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22 December 2010

Alcoholism

Alcohol dependence is a disease that involves addiction to alcohol. In addition to physical dependence, other psychological, genetic and social factors may contribute alcoholism.

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Summary

  • Alcoholism (the term alcohol dependence is preferred) is a disease that involves addiction to the drug alcohol.
  • In addition to physical dependence on alcohol, other psychological, genetic and social factors may contribute to development of the disease.
  • Alcohol dependence and alcohol abuse cause major social, economic and public health problems.
  • Symptoms of alcohol dependence include craving alcohol, loss of control, over use of alcohol, increasing tolerance to its effects, and withdrawal symptoms during periods of abstinence.
  • Many alcoholics deny having the disease; intervention may be necessary to persuade them to start treatment.
  • Treatment typically includes detoxification, counselling and psychotherapy, treatment of associated medical problems, and recovery and support programmes.

Alternative names

alcohol dependence; alcohol addiction

Definition

Alcoholism or alcohol dependence is a disease that involves physical and psychological dependence addiction to the drug alcohol. It is chronic, progressive and often fatal. Alcohol consumption reaches a level where it seriously interferes with your health, and social or occupational functioning. Alcoholics may continue to abuse alcohol despite the numerous negative consequences of the disease.

Medical practitioners use specific terminology:

alcohol abuse is used when alcohol is used in a manner that deviates from accepted social standards, e.g. drunk driving, excessive drinking

alcohol dependence implies repeated use of alcohol with or without physical dependence. Criteria include having to drink more and more to achieve the same effect, and drinking despite known negative consequences and physical dependence means an altered physiologic state, which leads to withdrawal symptoms if the alcohol is withdrawn.

 Causes and risk factors

Alcohol dependence is one of the most common illnesses, and the most common form of drug addiction. There is no definite cause of alcoholism; however, several factors may play a role in its development:

  • heavy drinking over time. Drinking steadily and heavily over time can lead to dependence by altering the levels of certain brain chemicals, causing you to crave alcohol to restore positive feelings or avoid negative ones. At-risk drinkers are men who consume 15 or more drinks a week, women who consume 12 or more drinks a week, or anyone who consumes five or more drinks per occasion at least once a week. (One drink is defined as a bottle of beer, a glass of wine, or a unit of spirits). Physical dependence, however, is not the sole cause of alcoholism; other factors usually come into play.
  • genetics. Your genetic makeup may cause brain chemical variations and make you more susceptible to alcohol dependency. Genetic factors may account for about half the total risk for developing alcoholism. Although your risk is higher if you had a parent who abused alcohol, a child of an alcoholic parent will not automatically develop alcoholism, and a person with no family history of alcoholism can develop the disease.
  • other psychiatric disease. There is a high incidence of other psychiatric disease in alcohol dependence (called dual diagnosis).
  • psychological factors. Some people drink to relieve stress, anxiety, depression or low self-esteem. Having certain clinical emotional disorders, such as severe depression, increases your risk for alcoholism. Alcoholism sometimes develops from efforts to self-treat a mental illness.
  • social and cultural factors. Your social environment, which includes elements such as peer pressure, availability of alcohol and social acceptance of its use may also encourage the development of alcoholism.
  • age. People who start drinking in their teens or earlier are at higher risk of becoming alcoholics. Although it usually takes years for adults to develop alcoholism, teenagers can become addicted within months. Rates of alcohol abuse are highest in people aged 18-29, and lowest among those 65 and older.
  • gender. Men are more likely to become alcoholics, although the incidence of alcoholism among women has increased over the past 30 years.

Symptoms and signs

Alcoholism includes the following general symptoms:

  • craving: a compulsion to drink
  • impaired control: signs that you have lost control over alcohol include trying, but failing to limit or reduce your drinking, and spending a great deal of time and energy acquiring, using or suffering the effects of alcohol
  • tolerance: if your body is alcohol-dependent, you might need to drink increasing amounts of alcohol to feel its effects
  • physical dependence also reveals itself through certain physiological changes when you stop drinking, called withdrawal symptoms; and through evidence of alcohol-associated illnesses (see complications)
  • continued use of alcohol despite knowing that it is harming you.

Other signs of alcoholism may include the following behaviours:

  • denying that you have a drinking problem, despite evidence to the contrary
  • hostility when confronted about your drinking
  • secretive behaviour: drinking alone; hiding alcohol and evidence that you've been drinking
  • memory problems; confused or sluggish thinking; difficulty concentrating
  • making a ritual of when you drink and becoming annoyed if this ritual is disturbed
  • irritability as your usual drinking time nears, especially if alcohol is unavailable
  • finding excuses to drink
  • losing interest in activities that used to bring you pleasure
  • gulping down drinks or ordering doubles
  • becoming intoxicated intentionally to feel good or "normal".
  • feeling that you need alcohol to function adequately
  • having problems with relationships, work or school, finances or the law
  • promising repeatedly to stop drinking
  • progressively drinking stronger alcoholic beverages or starting to drink progressively earlier in the day
  • being drunk for long periods
  • spending more and more time drinking rather than pursuing other interests
  • mood changes (anger, irritability)
  • personality changes (becoming jealous or distrustful)
  • driving while drunk
  • becoming violent towards yourself or others while drunk
  • neglecting your physical appearance.

Physical symptoms may include:

  • nausea or vomiting
  • shaking in the morning
  • poor eating habits and loss of appetite (substituting meals with alcohol)
  • stomach pain or cramps
  • diarrhoea
  • numbness or tingling
  • weakness in the legs and hands
  • red eyes, face or palms
  • unsteady walking or falling
  • blacking out (inability to remember detail of events while drinking)
  • loss of short-term memory
  • new and worsening medical problems (see complications).

Alcohol withdrawal symptoms may vary from mild to severe. The more common, milder symptoms may include:

  • restlessness
  • anxiety
  • shaking hands
  • insomnia
  • increased heart rate
  • rapid breathing
  • increased blood pressure
  • elevated temperature and sweating
  • loss of appetite, nausea or vomiting.

Severe withdrawal symptoms, or delirium tremens (DTs), may include:

  • extreme agitation
  • confusion
  • seizures
  • delusions or hallucinations.

Diagnosis

Doctors may overlook the possibility of alcoholism in a patient. Symptoms such as memory loss, for example, might be the both the result of ageing or a symptom of alcoholism. Because alcoholism usually involves denial, alcoholics may tell their doctors about related medical complaints, but hide their alcohol abuse.

If alcoholism is suspected, your doctor will take a medical history and ask questions about your use of alcohol and its effects on your life and people close to you. If answers to those questions suggest alcoholism, the doctor may perform a short screening test, using a standardised questionnaire. A history may be obtained from your family or friends if you are reluctant or unable to answer questions.

Your doctor will also perform a physical examination to look for medical problems associated with alcohol abuse. Laboratory tests may be performed, including various tests of blood and urine. A toxicology screen or measurement of blood alcohol level will confirm recent alcohol ingestion. This doesn't confirm alcoholism, however, because these tests show recent alcohol consumption, not long-term usage. Other blood tests measure the size of red blood cells, which increase with long-term alcohol use, and a factor called carbohydrate-deficient transferrin, which may indicate heavy alcohol consumption. Liver enzyme changes, such as a high level of gamma GT, are an indication of chronic alcohol intake.

Treatment

Only 15% of alcoholics seek treatment. Most alcoholics undergo screening or start treatment reluctantly because they are in denial about their disease. Often alcoholics enter treatment only after their family, friends or doctor persuade them to do so. Intervention is a process whereby concerned people close to the alcoholic step in and make a concerted effort to help the person accept the need for treatment. If you're considering intervention for a friend or family member, discuss how best to go about it with a professional experienced in this area. An alcoholic cannot be forced to get help except under certain circumstances, such as when their behaviour results in crime or following a medical emergency.

The first step in treatment is to determine whether the person seeking treatment is alcohol-dependent. If you have alcoholism, however, complete abstinence (cutting out alcohol altogether) is always necessary for successful recovery.

Alcoholism requires treatment programmes that include medical supervision and counselling. Treatment may involve an outpatient programme or a residential inpatient stay.

A typical treatment programme includes:

  • detoxification and withdrawal. Detoxification, which takes about four to seven days, involves the withdrawal of alcohol in a supervised setting. Tranquilizers called benzodiazepines (e.g. Valium or Librium) are often prescribed to control withdrawal symptoms. These are most common in the first five days after withdrawing alcohol.
  • recovery programmes. Recovery or rehabilitation programmes provide support after detoxification to maintain abstinence from alcohol. Counselling, psychological support and medical care are usually available within these programmes. Education about the disease and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centres are recovered alcoholics who serve as role models.
  • medical assessment and treatment of common medical problems associated with alcoholism. (See complications)
  • psychological support and psychiatric treatment. Group and individual counselling and therapy encourage recovery from the psychological aspects of alcoholism. An important aspect of counselling and treatment is to recognise and modify behaviour patterns that cause you to drink. Depression or other underlying mood disorders should be treated concurrently. Because alcoholism also impacts negatively on people close to the alcoholic, involvement of the family is essential for effective recovery.
  • emphasis on acceptance and abstinence. Effective treatment is impossible unless you accept that you are addicted and cannot afford to risk drinking.
  • drug treatments. In addition to tranquilizers to help you safely through withdrawal, a second type of medication may be used to help you remain sober. An alcohol-sensitizing drug, disulfiram (Antabuse), produces a physical reaction that includes flushing, nausea and headaches if you drink. Naltrexone (ReVia or Depade) is a newer drug that blocks the alcohol "high," and reduces the urge to drink. This medication lessens the craving for alcohol and helps prevent relapses.
  • additional ongoing support. Even if alcoholics have been sober for a long time, they may relapse and must continue to avoid alcohol. Many recovering alcoholics and their families find that joining support groups, most notably Alcoholics Anonymous (AA), is an essential part of coping with the disease. AA is a self-help group of recovering alcoholics that offers emotional support and an effective model of abstinence. Your doctor or counsellor can refer you to an AA group, which is also listed in the phone book and local newspapers and on the Internet. Al-Anon is a complementary self-help group, designed for people affected by another's alcoholism. Alateen groups provide support for teenage children of alcoholics.
  • general health improvement. Eating a balanced diet with vitamin supplements and getting regular exercise are important in regaining health.

Outcome

It is important to understand that alcoholism is similar to other diseases like diabetes, and will not simply go away after one treatment, even if the patient remains abstinent. Treatment programmes have varying success rates. Studies show that only a few alcoholics remain sober one year after treatment, while others have periods of sobriety, alternating with relapses. Many alcoholics relapse several times, but this does not mean that you cannot eventually achieve long-term sobriety. The longer you abstain from alcohol, the more likely you are to remain sober. You may feel a desire for alcohol throughout your life, however. Some alcoholics are unable to stop drinking for any length of time.

Alcoholism is a major social, economic and public health problem, involved in over half of all unnatural deaths and almost half of all traffic fatalities. A high percentage of suicides involve the use of alcohol in combination with other substances. Additional deaths are related to long-term medical complications associated with the disease. The life-span of an alcoholic is shortened by an average of 15 years, as a result of the various complications of the disease.

If you stop drinking, alcohol-associated health problems can often be controlled or prevented. However, some kinds of damage, such as to your liver or pancreas, may be permanent and can even be fatal.

Complications

Long-term alcohol abuse can have numerous medical complications, including:

  • liver disorders. Heavy drinking can cause hepatitis, or inflammation of the liver. This may eventually lead to changes in liver structure, called a fatty liver, and should drinking continue, may cause cirrhosis, the progressive and irreversible destruction of liver tissue.
  • gastrointestinal problems. Alcohol can cause inflammation and erosion of the stomach lining (gastritis, ulcers). It also interferes with absorption of B vitamins and other nutrients, leading to nutritional deficiencies. Heavy drinking can also cause inflammation and damage to the pancreas (pancreatitis). This hinders production of digestive juices and enzymes, and hormones that help regulate metabolism.
  • pancreatitis. Alcohol has a direct poisoning effect on the pancreas. Acute pancreatitis can be fatal. Chronic pancreatitis can result in diabetes.
  • diabetes complications. Alcohol inhibits the release of glucose from the liver and can increase the risk of low blood sugar (hypoglycaemia). This is dangerous if you have diabetes and take insulin to lower your blood sugar level.
  • cardiovascular problems. Excessive drinking can lead to high blood pressure and heart muscle damage (cardiomyopathy). These conditions increase the risk of heart failure or stroke.
  • reproductive problems. Alcohol abuse can cause erectile dysfunction, testicular atrophy and impotence in men. In women, it can interrupt menstruation.
  • birth defects. Excessive drinking during pregnancy can cause foetal alcohol syndrome. This condition results in both physical birth abnormalities and later developmental disabilities.
  • neurologic complications. Alcohol affects the nervous system and can result in cerebral atrophy (loss of brain cells), neuropathy (diseases of the nerves) and dementia (impaired brain function).
  • depression. About one-third of alcoholics also suffer major depression.
  • increased risk of cancer of the larynx, oesophagus, liver and colon
  • Severe alcohol withdrawal includes psychotic symptoms (loss of contact with reality), and may even be fatal.

Social consequences of alcoholism can be as serious as the medical problems, and may include:

  • domestic abuse, failed relationships, inappropriate jealousy
  • poor work or school performance
  • increased likelihood of road collisions and fatalities
  • greater susceptibility to unnatural injuries from other causes
  • higher incidence of suicide and murder
  • higher incidence of unemployment, crime and financial problems.

Prevention

Recognising a family history of alcoholism, or symptoms of problem drinking, is an important step toward seeking treatment before alcohol use progresses to alcoholism.

If you answer "yes" to one of the following questions, you may have a possible alcohol problem. More than one "yes" answer means it is highly likely that a problem exists, and you should seek help.

  • Do you ever feel you need to reduce your drinking?
  • Do people annoy you by questioning or criticising your drinking?
  • Do you ever feel guilty or bad about your drinking?
  • Do you ever drink in the morning to try to calm yourself or counteract a hangover?

Early intervention is particularly important for teenagers. To help prevent teenage alcohol use:

  • set a good example regarding alcohol use
  • encourage open communication with your children
  • discuss the medical and legal consequences of drinking.

Most adults can drink moderate amounts of alcohol and avoid alcohol-related problems. "Moderate" drinking means that women and older people should have no more than one drink per day and men no more than two drinks per day. Because of physiological differences, women become more easily intoxicated than men do. Women are more vulnerable to alcoholism. Physical changes associated with ageing can make older people easily intoxicated and more vulnerable to the effects alcohol.

Certain people should not drink at all, including: women who are pregnant or trying to become pregnant; people who plan to drive or engage in other activities requiring alertness and co-ordination; people taking certain medications; people with medical conditions that can be worsened by drinking; recovering alcoholics.

When to call the doctor

If you suspect that you or someone you know might have an alcohol problem, consult a doctor or other health professional as soon as possible. He or she can determine whether alcohol dependence exists in your case and, if so, suggest an appropriate course of action.

Go to an emergency room or call the local emergency number if severe confusion, seizures, bleeding, or other health problems develop in a person known or suspected to be an alcoholic.

Revised by Dr Rudoph Otto, MBChB, medical director, Chemical Dependency Unit, Crescent Clinic

Revised by Dr Duncan Laurenson, September 2010

 
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