Alcoholism

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Alcoholism is a multifactorial condition based upon possibly both genetic and environmental factors which is best explained as a continued detrimental use of alcohol or other sedatives despite one's best interest. It is a form of addiction, where addiction is defined as "compulsive drug use despite negative consequences" (Am J Psychiatry 2005; 162:1414-1422).

Discussion

The use of alcohol in this condition leads to impact upon physical, occupational, marital, educational, and other areas of function, despite which the individual continues to drink. The condition can be lifelong and can be sometimes treated through ongoing therapy accompanied by attendance at self-help meetings. Although medications have been developed to assist in the treatment of alcoholism, the research has not yet demonstrated long term efficacy for any specific methods of treatment. Alcoholics do not typically experience craving, unlike individuals afflicted with opioid dependence. Of importance is that frequency and quantity of alcohol use are not related to alcoholism; that is, individuals can drink a great deal without necessarily being alcoholic, and alcoholics may drink minimally and/or infrequently. As described in Psychiatric Annals by Pagano et al (June 2005), "alcoholism is a chronic, often progressive disease that can be fatal without intervention and treatment. Rationing or other attempts to control use fail as pathological attachment to the drug develops. Use continues despite serious adverse health, personal, work-related, and financial consequences. Comorbidity, genetic, and psychosocial factors contribute to the risk of developing this disease." The lifetime prevalence of thiis condition was estimated in the mid-1990s at approximately 15% (DSM-IV-TR).

It is critical in a discussion of alcoholism to understand the terminology used in the field. There are many terms, such as use, misuse, heavy use, addiction, abuse, dependence, all of which have different and sometimes non-standard meanings. Use refers to simple use of a substance. An individual who drinks a beer once a day uses alcohol. Misuse and Heavy Use do not have standard definitions in the field. Addiction has two meanings: the first is that of an individual who develops tolerance to the use of a substance (needs more of the substance to achieve the same effect received from a lesser dose at an earlier point in time) or withdrawal effects upon discontinuing use. The second definition of addiction is the one given at the start of the first paragraph. The first definition refers to physiologic dependence, something which for certain drugs can be created in anyone taking the drug. The second refers to the "disease" state of interest to readers of this section, and which cannot be created in an individual simply through use of the drug. Psychiatrists and some others refer to the second definition of addiction as dependence. This is where frequent confusion arises since physiologic dependence does not imply the existence of the disease state which psychiatrists call dependence. For example, a test subject might be given alcohol in increasing amounts each day to the extent that the individual would have severe withdrawal if the alcohol were suddenly stopped; in this case, physiologic dependence has formed, but no disease is present. Similarly, an alcoholic in recovery is not drinking at all yet still has the condition just as a diabetic who keeps his blood glucose at precisely 100 (normal) all the time is still diabetic. Neither individual would be likely to suffer significant symptoms secondary to their ongoing illness, yet both are still afflicted.

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"King Alcohol and his Prime Minister" circa 1820

Diagnosis

There have been many efforts at diagnostic approaches to alcoholism.

In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

The DSM IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism, one more closely based on specifics than the 1992 JAMA article. In part this is to assist in the development of research protocols in which findings can be compared with one another, but the DSM definition is the one in general use from a diagnostic standpoint. That definition is: Maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: Tolerance; Withdrawal; Taken in greater amounts or over longer time course than intended; Desire or unsuccessful attempts to cut down or control use; Great deal of time spent obtaining, using, or recovering from use; Social, occupational, or recreational activities given up or reduced; Continued use despite knowledge of physical or psychological sequelae.

Note that many sedative agents are cross-tolerant with alcohol (meaning that these agents can be taken instead of alcohol to relieve withdrawal symptoms or to maintain the level of sedation provided by alcohol). A more general diagnosis than alcohol dependence is that of sedative dependence. Whether an individual uses alcohol or another sedative, if they meet the criteria above, the process is likely the same.

Biological mechanism

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

As a "disease"

The American Society of Addiction Medicine and the American Medical Association both maintain extensive policy regarding alcoholism. The American Psychiatric Association recognizes the existence of "alcoholism" as the equivalent of alcohol dependence. With the publication of the DSM-III in 1980, two separate syndromes of alcohol dependence and alcohol abuse replaced the earlier category of alcoholism. The World Health Organization dropped the diagnostic category "alcoholism" in 1979, replacing it with the diagnostic categories "alcohol dependence" and "harmful use" (ICD-9, ICD-10)[1]. The American Hospital Association, the American Public Health Association, the National Association of Social Workers, and the American College of Physicians classify "alcoholism" as a disease.

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

The causes for alcohol abuse and dependence cannot be easily explained. However, the belief that the roots are from moral or ethical weakness on the part of the sufferer has been largely altered. A 1995 Gallup Poll found that 90% of Americans currently believe that "alcoholism" is a disease.^{[How to reference and link to summary or text]}

In contrast, in a 1988 U.S. Supreme Court decision on whether alcoholism is a condition for which the U.S. Veterans Administration should provide benefits, Justice Byron R. White agrees with the U.S. District Court that there exists "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility." [4][5]

Whether or not alcoholism is a disease remains a controversial subject. It should be noted that not all participants in the debate are without self-interest. For example, if alcoholism is not considered a disease, third party payments to physicians and hospitals for its treatment would cease.

Effects

Today, alcohol abuse and alcohol dependence are major public health problems in North America, costing the region's inhabitants, by some estimates, as much as US$170 billion annually. Alcohol abuse and alcohol dependence are life-threatening problems that sometimes end in death, particularly through liver, pancreatic, or kidney disease, internal bleeding, brain deterioration, alcohol poisoning, and suicide. Heavy alcohol consumption by a pregnant mother can also lead to fetal alcohol syndrome, an uncurable and damaging condition.

Additionally, alcohol abuse and alcohol dependence are major contributing factors for head injuries, motor vehicle accidents (MVA), violence and assaults, neurological, and other medical problems (cirrhosis, etc.).

Of the one half of the North American population who consume alcohol, it has been estimated by some that 10% are alcohol abusers and alcohol dependents, and 6% consume more than half of all alcohol.

Stereotypes of alcohol abusers and alcohol dependents are often found in fiction and popular culture: for example the "town drunk," or the stereotype of Russians and the Irish as alcoholics. In modern times, the recovery movement has led to more realistic portraits of abusers and dependents and their problems, such as in Charles R. Jackson's The Lost Weekend, or the films Days of Wine and Roses, and My Name is Bill W or the extreme "Leaving Las Vegas". Charles Bukowski describes honestly his alcohol addiction in the movie Barfly and in his other writings. Alcohol dependence can be harder to break and significantly more damaging than dependence on most other addictive substances. The physical symptoms when withdrawing from alcohol can be quite severe and dangerous, with death reported in extreme cases.

The alcoholic personality can exhibit a radical change when they drink, from passive when sober to aggressive when drunk, though the reverse can also be true.

An alcoholic does not have to be someone who is drunk every night, and a functional alcoholic can have largely normal work and family relationships. However, alcohol represents a major or the major focus of their lives.

Long-term

The long-term effects of high quantity alcohol use can include:

pancreatitis, or inflammation of the pancreas (but the acute and chronic form)
heart disease, including dilated cardiomyopathy
polyneuropathy, or damage to the nerves leading to poor sensation or pain
cirrhosis of the liver, a chronic disease characterized by destruction of liver cells and loss of liver function, and its numerous complications, including bleeding from esophageal varices
depression, insomnia, anxiety, and suicide
hypertension (high blood pressure)
increased incidence of many types of cancer, including breast cancer, head and neck cancer, esophageal cancer and colorectal cancer
nutritional deficiency of folic acid, thiamine (vitamin B1) and several others
Wernicke-Korsakoff syndrome, a neuropsychiatric disorder caused by thiamine deficiency that results from poor nutrition in alcoholics
personality changes toward others, especially those who are close
significant damage to occupational, social, and interpersonal areas, including sexual dysfunction

Screening

Several tools may be used to detect the habitual abuse of alcohol. The CAGE questionnaire, developed by Dr. John Ewing and named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Another screening questionnaire is the Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization.

The Alcohol Dependence Data Questionnaire [2] is a more sensitive diagnostic test than the CAGE test. The Alcohol Dependence Data Questionnaire serves to distinguish a diagnosis of alcohol dependence from one of alcohol abuse.

Blood tests

Although there is no blood test specific for alcohol abuse or alcohol dependence (alcoholism), prolonged heavy alcohol consumption may lead to several abnormalities, including:

Macrocytosis (enlarged MCV)¹
Elevated GGT²
Moderate elevation of AST and ALT and an AST:ALT ratio of 2:1.
High carbohydrate-deficient transferrin²

Treatments

Treatments for alcohol dependence include detoxification programs run by medical institutions. These may involve stays for a number of weeks in specialized hospital wards where drugs may be used to avoid withdrawal symptoms, which in severe cases may lead to death.

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues leading to alcohol dependence. Aversion therapies may be supported by drugs like Disulfiram, which causes a strong and prompt hangover whenever alcohol is consumed. Naltrexone may improve compliance with abstinence planning. The standard pharmocopoeia of antidepressants, anxiolytics, and other psychotropic drugs treat underlying mood disorders, neuroses, and psychoses associated with alcoholic symptoms.

Another treatment program is based on nutritional therapy. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be treated by a hypoglycemic diet, this can affect behaviour and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, resulting in poor treatment outcomes. See: [3]

In the mid-1930s, the mutual-help group-counselling approach to treatment began and has become very popular. Alcoholics Anonymous is possibly the best-known example of this movement. Other groups include LifeRing Secular Recovery and SMART Recovery.

Some programs attempt to help problem drinkers before they become dependents. These programs focus on harm-reduction and reducing alcohol intake as opposed to cold-turkey approaches. One such program is called Moderation Management.

Social impact

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A Soviet poster reading "Daddy, don't drink", referring to the massive alcohol abuse problem in Russia

The social problems arising from alcohol abuse can include loss of employment, financial problems, marital conflict and divorce, convictions for crimes such as drunk driving or public disorder, loss of accommodation, and loss of respect from others who may see the problem as self-inflicted and easily avoided. Alcohol dependence affects not only the addicted but can profoundly impact the family members around them. Children of alcohol dependents can be affected even after they are grown; the behaviors commonly exhibited by such children are collectively known as Adult Children of Alcoholics Syndrome. Al-Anon/Alateen, a group modelled after Alcoholics Anonymous, offers aid to friends and family members of alcohol dependents.

Many people incorrectly assume that once an alcohol dependent stops drinking, all is well. However, many people, especially members of Alcoholics Anonymous who have stopped drinking still refer to themselves as "alcoholics" or "recovering alcoholics."

Social versus physical dependence

Symptoms of a person's dependence on alcohol may include, but are not limited to, a feeling of necessity in regard to consumption of alcohol, or an inability to resist alcohol if offered. Though these symptoms often arise from a physical dependence on the substance, it is not uncommon for individuals, especially teenagers and adolescents between the ages of fifteen and twenty, to rely on alcohol as a means of social interaction. If a person cannot refuse alcohol in the presence of others, insists on drinking alcohol excessively for fear of alienation and neglect, or feels they cannot socially interact with others unless under the influence then this person is considered socially dependent on the substance.

These traits can be noticed in individuals with no history of alcohol consumption who relocate (such as students attending a new university) whereby an individual begins to consume alcohol in order to associate and relate to others. Social dependence, though not physically threatening in early stages, can lead to physical dependence if the person cannot control their urges and moreso their reasons for drinking.

It should be noted that use of the term 'urges' are not merely to express a sense of want for the taste of alcohol, but could also be an urge that is stimulated by an individuals satisfaction in what is often referred to as "the buzz." It is a sense of euphoria brought on in people bearing a low tolerance to alcohol in about 2-3 standard drinks in a short period of time. Individuals bearing a higher tolerance to alcohol usually still crave "the buzz". Over time, the amount of alcohol needed to achieve the same affect increases as tolerance increases.

A persons "social dependence" is defined by the Prevention Research Institute from Kentucky (www.askpri.com) as a condition that a person experiences and re-experiences in a social setting. It reflects the habitual experiences one has as they enjoy "partying" with the same people.

Politics and public health

Because alcohol abuse affects society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

Organisations working with alcohol abusers include:

Alcoholics Anonymous (AA)
IOGT International (IOGT)
LifeRing Secular Recovery (LifeRing)
Men For Sobriety (MFS)
Moderation Management (MM)
Rational Recovery (RR)
Secular Organizations for Sobriety (SOS)
Self-Management and Recovery Training (SMART)
Women For Sobriety (WFS)

Alcohol withdrawal

There are several distinct but not mutually exclusive clinical alcohol withdrawal syndromes caused by alcohol withdrawal:

Tremulousness - "the shakes"
Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure.
Seizures - acute grand mal seizures can occur in alcohol withdrawal in patients who have no history of seizure or any structural brain disease.
Hallucinations - usually visual or tactile in alcoholics
Delirium tremens - can be severe and often fatal.

Unlike withdrawal from opioids such as heroin, which can be unpleasant but never fatal, alcohol withdrawal can kill (by uncontrolled convulsions or delirium tremens) if it is not properly managed. The pharmacological management of alcohol withdrawal is based on the fact that alcohol, barbiturates, and benzodiazepines have remarkably similar effects on the brain and can be substituted for each other. Since benzodiazepines are the safest of the three classes of drugs, alcohol consumption is terminated and a long-acting benzodiazepine is substituted to block the alcohol withdrawal syndrome. The benzodiazepine dosage is then tapered slowly over a period of days or weeks.

External links

References

Tonnesen H, Hejberg L, Frobenius S, Andersen JR. Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics. Acta Med Scand. 1986;219(5):515-8. (Medline abstract)
Schwan R, Albuisson E, Malet L, Loiseaux MN, Reynaud M, Schellenberg F, Brousse G, Llorca PM. The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach. Drug Alcohol Depend. 2004 Jun 11;74(3):273-9. (Medline abstract)
Ewing, John A. “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984
U.S Supreme Court, Traynor v Turnage, 485 U.S 353 (1988) at 535-550
253 U.S Appellate District Court at 132-133

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