Alcoholism

December 1998

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, and psychology.

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 process.

Gender.

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.

Emotional Disorders.

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.

Personality Traits.

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.

Socioeconomic Factors.

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.

Geographic Factors.

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).

Sugar Cravings.

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.

Overdose.

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.

Medical Problems.

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 addiction.

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 Withdrawal?

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 disturbances.

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 brain damage.

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 absolutely necessary.

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 for Alcoholism?

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 years.

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 Relapse?

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.

Codependency.

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 purpose.

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 to individuals.

Where Else Can Help Be Obtained for Alcoholism?

Alcoholics Anonymous
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.

Hazelden Foundation
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 (http://www.hazelden.org/)
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.
Recovery (http://www.recovery.org/aa/) is a private web site with good links to other sites on alcoholism.

Recent Literature

Absence of opiate rewarding effects in mice lacking dopamine D2 receptors. Nature, 8/7/97

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, 12/11/97

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, 2/26/98

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.

About Well-Connected

Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.

Board of Editors

Harvey Simon, M.D., Editor­in­Chief
Massachusetts Institute of Technology; Physician, Massachusetts General Hospital

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 Hospital

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 Hospital

Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

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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