What Is Alcoholism?
What Causes Alcoholism?
Who Becomes an Alcoholic?
How Serious Is Alcoholism?
How Is Alcoholism Diagnosed?
What Is the Treatment for Alcohol Withdrawal?
What Are the Long-Term Treatments for Alcoholism?
Why Do People with Alcoholism Relapse?
Where Else Can Help Be Obtained for Alcoholism?
What Is Alcoholism?
Alcoholism is a chronic disease, progressive and often fatal; it is a primary
disorder and not a symptom of other diseases or emotional problems. The
chemistry of alcohol allows it to affect nearly every type of cell in the
body, including those in the central nervous system. In the brain, alcohol
interacts with centers responsible for pleasure and other desirable sensations.
After prolonged exposure to alcohol, the brain adapts to the changes alcohol
makes and becomes dependent on it. For people with alcoholism, drinking
becomes the primary medium through which they can deal with people, work,
and life. Alcohol dominates their thinking, emotions, and actions. The
severity of this disease is influenced by factors such as genetics, psychology,
culture, and response to physical pain.
Alcoholism can develop insidiously; often there is no clear line between
problem drinking and alcoholism [see Box, below]. The only early
indications of alcoholism may be the unpleasant physical responses to withdrawal
that occur during even brief periods of abstinence. Sometimes people experience
long-term depression or anxiety, insomnia, chronic pain, or personal or
work stress that lead to the use of alcohol for relief, but often no extraordinary
events have occurred that account for the drinking problem.
Alcoholics have little or no control over the quantity they drink or
the duration or frequency of their drinking. They are preoccupied with
drinking, deny their own addiction, and continue to drink even though they
are aware of the dangers. Over time, some people become tolerant to the
effects of drinking and require more alcohol to become intoxicated, creating
the illusion that they can "hold their liquor." They have blackouts after
drinking and frequent hangovers that cause them to miss work and other
normal activities. Alcoholics might drink alone and start early in the
day. They periodically quit drinking or switch from hard liquor to beer
or wine, but these periods rarely last. Severe alcoholics often have a
history of accidents, marital and work instability, and alcohol-related
health problems. Episodic violent and abusive incidents involving spouses
and children and a history of unexplained or frequent accidents are often
signs of drug or alcohol abuse.
Alcohol Use and Abuse
Experts define levels of alcohol use and abuse as follows (with a drink
defined as 12-oz of beer, 6 oz of wine, or 1.5 oz of 90-proof liquor):
Moderate drinking: equal to or less than two drinks a day for
men and equal to or less than one drink a day for women.
At-risk drinking: more than 14 drinks per week or 4 drinks at
one sitting for men and more than seven drinks a week or three drinks at
one sitting for women.
Alcohol abuse: one or more of the following alcohol-related problems
over a period of one year: failure to fulfill work or personal obligations;
recurrent use in potentially dangerous situations; problems with the law;
and continued use in spite of harm being done to social or personal relationships.
Alcohol dependence: The individual experiences three or more
of the following alcohol-related problems over a period of one year: increased
amounts of alcohol needed to produce an effect; withdrawal symptoms; drinking
more over a given period than intended; unsuccessful attempts to quit or
cut down; giving up significant leisure or work activities; continuing
drinking in spite of the knowledge of its physical or psychological harm
to oneself or others.
What Causes Alcoholism?
People have been drinking alcohol for perhaps 15,000 years. Just drinking
steadily and consistently over time can cause a sense of dependence and
withdrawal symptoms during periods of abstinence; this physical dependence,
however, is not the sole cause of alcoholism. To develop alcoholism, other
factors usually come into play, including biology and genetics, culture,
Brain Chemistry and Genetic Factors.
The craving for alcohol during abstinence, the pain of withdrawal, and
the high rate of relapse are due to the brain's adaptation to and dependence
on the changes in its own chemistry caused by long term use of alcohol.
Alcohol causes relaxation and euphoria but also acts as a depressant on
the central nervous system. Even after years of research, experts still
do not know exactly how alcohol affects the brain or how the brain affects
alcoholism. Alcohol appears to have major effects upon the hippocampus,
an area in the brain associated with learning and memory and the regulation
of emotion, sensory processing, appetite, and stress. Alcohol breaks down
into products called fatty acid ethyl esters, which appear to inhibit important
neurotransmitters (chemical messengers in the brain) in the hippocampus.
Of particular importance to researchers of alcoholism are the neurotransmitters
gamma aminobutyric acid (GABA), dopamine, and serotonin, which are strongly
associated with, emotional behavior and cravings. Research indicates that
dopamine transmission, particularly, is strongly associated with the rewarding
properties of alcohol, nicotine, opiates, and cocaine. Investigators have
focused on nerve-cell structures known as dopamine D2 receptors (DRD2),
which influence the activity of dopamine. Mice with few of these receptors
show low interest in and even aversion to alcohol.
In people with severe alcoholism, researchers have located a gene that
alters the function of DRD2. This gene is also found in people with attention
deficit disorder, who have an increased risk for alcoholism, and in people
with Tourette's syndrome and autism. One major study, however, found no
connection at all between the DRD2 gene and alcoholism. More work in this
area is needed. Researchers are also investigating genes that regulate
certain enzymes known as kinases that affect alcohol uptake in the brain
as well as genes that affect serotonin. Even if genetic factors can be
identified, however, they are unlikely to explain all cases of alcoholism.
In fact, lack of genetic protection may play a role in alcoholism. Because
alcohol is not found easily in nature, genetic mechanisms to protect against
excessive consumption may not have evolved in humans as they frequently
have for protection against natural threats.
Who Becomes an Alcoholic?
General Risks and Age.
Some population studies indicate that in a single year, between 7.4% and
9.7% of the population are dependent on alcohol, and between 13.7% and
23.5% of Americans are alcohol-dependent at some point in their lives.
A 1996 national survey reported that 11 million Americans are heavy drinkers
(five or more drinks per occasion on five or more days in a month) and
32 million engaged in binge drinking (five or more drinks on one occasion)
in the month previous to the survey. People with a family history of alcoholism
are more likely to begin drinking before the age of 20 and to become alcoholic.
But anyone who begins drinking in adolescence is at higher risk.
Currently 1.9 million young people between the ages of 12 and 20 are considered
heavy drinkers and 4.4 million are binge drinkers. Although alcoholism
usually develops in early adulthood, the elderly are not exempt. In fact,
in one study, 15% of men and 12% of women over age 60 drank more than the
national standard for excess alcohol consumption. Alcohol also affects
the older body differently; people who maintain the same drinking patterns
as they age can easily develop alcohol dependency without realizing it.
Physicians may overlook alcoholism when evaluating elderly patients, mistakenly
attributing the signs of alcohol abuse to the normal effects of the aging
Most alcoholics are men, but the incidence of alcoholism in women has been
increasing over the past 30 years. About 9.3% of men and 1.9% of women
are heavy drinkers, and 22.8% of men are binge drinkers compared to 8.7%
of women. In general, young women problem drinkers follow the drinking
patterns of their partners, although they tend to engage in heavier drinking
during the premenstrual period. Women tend to become alcoholic later in
life than men, and it is estimated that 1.8 million older women suffer
from alcohol addiction. Even though heavy drinking in women
usually occurs later in life, the medical problems women develop because
of the disorder occur at about the same age as men, suggesting that women
are more susceptible to the physical toxicity of alcohol.
Family History and Ethnicity.
The risk for alcoholism in sons of alcoholic fathers is 25%. The familial
link is weaker for women, but genetic factors contribute to this disease
in both genders. In one study, women with alcoholism tended to have parents
who drank. Women who came from families with a history of emotional disorders,
rejecting parents, or early family disruption had no higher risk for drinking
than women without such backgrounds. A stable family and psychological
health were not protective in people with a genetic risk. Unfortunately,
there is no way to predict which members of alcoholic families are most
at risk for alcoholism.
Irish and Native Americans are at increased risk for alcoholism; Jewish
and Asian Americans are at decreased risk. Overall, there is no difference
in alcoholic prevalence between African Americans, whites, and Hispanic
people. Although the biological causes of such different risks are not
known, certain people in these population groups may be at higher or lower
risk because of the way they metabolize alcohol. One study of Native Americans,
for instance, found that they are less sensitive to the intoxicating effects
of alcohol. This confirms other studies, in which young men with alcoholic
fathers exhibited fewer signs of drunkenness and had lower levels of stress
hormones than those without a family history. In other words, they "held
their liquor" better. Experts suggest such people may inherit a lack of
those warning signals that ordinarily make people stop drinking. Many Asians,
on the other hand, are less likely to become alcoholic because of a genetic
factor that makes them deficient in aldehyde dehydrogenase, a chemical
used by the body to metabolize ethyl alcohol. In its absence, toxic substances
build up after drinking alcohol and rapidly lead to flushing, dizziness,
and nausea. People with this genetic susceptibility, then, are likely to
experience adverse reactions to alcohol and therefore not become
alcoholic. This deficiency is not completely protective against drinking,
however, particularly if there is added social pressure, such as among
college fraternity members. It is important to understand that, whether
it is inherited or not, people with alcoholism are still legally responsible
for their actions.
Severely depressed or anxious people are at high risk for alcoholism, smoking,
and other forms of addiction. Major depression, in fact, accompanies about
one-third of all cases of alcoholism. It is more common among alcoholic
women (and women in general) than men. Interestingly, one study indicated
that depression in alcoholic women may cause them to drink less than nondepressed
alcoholic women, while in alcoholic men, depression has the opposite effect.
Depression and anxiety may play a major role in the development of alcoholism
in the elderly, who are often subject to dramatic life changes, such as
retirement, the loss of a spouse or friends, and medical problems. Problem
drinking in these cases may be due to self-medication of the anxiety or
depression. It should be noted, however, that in all adults with alcoholism
these mood disorders may be actually caused by alcoholism and often
abate after withdrawal from alcohol.
Studies are finding that alcoholism is strongly related to impulsive, excitable,
and novelty-seeking behavior, and such patterns are established early on,
if not inherited. People with attention deficit hyperactivity disorder,
a condition that shares these behaviors, have a higher risk for alcoholism.
Children who later become alcoholics or who abuse drugs are more likely
to have less fear of new situations than others, even if there is a risk
for harm. In a test of mental functioning, alcoholics (mostly women) did
not show any deficits in thinking but they were less able to inhibit their
responses than nonalcoholics. It was once thought that a family history
of passivity and abnormal dependency needs increased the risk for alcoholism,
but studies have not borne out this theory.
It has been long thought that alcoholism is more prevalent in people with
lower educational levels and in those who were unemployed. A thorough 1996
study, however, reported that the prevalence of alcoholism among adult
welfare recipients was 4.3% to 8.2%, which was comparable to the 7.4% found
in the general population. There was also no difference in prevalence between
poor African Americans and poor whites. People in low-income groups did
display some tendencies that differed from the general population. For
instance, as many women as men were heavy drinkers. Excessive drinking
may be more dangerous in lower income groups; one study found that it was
a major factor in the higher death rate of people, particularly men, in
lower socioeconomic groups compared with those in higher groups.
Although 54% of urban adults use alcohol at least once a month compared
to 42% in nonurban areas, living in the city or the country does not affect
the risks for bingeing or heavy alcohol use. One study reported that people
in the north central U.S. are at highest risk for heavy drinking (6.4%
heavy use and 19% binge drinking) and those in the Northeast have the lowest
risk (4.5% heavy use and 13% binge drinking).
People who crave sugar may also be at higher risk for alcoholism. In one
recent study, 62% of male alcoholics enjoyed a sweet sugar solution compared
with only 21% of those without a drinking problem. It is not known, however,
whether having a "sweet tooth" can be an early predictor of alcoholism
or whether alcohol abusers simply develop a taste for sweetness as a result
of their chronic alcohol abuse.
How Serious Is Alcoholism?
About 100,000 deaths a year can be wholly or partially attributed to drinking
, and alcoholism reduces life expectancy by 10 to 12 years. Next to smoking,
it is the most common preventable cause of death in America. Although studies
indicate that adults who drink moderately (about one drink a day) have
a lower mortality rate than their non-drinking peers, their risk for untimely
death increases with heavier drinking. Any protection that occurs with
moderate alcohol intake appears to be confined to adults over 60 who have
risks for heart disease. The earlier a person begins drinking heavily,
the greater their chance of developing serious illnesses later on. Alcoholism
can kill in many different ways, and, in general, people who drink regularly
have a higher rate of deaths from injury, violence, and some cancers.
Alcohol overdose can lead to death. This is a particular danger for adolescents
who may want to impress their friends with their ability to drink alcohol
but cannot yet gauge its effects.
Accidents, Suicide, and Murder.
Alcohol plays a major role in more than half of all automobile fatalities.
Less than two drinks can impair the ability to drive. Alcohol also increases
the risk of accidental injuries from many other causes. One study of emergency
room patients found that having had more than one drink doubled the risk
of injury, and more than four drinks increased the risk eleven times. Another
study reported that among emergency room patients who were admitted for
injuries, 47% tested positive for alcohol and 35% were intoxicated. Of
those who were intoxicated, 75% showed evidence of chronic alcoholism.
This disease is the primary diagnosis in one quarter of all people who
commit suicide, and alcohol is implicated in 67% of all murders.
Domestic Violence and Effects on Family.
Domestic violence is a common consequence of alcohol abuse. Research suggests
that for women, the most serious risk factor for injury from domestic violence
may be a history of alcohol abuse in her male partner. Alcoholism
in parents also increases the risk for violent behavior and abuse toward
their children. Children of alcoholics tend to do worse academically than
others, have a higher incidence of depression, anxiety, and stress and
lower self-esteem than their peers. One study found that children who were
diagnosed with major depression between the ages of six and 12 were more
likely to have alcoholic parents or relatives than were children who were
not depressed. Alcoholic households are less cohesive, have more conflicts,
and their members are less independent and expressive than households with
nonalcoholic or recovering alcoholic parents. In addition to their own
inherited risk for later alcoholism, one study found that 41% of children
of alcoholics have serious coping problems that may be life long. Adult
children of alcoholic parents are at higher risk for divorced and for psychiatric
symptoms. One study concluded that the only events with greater psychological
impact on children are sexual and physical abuse.
Alcohol can affect the body in so many ways that researchers are having
a hard time determining exactly what the consequences are of drinking.
It is well known, however, that chronic consumption leads to many problems,
some of them deadly.
Heart Disease. Large doses of alcohol can trigger irregular heartbeats
and raise blood pressure even in people with no history of heart disease.
A major study found that those who consumed more than three alcoholic drinks
a day had higher blood pressure than teetotalers. The more alcohol someone
drank, the greater the increase in blood pressure. People who were binge
drinkers had the highest blood pressures. One study found that
binge drinkers (people who have nine or more drinks once or twice a week)
had a risk for a cardiac emergency that was two and a half times that of
nondrinkers. Chronic alcohol abuse can also damage the heart muscle, which
leads to heart failure; women are particularly vulnerable to this disorder.
Contrary to many previous reports, a recent study suggested that moderate
to heaving drinking (more than two bottles of beer or two glasses of wine
day) was a greater risk factor for coronary artery disease than smoking.
As in other studies, light drinking (two to six drinks a week) was protective.
More research is needed to confirm or refute this new study. In any case,
moderate drinking does not appear to offer any heart benefits for people
who are at low risk for heart disease to begin with.
Cancer. Alcohol may not cause cancer, but it probably does increase
the carcinogenic effects of other substances, such as cigarette smoke.
Daily drinking increases the risk for lung, esophageal, gastric, pancreatic,
colorectal, urinary tract, liver, and brain cancers, lymphoma and leukemia.
About 75% of cancers of the esophagus and 50% of cancers of the mouth,
throat, and larynx are attributed to alcoholism. (Wine appears to pose
less danger for these cancers than beer or hard liquor.) Smoking combined
with drinking enhances risks for most of these cancers dramatically. When
women consume as little as one drink a day, they may increase their chances
of breast cancer by as much as 30%.
Liver Disorders. The liver is particularly endangered by alcoholism.
About 10% to 35% of heavy drinkers develop alcoholic hepatitis, and 10%
to 20% develop cirrhosis. In the liver, alcohol converts to
an even more toxic substance, acetaldehyde, which can cause substantial
damage. Not eating when drinking and consuming a variety of alcoholic beverages
are also factors that increase the risk for liver damage. People with alcoholism
are also at higher risk for hepatitis B and C, potentially chronic liver
diseases than can lead to cirrhosis and liver cancer. People with alcoholism
should be immunized against hepatitis B; they may need a higher-than-normal
dose of the vaccine for it to be effective. [See also Well-Connected,
Report #59, Hepatitis.]
Gastrointestinal Problems. Alcohol can cause diarrhea and hemorrhoids.
Alcohol can also contribute to serious infections of the pancreas and to
ulcers in people taking the painkillers known as nonsteroidal anti-inflammatory
drugs (such as aspirin or ibuprofen).
Pneumonia and Other Infections. Alcohol suppresses the immune
system, so people with alcoholism are prone to infections. In particularly,
acute alcoholism is strongly associated with very serious pneumonia. One
study on laboratory animals suggests that alcohol specifically damages
the bacteria-fighting capability of lung cells.
Mental and Neurologic Disorders. Alcohol has widespread effects
on the brain. One study that scanned the brains of inebriated subjects
suggested that while alcohol stimulates those parts of the brain related
to reward and induces euphoria, it does not appear to impair cognitive
performance (the ability to think and reason). Habitual use of alcohol,
however, eventually produces depression and confusion. In chronic cases,
gray matter is destroyed, possibly leading to psychosis and mental disturbances.
Alcohol can also cause milder neurologic problems, including insomnia and
headache (especially after drinking red wine). Except in severe
cases, neurologic damage is not permanent and abstinence nearly always
leads to recovery of normal mental function. Alcohol may increase the risk
for hemorrhagic stroke (caused by bleeding in the brain), although it may
protect against stroke caused by narrowed arteries.
Skin, Muscle, and Bone Disorders. Severe alcoholism is associated
with osteoporosis, wasting away of muscles with swelling and pain, skin
sores, and itching. In addition, alcohol-dependent women seem to face an
increased risk for damage to muscles, including muscles of the heart, from
the toxic effects of alcohol.
Hormonal Effects. Alcoholism increases levels of the female hormone
estrogen and reduces levels of the male hormone testosterone, factors that
contribute to impotence in men.
Smoking. Alcoholics who smoke face compound their health problems.
More alcoholics die from tobacco-related illnesses, such as heart disease
or cancer, than from chronic liver disease, cirrhosis, or other conditions
more directly tied to excessive drinking.
Diabetes. Alcohol can cause hypoglycemia, a drop in blood sugar,
which is especially dangerous for people with diabetes who are taking insulin.
Intoxicated diabetics may not be able to recognize symptoms of hypoglycemia,
a particularly hazardous condition.
Malnutrition and Wernicke-Korsakoff Syndrome. A pint of whiskey
provides about half the daily calories needed by an adult, but it has no
nutritional value. In addition to replacing food, alcohol may also interfere
with absorption of proteins, vitamins, and other nutrients. Of particular
concern in alcoholism is a severe deficiency in the B-vitamin thiamin,
which can cause a serious condition called Wernicke-Korsakoff syndrome.
Symptoms of this syndrome include severe loss of balance, confusion, and
memory loss. Eventually, it can result in permanent brain damage and death.
Another serious nutritional problem among alcoholics is deficiency of the
B vitamin folic acid, which can cause severe anemia.
Acute Respiratory Distress Syndrome. One study indicated that
intensive care patients with a history of alcohol abuse have a significantly
higher risk for developing acute respiratory distress syndrome (ARDS) during
hospitalization. ARDS is a form of lung failure that can be fatal. It is
can by caused by many of the medical conditions common in chronic alcoholism,
including severe infection, trauma, blood transfusions, pneumonia, and
other serious lung conditions.
Drug Interactions. The effects of many medications are strengthened
by alcohol, while others are inhibited. Of particular importance is its
reinforcing effect on antianxiety drugs, sedatives, antidepressants, and
antipsychotic medications. Alcohol also interacts with many drugs used
by diabetics. It interferes with drugs that prevent seizures or blood clotting.
It increases the risk for gastrointestinal bleeding in people taking aspirin
or other nonsteroidal inflammatory drugs including ibuprofen and naproxen.
In other words, taking almost any medication should preclude drinking alcohol.
Pregnancy and Infant Development.
Even moderate amounts of alcohol may have damaging effects on the developing
fetus, including low birth weight and an increased risk for miscarriage.
High amounts can cause fetal alcohol syndrome, which can result in mental
and growth retardation. One study indicates a significantly higher risk
for leukemia in infants of women who drink any type of alcohol during pregnancy.
Complications in Older People.
As people age, it takes fewer drinks to become intoxicated, and organs
can be damaged by smaller amounts of alcohol than in younger people. Also,
up to one-half of the 100 most prescribed drugs for older people react
adversely with alcohol.
How Is Alcoholism Diagnosed?
Even when people with alcoholism experience withdrawal symptoms, they nearly
always deny the problem, leaving it up to coworkers, friends, or relatives
to recognize the symptoms and take the first steps toward treatment.
Family members cannot always rely on a physician to make an initial
diagnosis. Although 15% to 30% of people who are hospitalized suffer from
alcoholism or alcohol dependence, physicians often fail to screen for the
problem. In addition, doctors themselves often cannot recognize the symptoms.
In one study, alcohol problems were detected by the physician in less than
half of patients who had them. It is particularly difficult to diagnose
alcoholism in the elderly, where symptoms of confusion, memory loss, or
falling may be attributed to the aging process alone. Heavy drinkers may
be more likely to complain to their doctors about so-called somatization
symptoms, which are vague ailments such as joint pain, intestinal problems,
or general weakness, that have no identifiable physical cause. Such complaints
should signal the physician to follow-up with screening tests for alcoholism.
Alcoholism is particularly less likely to be recognized in elderly women.
In fact, only 1% of older women who need treatment for alcoholism are diagnosed
accurately and treated appropriately. Instead, they are often diagnosed
with depression and may even be prescribed anti-anxiety drugs or antidepressants
that can have dangerous interactions with alcohol. Even when physicians
identify an alcohol problem, however, they are frequently reluctant to
confront the patient with a diagnosis that might lead to treatment for
Screening for Alcoholism.
A physician who suspects alcohol abuse should ask the patient questions
about current and past drinking habits to distinguish moderate from heavy
drinking. If alcohol abuse or dependency is indicated, the physician will
usually perform a screening test. Many are available for diagnosing alcoholism,
usually either standardized questionnaires that the patient can take on
their own or that are conducted by the physician. Because people with alcoholism
often deny their problem or otherwise attempt to hide it, the tests are
designed to elicit answers related to problems associated with drinking
rather than the amount of liquor consumed or other specific drinking habits.
The quickest test takes only one minute; it is called the CAGE test, an
acronym for the following questions: (C) attempts to Cut down on drinking;
(A) Annoyance with criticisms about drinking; (G) Guilt about drinking;
and (E) use of alcohol as an Eye-opener in the morning. This test and another
called the Self-Administered Alcoholism Screening Test (SAAST), however,
appear to be most useful in detecting alcoholism in white middle-aged males.
They are not very accurate for identifying alcohol abuse in older people,
white women, and African- and Mexican-Americans. A more effective test
for such individuals may be the Alcohol Use Disorders Identification Test
(AUDIT), which asks three questions about amount and frequency of drinking,
three questions about alcohol dependence, and four questions about problems
related to alcohol consumption. Other short screening tests are the Michigan
Alcoholism Screening Test (MAST) and The Alcohol Dependence Scale (ADS)
Laboratory and Other Tests.
Tests for alcohol levels in the blood are not useful for diagnosing alcoholism
because they reflect consumption at only one point in time and not long-term
usage. A mean corpuscular volume (MCV) blood test is sometimes used to
measure the size of red blood cells, which increase with alcohol use over
time. A test for a factor known as carbohydrate-deficient transferrin may
prove to be fairly accurate indicator of heavy drinking. A physical examination
and other tests should be performed to uncover any related medical problems.
Sometimes the results of tests that detect other problems, such as blood
tests reporting liver damage or low testosterone levels in men, can persuade
alcoholics to seek help.
Getting the Patient to Seek Treatment.
Once a diagnosis of alcoholism is made, the next major step is getting
the patient to seek treatment. One study reported that the main reasons
alcoholics do not seek treatment are lack of confidence in successful therapies,
denial of their own alcoholism, and the social stigma attached to the condition
and its treatment. Studies have found that even a brief intervention (e.g.,
several fifteen-minute counseling sessions with a physician and a follow-up
by a nurse) can be very effective in reducing drinking in heavy drinkers
who are not yet dependent. However, the best approaches are group meetings
between people with alcoholism and their friends and family members who
have been affected by the alcoholic behavior. Using this interventional
approach, each person affected offers a compassionate but direct and honest
report describing specifically how he or she has been specifically hurt
by their loved one's or friend's alcoholism. Children may even be involved
in this process, depending on their level of maturity and ability to handle
the situation. The family and friends should express their affection for
the patient and their intentions for supporting the patient through recovery,
but they must strongly and consistently demand that the patient seek treatment.
Employers can be particularly effective. Their approach should also be
compassionate but strong, threatening the employee with loss of employment
if he or she does not seek help. Some large companies provide access to
inexpensive or free treatment programs for their workers.
The alcoholic patient and everyone involved should fully understand
that alcoholism is a disease and that the responses to this diseaseneed,
craving, fear of withdrawalare not character flaws but symptoms, just as
pain or discomfort are symptoms of other illnesses. They should also realize
that treatment is difficult and sometimes painful, just as treatments for
other life-threatening diseases, such as cancer, are, but that it is the
only hope for a cure.
What Is the Treatment for Alcohol
Symptoms of Withdrawal.
When a person with alcoholism stops drinking, withdrawal symptoms begin
within six to 48 hours and peak about 24 to 35 hours after the last drink.
During this period the inhibition of brain activity caused by alcohol is
abruptly reversed. Stress hormones are over-produced and the central nervous
system becomes over-excited. About 5% of alcoholic patients experience
delirium tremens, which usually develops two to four days after the last
drink. Symptoms include fever, rapid heart beat, either high or low blood
pressure, extremely aggressive behavior, hallucinations, and other mental
Treatment of Withdrawal Symptoms.
Upon entering a hospital, patients should be given a physical examination
for any injuries or medical conditions and should be treated for any potentially
serious problems, such as high blood pressure or irregular heartbeat. The
immediate goal of treatment is to calm the patient as quickly as possible.
Patients are usually given one of the anti-anxiety drugs known as benzodiazepines,
which relieve withdrawal symptoms and help prevent progression to delirium
tremens. An injection of the B vitamin thiamine may be given to prevent
Wernicke-Korsakoff syndrome. Patients should be observed for at least two
hours to determine the severity of withdrawal symptoms. Physicians may
use assessment tests, such as the Clinical Institute Withdrawal
Assessment Scale (CIWA), to help determine treatment and whether the symptoms
will progress in severity. Older people with alcoholism are not at higher
risk for more severe symptoms than younger patients, but they may suffer
more complications during withdrawal, including delirium, falls, and a
decreased ability to perform normal activities.
Treatment for Mild to Moderate Withdrawal Symptoms.
About 95% of people have mild to moderate withdrawal symptoms, including
agitation, trembling, disturbed sleep, and lack of appetite. In 15% to
20% of people with moderate symptoms, brief seizures and hallucinations
may occur, but they do not progress to full-blown delirium tremens. Such
patients can nearly always be treated as outpatients. After being examined
and observed, the patient is usually sent home with a four-day supply of
anti-anxiety medication, scheduled for follow-up and rehabilitation, and
advised to return to the emergency room if withdrawal symptoms become severe.
If possible, a family member or friend should support the patient through
the next few days of withdrawal.
Treatment for Delirium Tremens, Seizures, and Other Severe Symptoms.
People with symptoms of delirium tremens must be treated immediately. Untreated
delirium tremens has a fatality rate that can be as high as 20%. They are
usually first given intravenous anti-anxiety medications and their physical
condition is stabilized. It is extremely important that fluids be administered.
Restraints may be necessary to prevent injury to themselves or others.
Seizures are usually self-limited and treated only with a benzodiazepine.
Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used
in patients who have a history of seizures, who have epilepsy, or whose
seizures cannot be controlled. Because phenytoin may lower blood pressure,
the patient's heart should be monitored during treatment. For hallucinations
or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol
(Haldol), may be administered. Lidocaine (Xylocaine) may be given to people
with disturbed heart rhythms.
Drugs Used for Mild to Moderate Withdrawal Symptoms.
Benzodiazepines. Benzodiazepines are anti-anxiety drugs that inhibit
nerve-cell excitability in the brain. They relieve withdrawal symptoms
and make it easier for patients to remain in treatment. The drugs may be
administered intravenously or orally, depending on the severity of symptoms.
For most adults with alcoholism, the longer-acting drugs, such as diazepam
(Valium) or chlordiazepoxide (Librium), are usually prescribed. To prevent
seizures, the physician may give the patient an initial, or loading, dose
of the long-acting drug diazepam with additional doses given every one
to two hours thereafter over the period of withdrawal. This regimen can
cause very heavy sedation. People with serious medical problems, particularly
respiratory disorders, may be given repeated doses of shorter-acting benzodiazepines,
such as lorazepam (Ativan) and oxazepam (Serax); these drugs can be withdrawn
immediately at any sign of trouble. Some physicians question the use of
any anti-anxiety medication for mild withdrawal symptoms. Others believe
that repeated withdrawal episodes, even mild forms, that are inadequately
treated may result in increasingly severe episodes with seizures and possible
Benzodiazepines are usually not prescribed for more than two weeks or
administered for more than three nights per week. Tolerance to these drugs
may develop after as little as four weeks of daily use. Physical dependence
may develop after just three months of normal dosage. People who discontinue
benzodiazepines after taking them for long periods may experience rebound
symptomssleep disturbance and anxietywhich can develop within hours or
days after stopping the medication. Some patients experience withdrawal
symptoms from the drugs, including stomach distress, sweating, and insomnia,
that can last from one to three weeks. Common side effects are day-time
drowsiness and a hung-over feeling. Respiratory problems may be exacerbated.
Benzodiazepines are potentially dangerous when used in combination with
alcohol. They should not be used by pregnant women or nursing mothers unless
Other Drugs for Mild to Moderate Withdrawal. Beta blockers, such
as propranolol (Inderal) and atenolol (Tenormin), may sometimes be used
in combination with a benzodiazepine. This class of drugs is effective
in slowing heart rate and reducing tremor. Other drugs being tested are
clonidine (Catapres) and carbamazepine (Tegretol). When used by themselves,
they do not, however, appear to be effective in reducing seizures or delirium.
Chlormethiazole, a derivative of vitamin B1, is presently used in Europe
and is showing promise in reducing agitation and seizures.
What Are the Long-Term Treatments
The two basic goals of long-term treatment are total abstinence and replacement
of the addictive patterns with satisfying, time-filling behaviors that
can fill the void in daily activity that occurs when drinking has ceased.
Some studies have reported that some people who are alcohol dependent can
eventually learn to control their drinking and do as well as those who
remain abstinent. There is no way to determine, however, which people can
stop after one drink and which cannot. Alcoholics Anonymous and other alcoholic
treatment groups whose goal is strict abstinence are greatly worried by
the publicity surrounding these studies, since many people with alcoholism
are eager for an excuse to start drinking again. At this time, abstinence
is the only safe route.
Inpatient versus Outpatient Treatment.
People with mild to moderate withdrawal symptoms are usually treated as
outpatients and assigned to support groups, counseling, or both. Inpatient
treatment in a general or psychiatric hospital or in a center dedicated
to treatment of alcohol and other substance abuse is recommended for patients
with a coexisting medical or psychiatric disorder and those who may harm
themselves or others, who have not responded to conservative treatments,
or who have a disruptive home environment. A typical inpatient regimen
includes a physical and psychiatric work-up, detoxification, treatment
with psychotherapy or cognitive-behavioral therapy, and an introduction
to Alcoholics Anonymous. Because of the high cost of inpatient care, its
advantages over outpatient care are currently being questioned. One study
compared employed alcoholics who were either hospitalized, treated as outpatients
with compulsory attendance at AA meetings, or allowed to choose their own
treatment optionincluding none at all. After two years, everyone experienced
fewer job problems, but those in the inpatient group had significantly
fewer rehospitalizations and remained abstinent longer than people in the
other two groups. Another study analyzing drug and alcohol treatment programs
found that 75% of inpatients completed therapy compared to only 18% of
outpatients. Other studies, however, have shown no difference in results
between inpatient and outpatient programs, and in one, the costs for AA
were 45% lower than other outpatient options. Studies have attempted to
uncover characteristics that might make people more likely to drop out
of either outpatient or inpatient programs. One study found that people
who drop out of outpatient treatments are more apt to be female, young,
unskilled, or have more than one addiction. Another reported that those
who leave inpatient treatment against medical advice tend to have jobs,
to be college educated, and have a history of leaving treatment.
Psychotherapy and Cognitive-Behavioral Therapy.
The two usual forms of therapy for alcoholics are cognitive-behavioral
and interactional group psychotherapy based on the Alcoholics Anonymous
12-step program. In one study, all treatment approaches were, on average,
equally effective as long as the individual program was competently administered.
Those with fewer psychiatric problems, however, did best with the AA approach.
This confirms an earlier study in which researchers categorized alcoholics
as either Type A or Type B. Type A individuals became alcoholic at a later
age, had less severe symptoms or fewer psychiatric problems, and had a
better outlook on life than those with Type B. The people in the Type A
group did well with the 12-step approach. They did not do as well with
cognitive-behavioral therapy. Type B people became alcoholic at an early
age, had a high family risk for alcoholism, more severe symptoms, and a
negative outlook on life. This group did poorly with interactional group
therapy but tended to do better with cognitive-behavioral therapy. This
difference in response to the two forms of treatments held up after two
Interactional Group Psychotherapy (12-Step Program). Alcoholics
Anonymous (AA), founded in 1935, is an excellent example of interactional
group psychotherapy and remains the most well-known program for helping
people with alcoholism. It offers a very strong support network using group
meetings open seven days a week in locations all over the world. A buddy
system, group understanding of alcoholism, and forgiveness for relapses
are AA's standard methods for building self-worth and alleviating feelings
of isolation. AA's 12-step approach to recovery includes a spiritual component
that might deter people who lack religious convictions. Prayer and meditation,
however, have been known to be of great value in the healing process of
many diseases, even in people with no particular religious assignation.
AA emphasizes that the "higher power" component of its program need not
refer to any specific belief system. Associated membership programs, Al-Anon
and Alateen, offer help for family members and friends.
Cognitive-Behavioral Therapy. Cognitive-behavioral therapy uses
a structured teaching approach and may be better than AA for severe alcoholism.
People with alcoholism are given instruction and homework assignments intended
to improve their ability to cope with basic living situations, control
their behavior, and change the way they think about drinking. For example,
patients might write a history of their drinking experiences and describe
what they consider to be risky situations. They are then assigned activities
to help them cope when exposed to "cues"places or circumstances that trigger
their desire to drink. Patients may also be given tasks that are designed
to replace drinking. An interesting and successful example of such a program
was one that enlisted patients in a softball team; this gave them the opportunity
to practice coping skills, develop supportive relationships, and engage
in healthy alternative activities. In one study of patients with both depression
and alcoholism, this therapeutic approach achieved 47% abstinence rates
after six months compared to only 13% abstinence in patients who received
standard treatments and relaxation techniques.
Medications to Aid in Abstinence.
Disulfiram. Disulfiram (Antabuse) causes distressing symptoms, including
flushing, headache, nausea, and vomiting, if a person drinks alcohol while
taking the drug. The symptoms can be triggered after drinking half a glass
of wine or half a shot of liquor and last from half an hour to two hours,
depending on dosage of the drug and the amount of alcohol consumed. One
dose of disulfiram is usually effective for one to two weeks. Overdose
can be dangerous, causing low blood pressure, chest pain, shortness of
breath, and even death. Studies have not shown the use of disulfiram to
have any effect on staying abstinent, although one study found that the
total number of drinking days was less in people who took the drug. The
drug may also be more effective in married patients or those with other
family members or caregivers, including AA "buddies", close by and vigilant
to ensure that they take it.
Naltrexone. Naltrexone (ReVia) appears to block the pleasurable
effects of alcohol and reduce cravings. When used with counseling or support
groups, studies indicate that it may be very effective for people with
low- to medium-risk for alcohol dependency. In one 10-week program, patients
who had been abstinent only 37% of the time increased this rate to 89%,
and the average number of drinks consumed when they did drink dropped from
9.5 to 2.5. The most common side effect of naltrexone is nausea, which
is usually mild and temporary. High doses cause liver damage. The drug
should not be administered to anyone who has used narcotics within a week
to 10 days.
Acamprosate. Acamprosate (Campral) calms the brain and
reduces cravings by inhibiting the transmission of the neurotransmitter
gamma aminobutyric acid (GABA). In one European study, 18% of patients
were still abstaining after a year compared to only 7% who did not take
the drug. Acamprosate is fully effective after about a week of treatment.
It may cause occasional diarrhea. At this time it is available only in
Europe but is being tested in America. It should be used along with counseling.
Combination therapy with naltrexone or disulfiram may be possible.
Antidepressant and Anti-anxiety Drugs. Depression is common among
alcohol-dependent people and can lead to a higher relapse rate. Antidepressants
may be helpful, particularly those that maintain elevated levels of serotonin
in the brain, since alcoholism has been associated with low serotonin levels.
Two studies have reported higher rates of abstinence, fewer heavy drinking
days, and fewer drinks in severe alcoholics who took fluoxetine (Prozac),
the most common antidepressant in a class known as serotonin reuptake inhibitors
(SSRIs). Other SSRIs include sertraline (Zoloft), paroxetine (Paxil), and
fluvoxamine (Luvox). Another small study reported that people given the
tricyclic antidepressant desipramine (Norpramin, Pertofrane)whether or
not they exhibited other symptoms of depressionhad fewer drinking days
and a longer period between relapses than those not taking the drug. A
unique anti-anxiety drug, buspirone (BuSpar), may also be beneficial for
alcoholics, particularly if they also suffer from anxiety. The drug has
few side effects and a low potential for abuse. It not only reduces anxiety,
but also appears to have modest effects on alcohol cravings. In one study,
alcoholics who took it had a slow return to alcohol consumption and fewer
drinking days than those not on the drug.
Other Drugs. Isradipine, a calcium channel blocker, reduced cravings
more effectively than naltrexone and the antidepressant paroxetine (Paxil)drugs
used to maintain abstinence. Calcium channel blockers are used to treat
high blood pressure and can have serious side effects, which should be
discussed with a physician. Another drug being investigated for withdrawal
and abstinence is gamma-hydroxybutyric acid (GHB). In one small
study, 58% of subjects remained abstinent during a six-month period. The
drug has a number of potentially very serious side effects, however.
Why Do People with Alcoholism
Between 80% and 90% of people treated for alcoholism relapseeven after
years of abstinence. Patients and their caregivers should understand that
relapses of alcoholism are analogous to recurrent flare-ups of chronic
physical diseases. One study found that three factors placed a person at
high risk for relapse: frustration and anger, social pressure, and internal
temptation. Treatment of relapses, however, does not always require starting
from scratch with detoxification or hospitalization; often, abstinence
can begin the next day. Self-forgiveness and persistence are behaviors
essential for permanent recovery.
Mental and Emotional Stress.
Alcohol blocks out emotional pain and is often perceived as a loyal friend
when human relationships fail. It is also associated with freedom and a
loss of inhibition that offsets the tedium of daily routines. When the
alcoholic tries to quit drinking, the brain seeks to restore what it perceives
to be its equilibrium. The brain's best weapons against abstinence are
depression and anxiety (the emotional equivalents of physical pain) that
continue to tempt alcoholics to return to drinking long after physical
withdrawal symptoms have abated. Even intelligence is no ally in this process,
for the brain will use all its powers of rationalization to persuade the
patient to return to drinking. It is important to realize that any life
change may cause temporary grief and anxiety, even changes for the better.
With time and the substitution of healthier pleasures, this emotional turmoil
weakens and can be overcome.
One of the most difficult problems facing a person with alcoholism is being
around people who are able to drink socially without danger of addiction.
A sense of isolation, a loss of enjoyment, and the ex-drinker's belief
that pitynot respectis guiding a friend's attitude can lead to loneliness,
low self-esteem, and a strong desire to drink. Close friends and even intimate
partners may have difficulty in changing their responses to this newly
sober person and, even worse, may encourage a return to drinking. To preserve
marriages to alcoholics, spouses often build their own self-images on surviving
or handling their mates' difficult behavior and then discover that they
are threatened by abstinence. Friends may not easily accept the sober,
perhaps more subdued, comrade. In such cases, separation from these "enablers"
may be necessary for survival. It is no wonder that, when faced with such
losses, even if they are temporary, a person returns to drinking. The best
course in these cases is to encourage close friends and family members
to seek help as well. Fortunately, groups such as Al-Anon exist for this
Social and Cultural Pressures.
The media portrays the pleasures of drinking in advertising and programming.
The medical benefits of light to moderate drinking are frequently publicized,
giving ex-drinkers the spurious excuse of returning to alcohol for their
health. These messages must be categorically ignored and acknowledged for
what they arean industry's attempt to profit from potential great harm
Where Else Can Help Be Obtained
General Service Office
475 Riverside Drive
New York, NY 10015
call (212-870-3400) or on the Internet (http://www.alcoholics-anonymous.org/)
Al-Anon Family Group Headquarters, Inc.
1600 Corporate Landing Pkwy
Virginia Beach, VA 23454-5617
Call (800-344-2666 in the US or 800-443-4525 in Canada) for meetings.
Or call (800-356-9996 in the US or 800-714-7498 in Canada) for literature
or on Internet (http://www.Al-Anon-Alateen.org/)
Al-Anon was started by the wife of the founder of Alcoholics Anonymous
to help families of alcoholics. They provide meetings established along
the lines of those of AA and educational material. Also available through
Al-Anon is Alateen, a support fellowship for adolescents affected by people
with alcoholism. (This group is not for teenagers with drinking problems.)
National Organization on Fetal Alcohol Syndrome
18 C Street North East
Washington, DC 20002
Call (202-785-4585 ) or on the Internet (http://www.nofas.org/)
National Clearinghouse of Alcohol and Drug Information
PO Box 2345
Rockville, MD 20852
Call (800-729-6686) or on the Internet (http://www.health.org/)
Offers many publications on alcohol and substance abuse.
PO Box 11
Center City, MN 55012-0011
Call (800-257-7800 or 1-651-257-4010 outside the U.S.) or on the Internet
Chemical dependency treatment center that provides educational materials
for adults and adolescents. Their web site is very useful.
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard - Willco Building
Bethesda, Maryland 20892-7003
On the Internet (http://www.niaaa.nih.gov/)
National Council on Alcoholism
12 West 21 Street
New York, NY 10010
Call (800-NCA-CALL) or on the Internet (http://www.ncadd.org/).
Their 800 number is a hotline that requires a touch-tone phone. A recorded
message provides local numbers for counseling, help, and information after
the caller keys in their zip code.
On the Internet:
Web of Addictions (http://www.well.com/user/woa/)
has good links and keeps up with current research.
is a private web site with good links to other sites on alcoholism.
Absence of opiate rewarding effects in mice lacking dopamine D2 receptors.
Alcohol and health. HealthNews, 3/31/98
Alcohol consumption and mortality among middle-aged and elderly U.S.
adults. The New England Journal of Medicine, 12/11/97
Alcoholic metabolism in Asian-American men with genetic polymorphisms
of aldehyde dehydrogenase. Annals of Internal Medicine, 9/1/97
Avoiding drug interactions. Harvard Health Letter, March 1998
Barriers to alcoholism treatment: reasons for not seeking treatment
in a general population sample. J Stud Alcohol 1997 Jul;58(4):365-71
Cognitive-behavioral treatment for depression in alcoholism. Journal
of Consulting Clinical Psychology, October 1997
Ethnic and sex bias in primary care screening tests for alcohol use
disorders. Annals of Internal Medicine, 9/1/98
Gender differences in comorbidly depressed alcohol-dependent outpatient.
Alcohol Clin Exp Res, December 1997
Hazards and benefits of alcohol. The New England Journal of Medicine,
Impact of age on the severity, course, and complications of alcohol
withdrawal. Archives of Internal Medicine, 10/27/97
The impact of alcohol-related diagnoses on pneumonia outcomes. Archives
of Internal Medicine, 7/14/97
Meta-analysis of randomized control trials addressing brief interventions
in heavy alcohol drinkers. Journal of General Internal Medicine, May 1997
Patients with alcohol problems. The New England Journal of Medicine,
A preliminary investigation of the management of alcohol dependence
with naltrexone by primary care providers. American Journal of Medicine,
Report on the first results from the annual 1996 National Household
Survey on Drug Abuse. National Clearinghouse of Alcohol and Drug Information.
Well-Connected reports are written and updated by experienced medical writers
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medical knowledge. A physician should always be consulted for any health
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Board of Editors
Harvey Simon, M.D., EditorinChief
Massachusetts Institute of Technology; Physician, Massachusetts General
Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital
John E. Godine, M.D., PhD, Metabolism
Harvard Medical School; Associate Physician, Massachusetts General
Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General
Hospital; Active Staff, Children's Hospital
Irene Kuter, M.D., D. Phil, Oncology
Harvard Medical School; Assistant Physician, Massachusetts General
Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General
Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation
Service, Massachusetts General Hospital
Carol Peckham, Editorial Director
Cynthia Chevins, Publisher
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