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What Facts Should I Know About Alcoholism?
What is alcoholic addiction?
Alcohol problems vary in severity from mild to life threatening and affect the individual, the person's family, and society in numerous adverse ways. Despite the focus on illegal drugs of abuse such as cocaine, alcohol remains the number-one drug problem in the United States. Nearly 17 million adults in the U.S. are dependent on alcohol or have other alcohol-related problems, and about 88,000 people die from preventable alcohol-related causes.
What are the causes and effects of alcoholism?
In teenagers, alcohol is the most commonly abused drug. Thirty-five percent of teens have had at least one drink by age 15. Even though it is illegal, about 8.7 million people 12 to 20 years of age have had a drink in the past month, and this age group accounted for 11% of all alcohol consumed in the U.S. Among underaged youth, alcohol is responsible for about 189,000 emergency-room visits and 4,300 deaths annually.
Withdrawal, for those physically dependent on alcohol, is much more dangerous than withdrawal from heroin or other narcotic drugs. Alcohol abuse and alcohol dependence are now grouped together under the diagnosis of alcohol use disorder.
- What was formerly called alcohol abuse refers to excessive or problematic use with one or more of the following:
- Failure to fulfill major obligations at work, school, or home
- Recurrent use in situations where it is hazardous (such as driving a car or operating machinery)
- Legal problems
- Continued use of alcohol despite having medical, social, family, or interpersonal problems caused by or worsened by drinking
- Despite negative outcomes resulting from drinking, the alcoholic continues to drink to try to attain the feeling of euphoria they first experienced when they started drinking.
How many drinks makes an alcoholic?
- Previously called alcohol dependence, this aspect of alcohol use disorder refers to a more serious kind of alcohol use disorder and involves excessive or maladaptive use leading to three or more of the following:
- Tolerance (need for more to achieve the desired effect, or achieving the effect with greater amounts of alcohol)
- Withdrawal symptoms following a reduction or cessation of drinking (such as sweating, rapid pulse, tremors, insomnia, nausea, vomiting, hallucinations, agitation, dizziness, shaking, anxiety, or seizures) or using alcohol to avoid withdrawal symptoms (for example, early morning drinking or drinking throughout the day)
- Drinking more alcohol or drinking over a longer period of time than intended (loss of control)
- Inability to cut down or stop
- Spending a great deal of time drinking or recovering from its effects
- Giving up important social, occupational, or recreational activities in favor or using alcohol
- Continuing to drink despite knowing alcohol use has caused or worsened problems
Binge drinking (consuming several drinks over a short period of time) can occur at any level of alcohol use disorder.
What Causes Alcoholism?
The cause of alcoholism is not well-established. There is growing evidence for genetic and biologic predispositions for this disease. First-degree relatives of individuals with alcohol use disorder are four to seven times more likely to develop alcoholism than the general population. Research has implicated a gene (D2 dopamine receptor gene) that, when inherited in a specific form, might increase a person's chance of developing alcoholism.
Usually, a variety of factors contribute to the development of a problem with alcohol. Social factors such as the influence of family, peers, and society, and the availability of alcohol, and psychological factors such as elevated levels of stress, inadequate coping mechanisms, and reinforcement of alcohol use from other drinkers can contribute to alcoholism. Also, the factors contributing to initial alcohol use may vary from those maintaining it, once the disease develops.
While it may not be causative, twice as many men are alcohol dependent. One study showed one-third of men age 18-24 met the criteria for alcohol dependence, and those who start drinking before age 15 are four times more likely to develop alcohol dependence. Men are more likely to engage in binge drinking or heavy drinking. They are also more likely to be involved in behaviors that harm themselves or others such as alcohol-related violence, using other drugs such as marijuana and cocaine, having sex with six or more partners, and earning mostly Ds and Fs in school grades.
What Are Alcoholism Symptoms and Signs?
Alcoholism is a disease. It is often diagnosed more through behaviors and adverse effects on functioning than by specific medical symptoms. Only two of the diagnostic criteria are physiological (tolerance and withdrawal symptoms).
- Alcohol use disorder is associated with a broad range of medical, psychiatric, and social effects, as well as legal, occupational, economic, and family problems. For example, parental alcoholism underlies many family problems such as divorce, spouse abuse, child abuse, and neglect, as well as dependence on public assistance, and criminal behaviors, according to government sources.
- The great majority of individuals with alcoholism go unrecognized by physicians and health-care professionals. This is largely because the person with alcohol use disorder is able to conceal the amount and frequency of drinking, deny problems caused by or made worse by drinking, there is gradual onset of the disease and effects on the body, and the body has the ability to adapt to increasing alcohol amounts up to a point.
- Family members often deny or minimize alcohol problems and unwittingly contribute to the continuation of alcoholism by well-meaning behaviors such as shielding (enabling) the person with alcohol dependence from adverse consequences of drinking or taking over family or economic responsibilities. Often the drinking behavior is concealed from loved ones and health-care professionals.
- Individuals with alcohol use disorder, when confronted, will often deny excess consumption of alcohol. Alcoholism is a diverse disease and is often influenced by the alcoholism sufferer's personality as well as by other factors. Signs of a drinking problem and symptoms often vary from person to person. There are certain behaviors and signs that indicate someone may have a problem with alcohol, including insomnia, frequent falls, bruises of different ages, blackouts, chronic depression, anxiety, irritability, tardiness or absence at work or school, loss of employment, divorce or separation, financial difficulties, frequent intoxicated appearance or behavior, weight loss, or frequent automobile collisions.
- Symptoms of intoxication include slurred speech, reduced inhibitions and judgment, lack of muscle control, problems with coordination, confusion, or problems with memory or concentration. Continued drinking causes a rise in the blood alcohol content (BAC) and high BAC can lead to breathing problems, coma, and even death.
- Signs of a drinking problem and symptoms often vary from person to person. There are certain behaviors and signs that indicate someone may have a problem with alcohol, including insomnia, frequent falls, bruises of different ages, blackouts, chronic depression, anxiety, irritability, aggression or lack of restraint, tardiness or absence at work or school, loss of employment, divorce or separation, financial difficulties, frequent intoxicated appearance or behavior, self-destructive behavior, weight loss, or frequent automobile collisions.
- Signs and symptoms of chronic alcohol abuse include medical conditions such as pancreatitis, gastritis, (liver) cirrhosis, neuropathy, anemia, cerebellar (brain) atrophy, alcoholic cardiomyopathy (heart disease), Wernicke's encephalopathy (abnormal brain functioning), Korsakoff's dementia, central pontine myelinolysis (brain degeneration), seizures, confusion, malnutrition, hallucinations, peptic (stomach) ulcers, and gastrointestinal bleeding.
- Compared with children in families without alcoholism, children of alcohol-dependent individuals are at increased risk for alcohol abuse, substance abuse, conduct problems, violent behavior, anxiety disorders, compulsive behavior, and mood disorders. Alcoholic individuals have a higher risk of psychiatric disorders and suicide. They often experience guilt, shame, loneliness, fear, and depression, especially when their alcohol use leads to significant losses (for example, job, relationships, status, economic security, or physical health). Many medical problems are caused by or made worse by alcoholism as well as by the alcoholic's poor adherence to medical treatment.
When Should Someone Seek Medical Care for Alcoholism?
People who drink alcohol to the point it interferes with their social life, professional life, or with their medical or mental health should contact a doctor to discuss the problem. The great difficulty lies in the fact that denial plays a large part in alcoholism. Consequently, alcoholics rarely seek professional help voluntarily.
Often a family member or employer convinces or forces the person with alcoholism to seek medical treatment. Even if an alcoholism sufferer accepts treatment because of pressure from family, an employer, or a medical professional, he or she can benefit from it. Treatment may help this person develop motivation to change the alcohol problem.
Alcohol is involved in 40% of motor-vehicle fatalities, 70% of drownings, 50% of suicides, and up to 40% of violent crimes, including homicide, rape, assault, and child and spousal abuse.
It is imperative emergency care be sought immediately when alcohol has contributed to an injury. This is important because someone who is intoxicated may not be able to reliably assess the severity of the injury they have sustained or inflicted. An intoxicated person may, for example, not notice they have a fractured neck vertebra (broken neck) until it is too late and paralysis has occurred.
Several alcohol-related conditions require immediate evaluation in a hospital's emergency department.
- Alcohol withdrawal requires emergency treatment. When withdrawing from alcohol, a person classically goes through four phases: tremulousness (the shakes), seizures, hallucinations, and delirium tremens (DTs). These stages are described in further detail:
- During the tremulous stage, the person will exhibit a tremor (shakiness) of his or her hands and legs. This can be seen if the person extends his or her hand and tries to hold it still. This symptom is often accompanied by anxiety and restlessness.
- Seizures can follow the tremulous stage. They are commonly generalized seizures during which the entire body shakes uncontrollably, the person loses consciousness and may lose control over their bladder or bowels. If you see someone having a seizure, first call 911. Then attempt to lay the person on one side so they don't inhale vomit or secretions into their lungs. If possible, protect the person's head or other body parts from knocking uncontrollably onto the floor or against other potentially harmful objects. Do not place anything inside the person's mouth while they are having a seizure.
- Hallucinations affect many people undergoing the late stages of major alcohol withdrawal. Visual hallucinations are the most common type of hallucination experienced during alcohol withdrawal. People will classically "see" insects or worms crawling on walls or over their skin. Often this is associated with tactile (feeling) hallucinations in which alcoholics think they feel insects crawling on their skin. This phenomenon is called formication. Auditory (hearing) hallucinations can also occur during withdrawal, although less commonly than the other types of hallucinations.
- The most dangerous stage of alcohol withdrawal is called delirium tremens (DTs) and it is a medical emergency. About 5% of people withdrawing from alcohol experience DTs. This condition usually occurs within 72 hours after drinking stops but can occur up to seven to 10 days later. The hallmark of this stage is profound delirium (confusion). People are awake but thoroughly confused. This is accompanied by agitation, delusions (beliefs that have no basis in reality), sweating, hallucinations, rapid heart rate, and high blood pressure. Even with appropriate medical treatment, this condition is associated with a 5% death rate.
- Alcoholic ketoacidosis (AKA) is another alcohol related condition for which emergency medical treatment should be sought. AKA often starts within two to four days after an alcoholic has stopped consuming alcohol, fluids, and food, often because of gastritis or pancreatitis. Not uncommonly, AKA and alcohol withdrawal syndromes are seen at the same time. AKA is characterized by nausea, vomiting, abdominal pain, dehydration, and an acetone-like odor on the person's breath. This occurs when the alcohol dependent person has become depleted of carbohydrate fuel stores and water. The body begins to metabolize ("burn") fat and protein into ketone bodies for energy. Ketone bodies are acids that accumulate in the blood, increasing its acidity and causing the person to feel even sicker, thus perpetuating a vicious cycle.
- Alcohol use disorder is often associated with other psychiatric disorders such as anxiety, depression, bipolar disorder, and psychosis. These psychiatric illnesses, often combined with a reduced level of sound judgment while intoxicated, leads to suicides and suicide attempts by people who are alcohol dependent. A person who has attempted suicide or is believed to be in serious or imminent danger of committing suicide should be taken quickly to the emergency department of a hospital.
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How Do Health Care Professionals Diagnose Alcoholism?
The diagnosis of alcohol use disorder is generally made by reviewing the person's behavior except when the person has symptoms of withdrawal or damage to organs that is clearly the result of alcohol consumption.
Alcohol use disorder is defined as the consumption of alcohol to the point at which it interferes with the individual's life from an occupational, social, or health standpoint. It follows that behavior exhibited by an individual with this disorder can be interpreted in different ways by different people. This often makes the diagnosis of alcoholism somewhat difficult.
- Several screening tests are routinely employed to identify people at risk for alcoholism. Such tests usually consist of one or more questionnaires. Commonly used tests are the Michigan Alcoholism Screening Test (MAST), the CAGE questionnaire, and the TACE questionnaire.
- The Michigan Alcoholism Screening Test (MAST) is a 22-question quiz often used in a clinical counseling setting.
- The CAGE questionnaire, for example, asks the following four questions. "Yes" answers to two or more of these questions indicate a high likelihood of alcoholism.
- Have you felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you felt bad or Guilty about your drinking?
- Have you ever had to drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?
- The TACE questionnaire is similar. It also asks four questions. The more "yes" answers a person has to these questions, the higher the likelihood of this person drinking excessively.
- Does it Take more than two drinks to get you high?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt you ought to Cut down on your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves (Eye opener)?
- A doctor may draw blood to evaluate your liver functions, check for the presence of anemia, and/or electrolyte imbalance (blood chemistry levels). Alcoholic individuals often have elevated liver function tests, which indicate liver damage. Gamma glutamyl transferase (GGT) is the most sensitive liver function test. It can be elevated after only a few weeks of excess alcohol consumption. Alcohol-dependent people may also have anemia (low blood cell count), as well as electrolyte disturbances including low potassium, low magnesium, and low calcium.
- Often the initial visit with a doctor is for medical or surgical complications of alcohol consumption. In those cases, the doctor will perform and order additional tests depending on the symptoms (for example, abdominal problems, heart failure, alcohol withdrawal, or cirrhosis).
Are There Any Home Remedies for Alcoholism or Alcohol Use Disorder?
Alcoholism is best treated by professionals trained in addiction medicine. Physicians and other health-care workers with such specialized training and experience are best suited to manage alcohol withdrawal and the medical and mental disorders associated with alcoholism.
Home therapy without supervision by a trained professional may be life threatening because of complications from alcohol withdrawal syndrome. Usually an alcoholic will begin to experience alcohol withdrawal six to eight hours after cutting down or stopping alcohol consumption.
Several levels of care are available to treat alcoholism. Medically managed hospital-based detoxification and rehabilitation programs are used for more severe cases of dependence that occur with medical and psychiatric complications. Medically monitored detoxification and rehabilitation programs are used for people who are dependent on alcohol and who do not require more closely supervised medical care. The purpose of detoxification is to safely withdraw the alcohol dependent person from alcohol and to help him or her enter a rehabilitation (rehab) treatment program. The purpose of a rehabilitation program is to help the individual with alcoholism accept that they have the disease, begin to develop skills for sober living, and get enrolled in ongoing treatment and self-help programs. Most detoxification programs last just a few days. Most medically managed or monitored rehabilitation programs last less than two weeks. Many alcoholic individuals benefit from longer-term rehabilitation programs, day treatment programs, or outpatient programs. These programs involve education, therapy, addressing problems contributing to or resulting from the alcoholism, and learning skills to manage the alcoholism over time.
These skills include, but are not limited to, the following:
- Learning to identify and manage what leads to cravings for alcohol ("triggers")
- Resisting social pressures to engage in substance use
- Changing health-care habits and lifestyle (for example, improving diet and sleep hygiene, and avoiding high-risk people, places, and events)
- Learning to challenge alcoholic thinking (thoughts such as, I need a drink to fit in, have fun, or deal with stress)
- Developing a recovery support system and learning how to reach out for help and support from others (for example, from members of self-help programs)
- Learning to deal with emotions (anger, anxiety, boredom, depression) and stressors without reliance on alcohol
- Developing a healthy, secure self-image that no longer includes alcohol
- Identifying and managing relapse warning signs before alcohol is used
- Anticipating the possibility of relapse and addressing high-risk relapse factors
What Is the Treatment for Alcoholism?
A team of professionals is often needed to treat the alcohol-dependent person. The physician usually plays a key role in medical stabilization and facilitating treatment entry, but others are routinely needed beyond the initial management (for example, alcoholism counselors, social workers, physicians specializing in psychiatry, family therapists, and pastoral counselors).
Treatment of alcoholism can be divided into three stages. Initially, the person has to be medically stabilized. Next, he or she must undergo a detoxification process, followed by long-term abstinence and rehabilitation.
- Stabilization: Many medical and surgical complications are associated with alcoholism, but only stabilization of alcohol withdrawal and alcoholic ketoacidosis are discussed here.
- Alcohol withdrawal is treated by oral or intravenous (IV) hydration along with medications that reverse the symptoms of alcohol withdrawal. The most common group of medications used to treat alcohol withdrawal symptoms is the sedative group, also called the benzodiazepines such as lorazepam (Ativan), diazepam (Valium), and chlordiazepoxide (Librium). They can be given by IV, orally, or by injection. Diazepam also comes as a rectal suppository. Chlordiazepoxide generally takes longer to have an effect than diazepam or lorazepam and is therefore less commonly used in withdrawal emergencies. Pentobarbital is another medication occasionally used to treat alcohol withdrawal. It has an effect similar to benzodiazepines but is more likely to slow down breathing, making it less attractive for this use. Occasionally, the agitated and confused person may have to be physically restrained until he or she becomes calm and coherent.
- Alcoholic ketoacidosis is treated with IV fluids and carbohydrates. This is usually done in the form of sugar-containing fluid given by IV until the person can resume drinking fluids and eating.
- People with alcoholism should receive supplemental thiamine (vitamin B1), either by injection, IV, or orally. Thiamine levels are often low in alcohol-dependent people, and deficiency of this important vitamin could lead to Wernicke's encephalopathy, a disorder characterized initially by the eyes looking in different directions from each other. If thiamine is given in a timely fashion, this potentially devastating disorder can be completely reversed. In the emergency setting, thiamine is customarily given as an injection. Folate (a vitamin) and magnesium are often given to individuals with alcoholism, as well.
- Detoxification: This stage involves stopping alcohol consumption. This is very difficult for an alcohol-dependent person, requires extreme discipline, and usually requires extensive support. It is often performed in an inpatient setting where alcohol is not available. The person is treated with the same medications discussed in the treatment of alcohol withdrawal, namely benzodiazepines. During detoxification, the medication is measured carefully to prevent physical withdrawal symptoms and is then gradually tapered off until no physical withdrawal symptoms are evident. This usually requires a few days to a week. As physician-assisted outpatient detoxification has become popular, it may become more difficult to obtain coverage for in-hospital detoxification.
- Rehabilitation: Short- and long-term residential programs aim to help people who are more severely dependent on alcohol develop skills not to drink, to build a recovery support system, and to work on ways to keep them from drinking again (relapsing).
- Short-term programs last less than four weeks. Longer programs last for a month to a year or more and are often referred to as sober-living facilities. These are structured programs that provide therapy, education, skills training, and help develop a long-term plan to prevent relapsing.
- Outpatient counseling (individually, in groups, and/or with families) can be used as a primary treatment method or as a "step-down" for people as they come out of a residential or structured day program.
- Outpatient counseling can provide education on alcoholism and recovery, can help the person learn skills and self-image not to drink, and spot early signs of potential relapse.
- There are several very effective individual treatments delivered by professional counselors in outpatient treatment clinics. These treatments are Twelve-Step Facilitation Therapy, Motivational Enhancement Therapy, and Cognitive-Behavioral Coping Skills. A well-known self-help program is Alcoholics Anonymous (AA). Other self-help programs (for example, Women for Sobriety, Rational Recovery, and SMART Recovery) allow alcoholics to stop drinking and remain sober on their own.
What Medications May Be Used in the Treatment of Alcoholism?
- Several medications are available to assist the person in abstaining from alcohol consumption.
- Perhaps the oldest and one of the most commonly used medications is disulfiram (Antabuse). It interferes with alcohol metabolism, resulting in a metabolite that makes the person very uncomfortable and nauseated when consuming alcohol. The greatest problem with disulfiram is that people will often stop taking the medication in order to drink alcohol. To overcome this problem, disulfiram is available as an implantable device that is inserted under the skin. Fatalities have been reported when people taking disulfiram have ingested large amounts of alcohol. Disulfiram has been associated with several types of neurologic conditions, including optic neuritis (inflammation of the optic nerve), which can lead to visual disturbances and eye pain.
- Other medications used in preventing alcohol relapse are naltrexone (ReVia), acamprosate (Campral), and a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). Some researchers suggest that naltrexone and acamprosate seem to be the most effective medications studied, and that SSRIs are not as effective. Disulfiram seems to have a positive effect on maintaining an alcohol-free lifestyle, yet the magnitude of this effect seems to be rather limited. Therefore, naltrexone is being increasingly used. Studies suggest alcoholics who drink while on naltrexone drink less alcohol and have less severe relapses compared with those not on it. Acamprosate is sometimes used to stabilize the chemical imbalance in the brain cause by alcoholism. When compared to placebo (sugar pills), it was effective in helping people abstain from alcohol. It is generally recommended that these medications be used in conjunction with alcoholism counseling.
Is Follow-Up Needed After Alcoholism Treatment?
The person suffering from alcohol use disorder must first make the decision to stop using alcohol. Without such a resolve, achieving long-term sobriety is unlikely.
- To avoid an impulsive relapse, the person's home should be free of alcohol.
- The person should enroll in a social support group or counseling program. Also, social situations that encourage alcohol consumption should be avoided.
- Cognitive behavioral therapy, aversion therapy, family therapy, and group psychotherapy can all be helpful.
- If medication is prescribed to help maintain sobriety, the person must take the medication according to a strict schedule. Meeting with a counselor is essential. When the urge to relapse becomes strong, the person should immediately contact a member of his or her support group and discuss the urge in an effort to resist it.
Is It Possible to Prevent Alcoholism?
Prevention of alcoholism is best accomplished by abstinence. You must first have access to alcohol before becoming dependent on the substance. A strong family history of alcoholism is a warning you are at increased risk of becoming dependent on alcohol. Increased awareness of such a risk factor may help modify your attitude toward alcohol consumption. A strong social support system and early medical or psychiatric intervention may also help prevent the escalating consumption of alcohol so characteristic of alcoholism.
What Is the Prognosis of Alcoholism?
- Remaining alcohol-free is a very difficult task for most people with alcohol use disorder. Individuals who do not seek help after detoxification tend to have a high relapse rate.
- Four key factors may increase the relapse rate:
- Less education about addiction and ways to resist urges to relapse
- Higher levels of frustration and anger
- More extensive history of cravings and other withdrawal symptoms
- More frequent consumption of alcohol prior to treatment
- If a person continues to drink excessively after numerous or ongoing treatments, their prognosis is very poor. Persistent heavy drinkers will often succumb to the effects of alcohol.
- Alcohol use disorder is a chronic disease not unlike diabetes or congestive heart failure. If alcoholism is considered a chronic disease, a treatment success rate of 50% is similar to the success rates in other chronic illnesses.
- Four key factors may increase the relapse rate:
For More Information About Alcoholism and Alcohol Use Disorder
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