Alcohol Dependence (Alcoholism)
What Is It?
Alcoholism (alcohol dependence) is the most severe type of drinking problem. There is no absolute number of drinks per day or quantity of alcohol that defines alcoholism, but experts have defined a limit above which the risks of drinking increase significantly.
Here are some defining characteristics of alcohol dependence:
Tolerance – The need to drink more and more alcohol to feel the same effects, or the ability to drink more than other people without getting drunk.
Withdrawal symptoms – After stopping or cutting back on drinking, symptoms are anxiety, sweating, trembling, trouble sleeping, nausea or vomiting, and, in severe cases, physical seizures and hallucinations.
Desire to stop drinking, but inability to do so.
Loss of control over the amount of alcohol consumed.
Preoccupation with drinking.
Paying less attention to other life activities.
Ignoring problems, sometimes very obvious ones.
A person with alcohol dependence has come to rely on alcohol physically, psychologically and emotionally. The brain adapts to the presence of alcohol and undergoes persistent changes. When alcohol use suddenly stops, the body's accustomed internal environment changes drastically, causing symptoms of withdrawal.
Alcoholism can be linked many psychological, interpersonal, social, economic and medical problems. Alcoholism can increase the risk of depression and suicide and play a role in violent crimes, including homicide and domestic violence (abuse of a spouse or child). It can lead to traffic accidents and even accidents involving intoxicated pedestrians who decide to walk home after drinking. Alcoholism also can lead to unsafe sexual behavior, resulting in accidental pregnancy or sexually transmitted diseases.
Alcohol dependence increases the risk of liver disease (hepatitis and cirrhosis), heart disease, stomach ulcers, brain damage, stroke and other health problems. In pregnant women who drink alcohol, there is also the danger that the child will develop fetal alcohol syndrome, a cluster of health problems including unusually low birth weight, facial abnormalities, heart defects and learning difficulties.
The lifetime chance of developing alcoholism is very difficult to determine, but it is very common. In the United States, about 1 in 16 adults have severe problems with drinking and millions more are engaged in what experts consider risky drinking. In fact, a recent analysis revealed that 30% of a representative sample of U.S. residents reported an alcohol use disorder at some time in their lives.
Alcohol problems come about from a combination of biological tendencies and environmental influences.
Biology. People with a family history of alcohol dependence are at greater risk for developing the illness themselves. For example, if a parent has alcohol dependence, a child has a four-times greater risk of becoming alcohol-dependent. This is partly due to inheriting genes that increase vulnerability, perhaps by governing a person's physical responses to alcohol or the experience of intoxication. Sometimes alcohol is used to blot out feelings arising from an underlying depression or anxiety disorder.
Environment. Alcohol may be a big part of a person's social group or may have been a part of family life (sometimes quite destructively). A person may turn to alcohol to get relief from stress (which frequently backfires, because the drinking causes problems of its own). Family support and healthy friendships can reduce the risk.
Alcohol dependence can involve any of the following symptoms or behaviors:
Having long episodes of intoxication
Having work problems or financial problems caused by drinking
Losing interest in food
Being careless about personal appearance
Hurting oneself or someone else while intoxicated
Hiding liquor bottles and glasses to hide the evidence of drinking
Experiencing mood or personality changes
Because large amounts of alcohol can be toxic to the body (for example, the cardiovascular, gastrointestinal or nervous systems), alcoholism also may cause physical symptoms:
Morning nausea or shaking
Signs of malnutrition due to a poor diet
Abdominal pain or diarrhea
A flushed red color to the face and palms
Numbness, weakness or tingling in the arms or legs
Unusually frequent accidental injuries, especially falls
Even though alcohol related disorders are very common, only a small minority of individuals recognize the problem and get help. Therefore, screening is very important, whether it is done by primary care physicians or friends and family.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) now recommends that primary care physicians ask a very simple, but specific question – How many times in the past year have you had:
(Men) 5 or more drinks in a day?
(Women) 4 or more drinks in a day?
The goal with this question is to get a quick idea whether or not the person is at increased risk for developing alcohol-related problems. The limits are different for women and men because of known differences in how alcohol is absorbed, distributed and eliminated from the body. Thus, the risk goes up for men who drink more than 4 standard drinks in a day (or more than 14 in a week); while for women, the limit is lower – 3 drinks in a day (and 7 drinks in a week).
Almost always, people feel nervous or defensive about their drinking, which is one reason this very common problem so often goes undetected or unaddressed. The NIAAA therefore recommends that physicians make a point of using their time with patients to educate them about drinking and its dangers.
As a screening test, the single question about drinking patterns is as good as slightly more detailed ones, such as the CAGE test. CAGE questions may be easier for concerned family members and friends to ask, since they may hesitate to ask direct questions about quantity.
The word "CAGE" is a device for remembering the questions (see the highlighted words):
Do you worry that you might need to CUT down on drinking?
Do you feel ANNOYED because other people have criticized your drinking?
Do you feel GUILTY about drinking?
Do you need a morning EYE OPENER drink to steady your nerves or to fight a hangover?
Another screening questionnaire used by physicians is the 10-question AUDIT (Alcohol Use Disorders Identification Test) developed by the World Health Organization.
Doctors often also ask whether a person has alcohol-related problems at work, at home or with the law, such as getting into fights or driving while intoxicated. The doctor may ask about physical symptoms of alcoholism. As embarrassing as the answers may be, the doctor should view drinking problems as an understandable human predicament and not a reason for their patients to feel ashamed.
A physical examination can reveal signs of poor nutrition and alcohol-related liver or nerve damage. Blood tests can check for anemia, vitamin deficiencies and abnormal levels of liver chemicals.
The NIAAA has a very helpful set of resources for the general public and for clinicians. They are all easily available online at www.niaaa.nih.gov.
For most people who have alcohol dependence, the first alcohol-related life problems usually appear in the mid-20s to early 40s. Left untreated, alcoholism often persists and gets worse over time. Up to 30% of people with alcohol dependence do manage to abstain from alcohol or control their drinking without formal treatment. On the other hand, the illness can be fatal – there are approximately 100,000 alcohol-related deaths per year in the United States.
There is no absolute way to prevent alcoholism. Screening is important, because early detection and treatment can prevent dangerous complications.
Only a minority of people with drinking problems are able to cut down and drink "in moderation." More often, once a person has lost control of his or her drinking, the safest approach is usually to stop drinking alcohol completely.
The first step in this process is recognizing the problem. The well-known phenomenon of denial, which is a common part of the illness, often turns the illness into a chronic one. Unfortunately, the longer the illness persists, the harder it is to treat.
A doctor or substance abuse expert may be able to help a person look at the consequences of drinking. A nonjudgmental approach to the discussion is essential. If an individual is beginning to think about alcohol as a problem worth trying to solve, educational groups may provide support for weighing the pros and cons of drinking.
It is never easy for family members and friends to identify the problem. A professional may have to help loved ones – kindly, but firmly – talk to the drinker about the painful impact drinking has on them.
Once an individual commits to stopping drinking, the physician will look for and treat withdrawal symptoms. Depending on the amount and duration of drinking and any symptoms, detoxification (often simply called "detox") from alcohol can be done as an outpatient, or as an inpatient in a hospital or drug treatment facility. During the withdrawal process, the doctor may prescribe a class of antianxiety drugs called benzodiazepines for a short period in order to reduce withdrawal symptoms.
After weaning from alcohol, medication in some cases can help reduce cravings. Two medications that fit in this category are naltrexone (ReVia) and acamprosate (Campral). As an alternative, sometimes the drug disulfiram (Antabuse) may be prescribed. Disulfiram does not reduce craving, but it creates an incentive not to drink, because drinking alcohol while taking it causes nausea and vomiting. A drug called topiramate (Topamax), which is used to treat seizures and migraine headaches, may diminish the reinforcing effects of alcohol, but it is not yet approved for this use by the Food and Drug Administration (FDA). Also not approved by the FDA, there is limited evidence that baclofen (Lioresal), a drug used to treat muscle spasticity, could help people quit alcohol use.
After detoxification, many people with alcohol disorders need some form of long-term support or counseling to remain sober. Recovery programs focus on teaching a person with alcoholism about the disease, its risks, and ways to cope with life's usual stresses without turning to alcohol. Psychotherapy may help a person understand the influences that trigger drinking. Many patients benefit from self-help groups such as Alcoholics Anonymous (AA), Rational Recovery or SMART (Self Management and Recovery Training).
It is very important to treat any other problems, such as depression or anxiety, which may contribute to the risk of drinking.
If the doctor suspects that alcohol-related damage to the liver, stomach or other organs, additional tests may be necessary. A healthy diet with vitamin supplements, especially B vitamins, is helpful.
When To Call a Professional
Call your doctor whenever you or someone you love has an alcohol-related problem. Remember, alcoholism is not a sign of weakness or poor character. It is an illness that can be treated. The sooner treatment begins, the easier alcoholism is to treat.
About 30% of alcoholics are able to abstain from alcohol permanently without the help of formal treatment or a self-help program. For the rest, the course of the illness is very varied. Some people will go through periods where they remain sober, but then relapse. Others have a hard time sustaining any period of sobriety.
It is clear, however, that the more sober days you have, the greater the chance that you will remain sober. Another motivating fact – remaining sober can increase life expectancy by 15 or more years.
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
5635 Fishers Lane
Bethesda, MD 20892-9304
www.niaaa.nih.gov/ (Especially "Rethinking Drinking" and "Helping Patients Who Drink Too Much.")
National Clearinghouse for Alcohol and Drug Information (NCADI)
P.O. Box 2345
Rockville, MD 20847-2345
Alcoholics Anonymous World Services, Inc.
P.O. Box 459
New York, NY 10163
Al-Anon Family Group Headquarters, Inc.
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
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