including children, adults, and the elderly), most ethnicities and cultures, and both genders.
- Who Becomes Alcoholic?
- Other Drug Use Associated with Alcohol Dependence
- Dependence Syndrome and Screening Instruments
- Alcoholism Treatment: Pharmacological Approaches
- Psychiatric and Medical Complications
- Alcoholism Treatment: Behavioral Approaches
- Long-Term Recovery from Alcoholism
- Beneficial Versus Harmful Effects of Alcohol
- 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
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.
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