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Alcoholism is a term with multiple and sometimes conflicting definitions. In common and historic usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages, despite health problems and negative social consequences. Modern medical definitions[1] describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences. In the 19th and early 20th centuries, alcoholism, also referred to as dipsomania[2] described a preoccupation with, or compulsion toward the consumption of, alcohol and/or an impaired ability to recognize the negative effects of excessive alcohol consumption.
Although not all of these definitions specify current and on-going use of alcohol as a qualifier for alcoholism, some do, as well as remarking on the long-term effects of consistent, heavy alcohol use, including dependence and symptoms of withdrawal.
While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, stress,[3] emotional health, genetic predisposition, age, and gender have been identified. For example, those who consume alcohol at an early age, by age 16 or younger, are at a higher risk of alcohol dependence or abuse. Also, studies indicate that the proportion of men with alcohol dependence is higher than the proportion of women, 7% and 2.5% respectively, although women are more vulnerable to long-term consequences of alcoholism. Around 90% of adults in United States consume alcohol, and more than 700,000 of them are treated daily for alcoholism.[4] Professor David Zaridze, who led the international research team, calculated that alcohol had killed three million Russians since 1987.[5]
Medical definitions
The National Council on Alcoholism and Drug Dependence and American Society of Addiction Medicine define alcoholism as “a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking.”[6] The DSM-IV (the standard for diagnosis in psychiatry and psychology) defines alcohol abuse as repeated use despite recurrent adverse consequences.[7] It further defines alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink.[7] (See DSM diagnosis below.) Within psychology and psychiatry, alcoholism is the popular term for alcohol dependence.[7] Note that there is debate whether dependence in this use is physical (characterised by withdrawal), psychological (based on reinforcement), or both.[citation needed]
Terminology
Many terms are applied to a drinker’s relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. Because alcoholism is often used in a derogatory sense in politics and religion, the meanings of the words surrounding it are often used imprecisely.
Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol. Misuse, problem use, abuse,[8] and heavy use do not have standard definitions, but suggest consumption of alcohol to the point where it causes physical, social, or moral harm to the drinker. The definitions of social and moral harm are highly subjective and therefore differ from individual to individual.
Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescription medications in excess of the prescribed dosage, sometimes refers to use of a prescription drug without a prescription, and sometimes refers to use that results in long-term health problems. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion with audiences that do not necessarily share a single definition.
Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. The American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full.
The term dipsomania is used in medical and psychiatric circles to identify a condition which is characterized by the uncontrollable craving for alcohol or other intoxicants, which manifests for unknown reasons, and can be confused with alcoholism.
Identification and diagnosis
Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker’s life compared with the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic’s life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify. Unless they have M.C. type symptoms, and in these cases are probably alcoholics, no diagnosis needed.
Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.
Screening
Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.
â–ª The CAGE questionnaire, 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:
1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. 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?[24][25]
The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.
â–ª The Alcohol Dependence Data Questionnaire is a more sensitive diagnostic test than the CAGE test.[26] It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.
â–ª The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses,[27] driving under the influence being the most common.
â–ª The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally.[28] Like the CAGE questionnaire, it uses a simple set of questions – a high score earning a deeper investigation.
â–ª The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.[29]
Genetic predisposition testing
Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut suggest that alcoholism does not have a single cause””including genetic””but that genes do play an important role “by affecting processes in the body and brain that interact with one another and with an individual’s life experiences to produce protection or susceptibility.” They also report that fewer than a dozen alcoholism-related genes have been identified, but that more likely await discovery.[30]
At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction.[31] Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol.[32] Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.[30]
DSM diagnosis
The DSM-IV diagnosis of alcohol dependence represents one approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcohol dependence diagnosis 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.
Urine and blood tests
There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:
â–ª Macrocytosis (enlarged MCV)1
â–ª Elevated GGT²
â–ª Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1.
â–ª High carbohydrate deficient transferrin (CDT)
However, none of these blood tests for biological markers are as sensitive as screening questionaires.
Effects of long term alcohol misuse
Main article: Long-term effects of alcohol
The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging to physical health. The secondary damage caused by an inability to control one’s drinking manifests in many ways. Alcoholism also has significant social costs to both the alcoholic and their family and friends.[33] Alcoholism can have adverse effects on mental health causing psychiatric disorders to develop.[34] Over fifty percent of suicides are related to alcohol or drug dependence. Approximately 25 percent alcoholics commit suicide. In adolescents the figure is higher with alcohol or drug misuse playing a role in up to 70 percent of suicides.[35] Alcoholism also has a significant adverse impact on mental health. The risk of suicide among alcoholics has been determined to be 5,080 times that of the general public.[36]
Physical health effects
It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption may include cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources.The adverse effects of alcoholism is picturised in alcoholic’s body designed by Dr Shankar HS Ram ([2]). Severe cognitive problems are not uncommon in alcoholics. Approximately 10% of all dementia cases are alcohol related making alcohol the 2nd leading cause of dementia.[37]
Mental health effects
Long term misuse of alcohol can cause a wide range of mental health effects. Alcohol misuse is not only toxic to the body but also to brain function and thus psychological well being can be adversely affected by the long-term effects of alcohol misuse. Psychiatric disorders are common in alcoholics, especially anxiety and depression disorders, with as many as 25% of alcoholics presenting with severe psychiatric disturbances. Typically these psychiatric symptoms caused by alcohol misuse initially worsen during alcohol withdrawal but with abstinence these psychiatric symptoms typically gradually improve or disappear altogether.[38] Psychosis, confusion and organic brain syndrome may be induced by chronic alcohol abuse which can lead to a misdiagnosis of major mental health disorders such as schizophrenia.[39] Panic disorder can develop as a direct result of long term alcohol misuse. Panic disorder can also worsen or occur as part of the alcohol withdrawal syndrome.[40] Chronic alcohol misuse can cause panic disorder to develop or worsen an underlying panic disorder via distortion of the neurochemical system in the brain.[41]
The co-occurrence of major depressive disorder and alcoholism is well documented.[42][43][44] Among those with comorbid occurrences, a distinction is commonly made between depressive episodes that are secondary to the pharmacological or toxic effects of heavy alcohol use and remit with abstinence, and depressive episodes that are primary and do not remit with abstinence. Additional use of other drugs may increase the risk of depression in alcoholics.[45] Depressive episodes with an onset prior to heavy drinking or those that continue in the absence of heavy drinking are typically referred to as “independent” episodes, whereas those that appear to be etiologically related to heavy drinking are termed “substance-induced”.[46][47][48]
Social effects
The social problems arising from alcoholism can be massive and are caused in part due to the serious pathological changes induced in the brain from prolonged alcohol misuse and partly because of the intoxicating effects of alcohol.[33][37] Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic’s behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic’s children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.
Alcohol withdrawal
Main article: Alcohol withdrawal syndrome
Alcohol withdrawal differs significantly from most other drugs in that it can be directly fatal. For example it is extremely rare for heroin withdrawal to be fatal. When people die from heroin or cocaine withdrawal they typically have serious underlying health problems which are made worse by the strain of acute withdrawal. An alcoholic, however, who has no serious health issues, has a significant risk of dying from the direct effects of withdrawal if it is not properly managed. [33] Sedative-hypnotic drugs such as barbiturates and benzodiazepines which have a similar mechanism of action to alcohol (which is also a sedative-hypnotic) also have a similar risk of causing death during withdrawal.[49]
Alcohol’s primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person’s nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.[50][51]
Acute withdrawal symptoms tend to subside after one to three weeks. Less severe symptoms (e.g. insomnia and anxiety, anhedonia) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more.[52][53][54] Withdrawal symptoms begin to subside as the body and central nervous system makes adaptations to reverse tolerance and restore GABA function towards normal.[55][56] Other neurotransmitter systems are involved, especially glutamate and NMDA.[57]
Treatments
Treatments for alcoholism (antidipsotropic) are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.
Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.[17]
Effectiveness
When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own.[58] A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.[59]
Detoxification
Main article: Alcohol detoxification
Alcohol detoxification or ‘detox’ for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.
Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or ‘rehabs’) may take place in an inpatient or outpatient setting.
Group therapy and psychotherapy
A regional service center for Alcoholics Anonymous.
After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.
The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more members than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.
Rationing and moderation
Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency.[60] A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was “Abstinence represents the most stable form of remission for most recovering alcoholics”.[61]
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