ALCOHOLISM

December 1999

WHAT IS ALCOHOLISM?
Alcoholism is a chronic, progressive, and often fatal disease; it is a primary disorder and not a symptom of other diseases or emotional problems. The chemistry of alcohol allows it to affect nearly every type of cell in the body, including those in the central nervous system. In the brain, alcohol interacts with centers responsible for pleasure. After prolonged exposure to alcohol, the brain adapts to the changes alcohol makes and becomes dependent on it. For people with alcoholism, drinking becomes the primary means through which they can deal with people, work, and life. Alcohol dominates their thinking, emotions, and actions. The severity of this disease is influenced by factors such as genetics, psychology, culture, and response to physical pain. Alcoholism can develop insidiously; often there is no clear line between problem drinking and alcoholism. In addition to alcohol dependence, experts are now defining alcohol use by levels of harm that it may be causing. This information is useful to determine possible interventions at earlier stages [see Box, below]. The only early indications of alcoholism may be the unpleasant physical responses to withdrawal that occur during even brief periods of abstinence. Sometimes people experience long-term depression or anxiety, insomnia, chronic pain, or personal or work stress that lead to the use of alcohol for relief, but often no extraordinary events have occurred that account for the drinking problem. Alcoholics have little or no control over the quantity they drink or the duration or frequency of their drinking. They are preoccupied with drinking, deny their own addiction, and continue to drink even though they are aware of the dangers. Over time, some people become tolerant to the effects of drinking and require more alcohol to become intoxicated, creating the illusion that they can "hold their liquor." They have blackouts after drinking and frequent hangovers that cause them to miss work and other normal activities. Alcoholics might drink alone and start early in the day. They periodically quit drinking or switch from hard liquor to beer or wine, but these periods rarely last. Severe alcoholics often have a history of accidents, marital and work instability, and alcohol-related health problems. Episodic violent and abusive incidents involving spouses and children and a history of unexplained or frequent accidents are often signs of drug or alcohol abuse.

Alcohol Use and Abuse Experts now define levels of alcohol use by how harmful it is as well as how dependent a person is on it (with a drink defined as 12-oz of beer, 6 oz of wine, or 1.5 oz of 90-proof liquor). Moderate Drinking: equal to or less than two drinks a day for men and equal to or less than one drink a day for women. Heavy Drinking: more than 14 drinks per week or 4 drinks at one sitting for men and more than seven drinks a week or three drinks at one sitting for women. (Drinking over this amount puts a person at risk for adverse health events.) Hazardous Drinking: Hazardous drinking is an average consumption of 21 drinks or more per week for men (or 7 or more drinks per occasion at least 3 times a week) and 14 or more drinks per week for women (or more than 5 drinks per occasion at least 3 times a week). Hazardous drinking is considered to place individuals at risk for adverse health events. Harmful Drinking: Harmful drinking occurs when alcohol consumption has actually caused physical or psychologic harm. This is determined if there is clear evidence that alcohol is responsible for such harm, the nature of that harm can be identified, alcohol consumption has persisted for at least a month or has occurred repeatedly for the past year, and the individual is not alcohol dependent. Alcohol Abuse: one or more of the following alcohol-related problems over a period of one year: failure to fulfill work or personal obligations; recurrent use in potentially dangerous situations; problems with the law; and continued use in spite of harm being done to social or personal relationships. Alcohol Dependence: The individual experiences three or more of the following alcoholrelated problems over a period of one year: increased amounts of alcohol needed to produce an effect; withdrawal symptoms or drinking alcohol to avoid these symptoms; drinking more over a given period than intended; unsuccessful attempts to quit or cut down; giving up significant leisure or work activities; continuing drinking in spite of the knowledge of its physical or psychological harm to oneself or others.

WHAT CAUSES ALCOHOLISM?

People have been drinking alcohol for perhaps 15,000 years. Just drinking steadily and consistently over time can produce dependence and cause withdrawal symptoms during periods of abstinence; this physical dependence, however, is not the sole cause of alcoholism. To develop alcoholism, other factors usually come into play, including biology genetics, culture, and psychology.

Genetic Factors
Genetic factors play a significant role in alcoholism and may account for about half of the total risk for alcoholism. They effect men and women equally. Researchers are investigating a number of inherited traits that make particular individuals susceptible to this disorder. Even if genetic factors can be identified, however, they are unlikely to explain all cases of alcoholism. In fact, it may be a natural lack of genetic protection that plays a major role in alcoholism. Because alcohol is not found easily in nature, genetic mechanisms to protect against excessive consumption may not have evolved in humans as they frequently have for protection against natural threats. It is important to understand that, whether they inherit the disorder or not, people with alcoholism are still legally responsible for their actions. Inheriting genetic traits does not doom a child to an alcoholic future. Environment, personality, and emotional factors also play a strong role. [ See Who Becomes an Alcoholic? Below.]

Brain Chemicals
Alcohol has widespread effects on the brain. Of particular interest to researchers are a number of brain chemicals that include gamma aminobutyric acid (GABA), dopamine, serotonin, glutamate, norepinephrine, and opioid peptides. Genetic factors that cause imbalances in one or more of these brain chemicals and which may increase the risk for alcohol dependency are under intense scrutiny. Long-term use of alcohol itself, however, can cause adaptations that change the brain's chemistry and cause cravings, pain on withdrawal, and addiction. Such changes include depletion of gammaaminobutyric acid (which inhibits impulsivity), an increase in glutamate (which produces an over-excited nervous system), and higher levels of norepinephrine and corticotropin releasing factor (which causes stress and tension). When a person with alcoholism stops drinking, the hyperactivity in the brain caused by these events produces an intense need to calm down with the use of yet more alcohol. In addition, the patient continues to seek euphoria and pleasure produced by other chemicals. Serotonin and opioid peptides are important for feelings of well being. A rapid release in the brain of alcohol-induced dopamine causes euphoria, and repeated alcohol administration increases the sensitivity to these dopamine pathway. Animal studies indicate, however, that heavy drinking depletes the stores of dopamine and serotonin over time. Cravings for alcohol which lead to dependency or relapse then appear to be produced by two effects: the need to reduce agitation caused by an overexcited nervous system and the desire to restore pleasurable feelings that have been reduced by lower activity of dopamine and serotonin. One recent study suggested that agitation may be the more important factor in causing a relapse than mood shifts.

Levels of Response to Alcohol

A number of studies on twins and population groups at risk for alcoholism, such as

Native Americans, have suggested that genetic factors may determine one's level of response to alcohol. Such studies have found that people with a family history of alcohol tend to be able to drink more to achieve a level of intoxication than other people experience with less liquor. In other words, they "hold their liquor" better. Experts suggest such people may inherit a lack of those warning signals that ordinarily make people stop drinking. Some research suggests this factor may contribute to between 40% and 60% of alcoholism cases related to genetic factors.

Factors Affecting Aldehyde or Alcohol Dehydrogenase

Alcohol is metabolized in a two-stage process. It is first converted to acetaldehyde by a chemical called alcohol dehydrogenase (ADH), which is then converted into acetate by another chemical called aldehyde dehydrogenase (ALDH). Genes that affect either ADH or ALDH are under intense scrutiny for either their protective or harmful roles or both. For example, many Asians and possibly many Jewish people, are less likely to become alcoholic because of a genetic factor that makes them deficient in ALDH. In its absence, acetate, which is toxic, builds up after drinking alcohol and rapidly leads to flushing, dizziness, and nausea. People with this genetic susceptibility, then, are likely to experience adverse reactions to alcohol and therefore more likely not to become alcoholic. (This deficiency is not completely protective against drinking, however, particularly if there is added social pressure, such as among college fraternity members.) Investigators are looking for variants in the ALDH gene that may increase production of this enzyme, which in turn may make people genetically susceptible to alcoholism. Social and Emotional Causes of Alcoholic Relapse Between 80% and 90% of people treated for alcoholism relapse, even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. One study found that three factors placed a person at high risk for relapse: frustration and anger, social pressure, and internal temptation. Another study suggests that impaired sleep is also an important predictor of relapse. Mental and Emotional Stress. Alcohol blocks out emotional pain and is often perceived as a loyal friend when human relationships fail. It is also associated with freedom and a loss of inhibition that offsets the tedium of daily routines. When the alcoholic tries to quit drinking, the brain seeks to restore what it perceives to be its equilibrium. The brain's best weapons against abstinence are depression and anxiety (the emotional equivalents of physical pain) that continue to tempt alcoholics to return to drinking long after physical withdrawal symptoms have abated. Even intelligence is no ally in this process, for the brain will use all its powers of rationalization to persuade the patient to return to drinking. According to an interesting 1999 study, however, although a person's IQ had no effect on abstinence, a high verbal ability appeared to aid the alcoholic in remaining sober. It is important to realize that any life change may cause temporary grief and anxiety, even changes for the better. With time and the substitution of healthier pleasures, this emotional turmoil weakens and can be overcome.

Codependency. One of the most difficult problems facing a person with alcoholism is being around people who are able to drink socially without danger of addiction. A sense of isolation, a loss of enjoyment, and the ex-drinker's belief that pity, not respect, is guiding a friend's attitude can lead to loneliness, low self-esteem, and a strong desire to drink. Close friends and even intimate partners may have difficulty in changing their responses to this newly sober person and, even worse, may encourage a return to drinking. To preserve marriages to alcoholics, spouses often build their own self-images on surviving or handling their mates' difficult behavior and then discover that they are threatened by abstinence. Friends may not easily accept the sober, perhaps more subdued, comrade. In such cases, separation from these "enablers" may be necessary for survival. It is no wonder that, when faced with such losses, even if they are temporary, a person returns to drinking. The best course in these cases is to encourage close friends and family members to seek help as well. Fortunately, groups such as Al-Anon exist for this purpose. Social and Cultural Pressures. The media portrays the pleasures of drinking in advertising and programming. The medical benefits of light to moderate drinking are frequently publicized, giving ex-drinkers the spurious excuse of returning to alcohol for their health. These messages must be categorically ignored and acknowledged for what they are, an industry's attempt to profit from potentially great harm to individuals.

WHO BECOMES AN ALCOHOLIC?

General Risks and Age
Some population studies indicate that in a single year, between 7.4% and 9.7% of the population are dependent on alcohol, and between 20% and 25% of Americans identify themselves as heavy drinkers when they visit their physician. A 1996 national survey reported that 11 million Americans are heavy drinkers and 32 million engaged in binge drinking (five or more drinks on one occasion) in the month previous to the survey. People with a family history of alcoholism are more likely to begin drinking before the age of 20 and to become alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges and driving after drinking, than young drinkers without a family history of alcoholism. But anyone who begins drinking in adolescence is at risk for developing alcoholism. Currently 1.9 million young people between the ages of 12 and 20 are considered heavy drinkers and 4.4 million are binge drinkers. Although alcoholism usually develops in early adulthood, the elderly are not exempt. A survey of 5,000 adults over 60 reported that 15% of men and 12% of women were hazardous drinkers, and 9% of men and 3% of women were alcohol dependent. In another study, the prevalence of problem drinking was as high as 49% among nursing home patients. Alcohol also affects the older body differently; people who maintain the same drinking patterns as they age can easily develop alcohol dependency without

realizing it. Physicians may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process.

Gender
Most alcoholics are men, but the incidence of alcoholism in women has been increasing over the past 30 years. About 9.3% of men and 1.9% of women are heavy drinkers, and 22.8% of men are binge drinkers compared to 8.7% of women. In general, young women problem drinkers follow the drinking patterns of their partners, although they tend to engage in heavier drinking during the premenstrual period. Women tend to become alcoholic later in life than men, and it is estimated that 1.8 million older women suffer from alcohol addiction. Even though heavy drinking in women usually occurs later in life, the medical problems women develop because of the disorder occur at about the same age as men, suggesting that women are more susceptible to the physical toxicity of alcohol.

Family History and Ethnicity

The risk for alcoholism in sons of alcoholic fathers is 25%. The familial link is weaker for women, but genetic factors contribute to this disease in both genders. In one study, women with alcoholism tended to have parents who drank. Women who came from families with a history of emotional disorders, rejecting parents, or early family disruption had no higher risk for drinking than women without such backgrounds. A stable family and psychological health were not protective in people with a genetic risk. Unfortunately, there is no way to predict which members of alcoholic families are most at risk for alcoholism. Some population groups, such as Irish and Native Americans, have an increased incidence in alcoholism while others, such as Jewish and Asian Americans, have lower risk. Overall, there is no difference in alcoholic prevalence between African Americans, whites, and Hispanic people. Although the biological causes of such different risks are not known, certain people in these population groups may be at higher or lower risk because of the way they metabolize alcohol. [ See Genetic Factors under What Causes Alcoholism? above .]

Emotional Disorders
Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. Major depression, in fact, accompanies about one-third of all cases of alcoholism. It is more common among alcoholic women (and women in general) than men. Depression and anxiety may play a major role in the development of alcoholism in the elderly, who are often subject to dramatic life changes, such as retirement, the loss of a spouse or friends, and medical problems. Problem drinking in

these cases may be due to self-medication of the anxiety or depression. It should be noted, however, that it is not always clear whether people with emotional disorders are self-medicating with alcohol or whether long-term alcoholism itself causes chemical changes that produce anxiety and depression.

Personality Traits
Studies are finding that alcoholism is strongly related to impulsive, excitable, and novelty-seeking behavior, and such patterns are established early on, if not inherited. People with attention deficit hyperactivity disorder, a condition that shares these behaviors, have a higher risk for alcoholism. In a test of mental functioning, alcoholics (mostly women) did not show any deficits in thinking but they were less able to inhibit their responses. Children who later become alcoholics or who abuse drugs are more likely to have less fear of new situations than others, even if there is a greater risk for harm than in nonalcoholics. On the other hand, studies are also finding an association between alcohol use and having social phobia, a form of anxiety in which the individual has an intense fear of being publicly scrutinized and humiliated. Such individuals may use alcohol as a way to become less inhibited in public situations.

Socioeconomic Factors
It has been long thought that alcoholism is more prevalent in people with lower educational levels and in those who are unemployed. A thorough 1996 study, however, reported that the prevalence of alcoholism among adult welfare recipients was 4.3% to 8.2%, which was comparable to the 7.4% found in the general population. There was also no difference in prevalence between poor African Americans and poor whites. People in low-income groups did display some tendencies that differed from the general population. For instance, as many women as men were heavy drinkers. Excessive drinking may be more dangerous in lower income groups; one study found that it was a major factor in the higher death rate of people, particularly men, in lower socioeconomic groups compared with those in higher groups.

Geographic Factors
Although 54% of urban adults use alcohol at least once a month compared to 42% in nonurban areas, living in the city or the country does not affect the risks for bingeing or heavy alcohol use. One study reported that people in the north central US are at highest risk for heavy drinking (6.4% heavy use and 19% binge drinking) and those in the Northeast have the lowest risk (4.5% heavy use and 13% binge drinking).

Smokers
Researchers are finding common genetic factors in alcohol and nicotine addiction,

which may explain, in part, why alcoholics are often smokers. Alcoholics who smoke compound their health problems. More alcoholics die from tobacco-related illnesses, such as heart disease or cancer, than from chronic liver disease, cirrhosis, or other conditions that are more directly tied to excessive drinking.

Sugar Cravings
People who crave sugar may also be at higher risk for alcoholism. In one recent study, 62% of male alcoholics enjoyed a sweet sugar solution compared with only 21% of those without a drinking problem. It is not known, however, whether having a "sweet tooth" can be an early predictor of alcoholism or whether alcohol abusers simply develop a taste for sweetness as a result of their chronic alcohol abuse.

HOW SERIOUS IS ALCOHOLISM?

About 100,000 deaths a year can be wholly or partially attributed to drinking, and alcoholism reduces life expectancy by 10 to 12 years. Next to smoking, it is the most common preventable cause of death in America. Although studies indicate that adults who drink moderately (about one drink a day) have a lower mortality rate than their non-drinking peers, their risk for untimely death increases with heavier drinking. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Alcoholism can kill in many different ways, and, in general, people who drink regularly have a higher rate of deaths from injury, violence, and some cancers.

Overdose
Alcohol overdose can lead to death. This is a particular danger for adolescents who may want to impress their friends with their ability to drink alcohol but cannot yet gauge its effects.

Accidents, Suicide, and Murder

Alcohol plays a major role in more than half of all automobile fatalities. Less than two drinks can impair the ability to drive. Alcohol also increases the risk of accidental injuries from many other causes. One study of emergency room patients found that having had more than one drink doubled the risk of injury, and more than four drinks increased the risk eleven times. Another study reported that among emergency room patients who were admitted for injuries, 47% tested positive for alcohol and 35% were intoxicated. Of those who were intoxicated, 75% showed evidence of chronic alcoholism. This disease is the primary diagnosis in one quarter of all people who commit suicide, and alcohol is implicated in 67% of all murders.

Domestic Violence and Effects on Family

Domestic violence is a common consequence of alcohol abuse. Research suggests that for women, the most serious risk factor for injury from domestic violence may be a history of alcohol abuse in her male partner. Alcoholism in parents also increases the risk for violent behavior and abuse toward their children. Children of alcoholics tend to do worse academically than others, have a higher incidence of depression, anxiety, and stress and lower self-esteem than their peers. One study found that children who were diagnosed with major depression between the ages of six and 12 were more likely to have alcoholic parents or relatives than were children who were not depressed. Alcoholic households are less cohesive, have more conflicts, and their members are less independent and expressive than households with nonalcoholic or recovering alcoholic parents. In addition to their own inherited risk for later alcoholism, one study found that 41% of children of alcoholics have serious coping problems that may be life long. Adult children of alcoholic parents are at higher risk for divorce and for psychiatric symptoms. One study concluded that the only events with greater psychological impact on children are sexual and physical abuse.

The Effect of Alcohol on Mental Functioning

Drinking too much alcohol can cause mild neurologic problems in anyone, including insomnia and headache (especially after drinking red wine). Long-term alcohol use appears to have major effects upon the hippocampus, an area in the brain associated with learning and memory and the regulation of emotion, sensory processing, appetite, and stress. Brain scans of people with long-term alcoholism have shown atrophy in different parts of the brain and reduced brain activity, which fortunately seems to be reversible with continued abstinence. In a 1999 study, loss of verbal memory and slower reaction times were associated with a higher incidence of recent alcohol use (ie, within the last 3 months). A history of lifetime alcohol use, however, did not seem to impair mental functioning of patients with mild to moderate alcoholism. One study that uses imaging techniques to scan the brains of inebriated subjects suggested that while alcohol stimulates those parts of the brain related to reward and induces euphoria, it does not appear to impair cognitive performance (the ability to think and reason). Except in severe cases, any neurologic damage is not permanent and abstinence nearly always leads to recovery of normal mental function. Severely alcoholic patients, however, often have co-existing psychiatric or neurologic problems, and habitual use of alcohol eventually produces depression and confusion .

Medical Problems
Alcohol can affect the body in so many ways that researchers are having a hard time determining exactly what the consequences are from drinking. It is well known, however, that chronic consumption leads to many problems, some of them deadly.

Frequent heavy drinking is associated with a higher risk for alcohol-related medical disorders (pancreatitis, upper gastrointestinal bleeding, nerve damage, and impotence) than is episodic drinking or continuous drinking without intoxication. As people age, it takes fewer drinks to become intoxicated, and organs can be damaged by smaller amounts of alcohol than in younger people. Also, up to one-half of the 100 most prescribed drugs for older people react adversely with alcohol. Alcohol abusers who require surgery also have an increased risk of postoperative complications, including infections, bleeding, insufficient heart and lung functions, and problems with wound healing. Alcohol withdrawal symptoms after surgery may impose further stress on the patient and hinder recuperation. Liver Disorders. The liver is particularly endangered by alcoholism. About 10% to 35% of heavy drinkers develop alcoholic hepatitis, and 10% to 20% develop cirrhosis. In the liver, alcohol converts to toxic chemicals, such as acetaldehyde, which trigger the production of immune factors called cytokines. In large amounts, these agents cause inflammation and tissue injury and are proving to be major culprits in the destructive process in the liver. Not eating when drinking and consuming a variety of alcoholic beverages are also factors that increase the risk for liver damage. People with alcoholism are also at higher risk for hepatitis B and C, potentially chronic liver diseases than can lead to cirrhosis and liver cancer. People with alcoholism should be immunized against hepatitis B; they may need a higher-than-normal dose of the vaccine for it to be effective. [ See also Well-Connected, Report #59, Hepatitis.] Gastrointestinal Problems. Alcohol can cause diarrhea and hemorrhoids. Alcohol abuse can cause ulcers, particularly in people taking the painkillers known as nonsteroidal anti-inflammatory drugs (such as aspirin or ibuprofen). Alcohol can contribute to serious and chronic inflammation of the pancreas (pancreatitis) in people who are susceptible to this condition. Heart Disease and Stroke. The effects of alcohol on heart disease vary depending on consumption. Evidence strongly suggests that light to moderate alcohol, particularly grape wine, consumption (one or two drinks a day) protects the heart. The benefits are strongest in people at high risk for heart disease and may be fairly small in those at low risk. Light to moderate alcohol intake may even reduce the risk of sudden cardiac death. Large doses of alcohol, however, can trigger irregular heartbeats and raise blood pressure even in people with no history of heart disease. A major study found that those who consumed more than three alcoholic drinks a day had higher blood pressure than teetotalers. The more alcohol someone drank, the greater the increase in blood pressure, with binge drinkers (people who have nine or more drinks once or twice a week) being at greatest risk. One study found that binge drinkers had a risk for a cardiac emergency that was two and a half times that of nondrinkers. Alcohol abuse has also been associated with and may actually be one cause of idiopathic dilated cardiomyopathy, a condition in which the heart enlarges and its muscles weaken, putting the patient at risk for heart failure. Alcohol may also increase the risk for hemorrhagic stroke (caused by bleeding in the brain), although, as with heart disease, it may protect against stroke caused by narrowed arteries. Cancer. Alcohol may not cause cancer, but it probably does increase the carcinogenic effects of other substances, such as cigarette smoke. One study indicated that alcohol, in

combination with tobacco smoke, causes genetic damage that is associated with the development of cancer in the upper airways, the esophagus, and liver; abstaining from alcohol appeared to reverse this damage. Moderate use of alcohol has been associated with a higher risk for breast cancer because of increased estrogen levels or possibly because the liver overproduces certain carcinogenic growth factors in response to alcohol. Pneumonia and Other Infections. Acute alcoholism is strongly associated with very serious pneumonia. One study on laboratory animals suggests that alcohol specifically damages the bacteria-fighting capability of lung cells. Chronic alcoholism also causes changes in the immune system, although in people without any existing medical problems these changes do not appear to be significant. Skin, Muscle, and Bone Disorders. Severe alcoholism is associated with osteoporosis (loss of bone density), muscular deterioration, skin sores, and itching. Alcohol-dependent women seem to face a higher risk than men for damage to muscles, including muscles of the heart, from the toxic effects of alcohol. Hormonal Effects. Alcoholism increases levels of the female hormone estrogen and reduces levels of the male hormone testosterone, factors that contribute to impotence in men. Pregnancy and Infant Development. Even moderate amounts of alcohol may have damaging effects on the developing fetus, including low birth weight and an increased risk for miscarriage. High amounts can cause fetal alcohol syndrome, which can result in mental and growth retardation. One study indicates a significantly higher risk for leukemia in infants of women who drink any type of alcohol during pregnancy. Diabetes. Moderate alcohol consumption may help protect the hearts of adults with older-onset, also called type 2 diabetes. It should be noted, however, that alcohol can cause hypoglycemia, a drop in blood sugar, which is especially dangerous for people with diabetes who are taking insulin. Intoxicated diabetics may not be able to recognize symptoms of hypoglycemia, a particularly hazardous condition. Malnutrition and Wernicke-Korsakoff Syndrome. A pint of whiskey provides about half the daily calories needed by an adult, but it has no nutritional value. In addition to replacing food, alcohol may also interfere with absorption of proteins, vitamins, and other nutrients. Of particular concern in alcoholism is a severe deficiency in the Bvitamin thiamin, which can cause a serious condition called Wernicke-Korsakoff syndrome. Symptoms of this syndrome include severe loss of balance, confusion, and memory loss. Eventually, it can result in permanent brain damage and death. Another serious nutritional problem among alcoholics is deficiency of the B vitamin folic acid, which can cause severe anemia. Acute Respiratory Distress Syndrome. One study indicated that intensive care patients with a history of alcohol abuse have a significantly higher risk for developing acute respiratory distress syndrome (ARDS) during hospitalization. ARDS is a form of lung failure that can be fatal. It is can by caused by many of the medical conditions common in chronic alcoholism, including severe infection, trauma, blood transfusions,

pneumonia, and other serious lung conditions. Drug Interactions. The effects of many medications are strengthened by alcohol, while others are inhibited. Of particular importance is its reinforcing effect on antianxiety drugs, sedatives, antidepressants, and antipsychotic medications. Alcohol also interacts with many drugs used by diabetics. It interferes with drugs that prevent seizures or blood clotting. It increases the risk for gastrointestinal bleeding in people taking aspirin or other nonsteroidal inflammatory drugs including ibuprofen and naproxen. In other words, taking almost any medication should preclude drinking alcohol.

HOW IS ALCOHOLISM DIAGNOSED?

Even when people with alcoholism experience withdrawal symptoms, they nearly always deny the problem, leaving it up to coworkers, friends, or relatives to recognize the symptoms and to take the first steps toward treatment. Family members cannot always rely on a physician to make an initial diagnosis. Although 15% to 30% of people who are hospitalized suffer from alcoholism or alcohol dependence, physicians often fail to screen for the problem. In addition, doctors themselves often cannot recognize the symptoms. In one study, alcohol problems were detected by the physician in less than half of patients who had them. It is particularly difficult to diagnose alcoholism in the elderly, where symptoms of confusion, memory loss, or falling may be attributed to the aging process alone. Heavy drinkers may be more likely to complain to their doctors about so-called somatization symptoms, which are vague ailments such as joint pain, intestinal problems, or general weakness, that have no identifiable physical cause. Such complaints should signal the physician to follow-up with screening tests for alcoholism. Alcoholism is particularly less likely to be recognized in elderly women. In fact, only 1% of older women who need treatment for alcoholism are diagnosed accurately and treated appropriately. Instead, they are often diagnosed with depression and may even be prescribed anti-anxiety drugs or antidepressants that can have dangerous interactions with alcohol. Even when physicians identify an alcohol problem, however, they are frequently reluctant to confront the patient with a diagnosis that might lead to treatment for addiction.

Screening for Alcoholism

A physician who suspects alcohol abuse should ask the patient questions about current and past drinking habits to distinguish moderate from heavy drinking. If alcohol abuse or dependency is indicated, the physician will usually perform a screening test. Many are available for diagnosing alcoholism, usually either standardized questionnaires that the patient can take on their own or that are conducted by the physician. Because people with alcoholism often deny their problem or otherwise attempt to hide it, the tests are designed to elicit answers related to problems associated with drinking rather than the amount of liquor consumed or other specific drinking habits. The quickest test takes only one minute; it is called the CAGE test, an acronym for the following

questions: (C) attempts to Cut down on drinking; (A) Annoyance with criticisms about drinking; (G) Guilt about drinking; and (E) use of alcohol as an eye-opener in the morning. This test and another called the Self-Administered Alcoholism Screening Test (SAAST), appear to be most useful in detecting alcoholism in white middle-aged males. They are not very accurate for identifying alcohol abuse in older people, white women, and African- and Mexican-Americans. A more effective test for such individuals may be the Alcohol Use Disorders Identification Test (AUDIT), which asks three questions about amount and frequency of drinking, three questions about alcohol dependence, and four questions about problems related to alcohol consumption. AUDIT is an important component in screening for alcoholism in anyone, because it is the only test specifically designed to identify hazardous or harmful drinking. Other short screening tests are the Michigan Alcoholism Screening Test (MAST) and The Alcohol Dependence Scale (ADS).

Laboratory and Other Tests

Tests for alcohol levels in the blood are not useful for diagnosing alcoholism because they reflect consumption at only one point in time and not long-term usage. A mean corpuscular volume (MCV) blood test is sometimes used to measure the size of red blood cells, which increase with alcohol use over time. A test for a factor known as carbohydrate-deficient transferrin may prove to be fairly accurate indicator of heavy drinking. A physical examination and other tests should be performed to uncover any related medical problems. Sometimes the results of tests that detect other problems, such as blood tests reporting liver damage or low testosterone levels in men, can persuade alcoholics to seek help.

WHAT ARE THE GENERAL GUIDELINES FOR TREATING ALCOHOLISM?

Getting the Patient to Seek Treatment
Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. One study reported that the main reasons alcoholics do not seek treatment are lack of confidence in successful therapies, denial of their own alcoholism, and the social stigma attached to the condition and its treatment. The best approaches for motivating a patient to seek treatment are group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this interventional approach, each person affected offers a compassionate but direct and honest report describing specifically how he or she has been specifically hurt by their loved one's or friend's alcoholism. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation. The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and

consistently demand that the patient seek treatment. Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if he or she does not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers. The alcoholic patient and everyone involved should fully understand that alcoholism is a disease and that the responses to this disease, need, craving, fear of withdrawal, are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as treatments for other life-threatening diseases, such as cancer, are, but that it is the only hope for a cure.

Treatment Options
A number of treatment options now exist for alcoholism, including psychotherapy, medications that target brain chemicals involved in addiction, and social support groups such as Alcoholics Anonymous. Studies are suggesting the cognitive therapies and medications, such as naltrexone, may be very effective for some people. Even brief intervention by a family doctor can be helpful for reducing alcohol intake in many heavy drinkers. People with mild to moderate withdrawal symptoms are usually treated as outpatients and assigned to support groups, counseling, or both. Inpatient treatment can be performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. It is recommended for patients with a coexisting medical or psychiatric disorder and those who may harm themselves or others, who have not responded to conservative treatments, or who have a disruptive home environment. A typical inpatient regimen may include a physical and psychiatric workup, detoxification, treatment with medications and psychotherapy or cognitivebehavioral therapy, and an introduction to Alcoholics Anonymous. Because of the high cost of inpatient care, its advantages over outpatient care are being questioned. One study compared employed alcoholics who were either hospitalized, treated as outpatients with compulsory attendance at AA meetings, or allowed to choose their own treatment option, including none at all. After two years, everyone experienced fewer job problems, but those in the inpatient group had significantly fewer rehospitalizations and remained abstinent longer than people in the other two groups. Another study analyzing drug and alcohol treatment programs found that 75% of inpatients completed therapy compared to only 18% of outpatients. Other studies, however, have shown no difference in results between inpatient and outpatient programs. Given the current economic climate, it seems unlikely that most care providers will choose inpatient treatment for alcoholics who are not a threat to others or themselves if there are alternatives. Treatment for the Medically or Mentally Ill Alcoholic. Severe alcoholism is often complicated by the presence of serious medical or mental illnesses. A program called integrated outpatient treatment (IOT) has been designed specifically for medically ill alcoholics. The patient visits a clinic once a month for both intensive alcohol treatment

and a physical check-up, which includes tracking factors, such as liver function, that are affected by drinking. Patients are motivated through discussions of benefits and costs of drinking and by reporting any barriers to changing their habits and learning strategies to overcome them. One study showed that IOT significantly increased abstinence and the number of treatment visits. IOT may even improve survival rates. Interestingly, however drinking also significantly decreased in a comparison group of patients who were treated only for their medical conditions. Treatment for patients with both alcoholism and mental illness is particularly difficult. The greater the psychiatric distress a person is experiencing, the more he or she is tempted to drink, particularly in negative situations. Antidepressants or anti-anxiety medications in addition to support services may help people with depression and anxiety. People with alcoholism and more severe problems, such as schizophrenia or severe bipolar disorder probably need more intense help. AA groups are underused by patients with a double-diagnosis of mental illness and alcoholism because the focus of the organization is on addiction not psychiatric problems. Some AA members have even been known to discourage patients with dual disorders to go off their medications. In one survey 54% of AA members felt that such patients would do better in groups designed especially for dual disorders. Unfortunately, no such programs are available.

Treatment Goals
The ideal goals of long-term treatment by many physicians and organizations such as AA are total abstinence and replacement of the addictive patterns with satisfying, timefilling behaviors that can fill the void in daily activity that occurs when drinking has ceased. Because abstinence is so difficult to attain, many professionals choose to treat alcoholism as a chronic disease; that is, they expect and accept relapse but they aim for as long a remission period as possible. Even reducing alcohol intake can lower the risk for alcohol-related medical problems. Studies suggest, however, that patients who secure total abstinence have better survival rates, mental health, and marriages and they are more responsible parents and employees than those who continue to drink or relapse. There is also no way to determine which people can stop after one drink and which ones cannot. Alcoholics Anonymous and other alcoholic treatment groups whose goal is strict abstinence are greatly worried by the publicity surrounding these studies, since many people with alcoholism are eager for an excuse to start drinking again. At this time, seeking total abstinence is the only safe route.

WHAT IS THE TREATMENT FOR ALCOHOL WITHDRAWAL?

Symptoms of Withdrawal
When a person with alcoholism stops drinking, withdrawal symptoms begin within six

to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are over-produced and the central nervous system becomes over-excited. Seizures occur in about 10% of adults during withdrawal, and in about 60% of these patients, the seizures are multiple. The time between the first and last seizure is usually six hours or less. About 5% of alcoholic patients experience delirium tremens, which usually develops two to four days after the last drink. Symptoms include fever, rapid heart beat, either high or low blood pressure, extremely aggressive behavior, hallucinations, and other mental disturbances. Although it is not clear if older people with alcoholism are at higher risk for more severe symptoms than younger patients, several studies have indicated that they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Initial Assessment
Upon entering a hospital because of alcohol withdrawal, patients should be given a physical examination for any injuries or medical conditions and should be treated for any potentially serious problems, such as high blood pressure or irregular heartbeat. The immediate goal of treatment is to calm the patient as quickly as possible. Patients are usually given one of the anti-anxiety drugs known as benzodiazepines, which relieve withdrawal symptoms and help prevent progression to delirium tremens. An injection of the B vitamin, thiamine, may be given to prevent Wernicke-Korsakoff syndrome. Patients should be observed for at least two hours to determine the severity of withdrawal symptoms. Physicians may use assessment tests, such as the Clinical Institute Withdrawal Assessment Scale (CIWA), to help determine treatment and whether the symptoms will progress in severity.

Treatment for Withdrawal Symptoms

About 95% of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15% to 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients can nearly always be treated as outpatients. After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms become severe. If possible, a family member or friend should support the patient through the next few days of withdrawal. Benzodiazepines. Benzodiazepines are anti-anxiety drugs that inhibit nerve-cell excitability in the brain and help reduce the risk for seizures. They also relieve withdrawal symptoms, and make it easier for patients to remain in treatment. They include diazepam (Valium), lorazepam (Ativan), midazolam (Versed), and oxazepam (Serax). These drugs vary in how long they are effective. Diazepam has a longer duration of action than lorazepam or midazolam, for example. Typically, the physician may give the patient an initial, or loading, intravenous dose of diazepam with

additional doses given every one to two hours thereafter over the period of withdrawal. This regimen can cause very heavy sedation. Lorazepam and oxazepam are easier for the liver to metabolize than other benzodiazepines and often prove useful for treating alcoholic patients. Some physicians question the use of any anti-anxiety medication for mild withdrawal symptoms. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe and frequent seizures with possible brain damage. Benzodiazepines may be administered intravenously or orally, depending on the severity of symptoms. One study reported that when a single, intravenous dose, lorazepam, was given within several hours of a first alcohol-related seizure, it reduced the risk for subsequent ones. Benzodiazepines are usually not prescribed for more than two weeks or administered for more than three nights per week. Tolerance to these drugs may develop after as little as four weeks of daily use. Physical dependence may develop after just three months of normal dosage. People who discontinue benzodiazepines after taking them for long periods may experience rebound symptoms, sleep disturbance and anxiety, which can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms from the drugs, including stomach distress, sweating, and insomnia, that can last from one to three weeks. Common side effects are day-time drowsiness and a hung-over feeling. Respiratory problems may be exacerbated. Benzodiazepines are potentially dangerous when used in combination with alcohol. They should not be used by pregnant women or nursing mothers unless absolutely necessary. Other Drugs for Mild to Moderate Withdrawal. Beta-blockers, such as propranolol (Inderal) and atenolol (Tenormin), may sometimes be used in combination with a benzodiazepine. This class of drugs is effective in slowing heart rate and reducing tremor. Other drugs being tested are clonidine (Catapres) and carbamazepine (Tegretol). When used by themselves, they do not, however, appear to be effective in reducing seizures or delirium. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe and is showing promise in reducing agitation and seizures.

Treatment for Delirium Tremens, Seizures, and Other Severe Symptoms

People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. Symptomatic patients are usually given intravenous anti-anxiety medications. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to themselves or others. Seizures are usually self-limited and treated with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or in those whose seizures cannot be controlled. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Lidocaine (Xylocaine) may be given to people with disturbed heart rhythms.

WHAT ARE THE LONG-TERM TREATMENTS FOR ALCOHOLISM TO PREVENT RELAPSE?

Psychotherapy and Cognitive-Behavioral Therapy
The two usual forms of therapy for alcoholics are cognitive-behavioral and interactional group psychotherapy based on the Alcoholics Anonymous 12-step program. In one study, all treatment approaches were, on average, equally effective as long as the individual program was competently administered. Those with fewer psychiatric problems, however, did best with the AA approach. This confirms an earlier study in which researchers categorized alcoholics as either Type A or Type B. Type A individuals became alcoholic at a later age, had less severe symptoms or fewer psychiatric problems, and had a better outlook on life than those with Type B. The people in the Type A group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy. Type B people became alcoholic at an early age, had a high family risk for alcoholism, more severe symptoms, and a negative outlook on life. This group did poorly with interactional group therapy but tended to do better with cognitive-behavioral therapy. This difference in response to the two forms of treatments held up after two years. Interactional Group Psychotherapy (12-Step Program ). Alcoholics Anonymous (AA), founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well-known program for helping people with alcoholism. It offers a very strong support network using group meetings open seven days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation. AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends. Cognitive-Behavioral Therapy. Cognitive-behavioral therapy uses a structured teaching approach and may be better than AA for severe alcoholism. People with alcoholism are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. For example, patients might write a history of their drinking experiences and describe what they consider to be risky situations. They are then assigned activities to help them cope when exposed to "cues," places or circumstances that trigger their desire to drink. Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team; this gave them the opportunity to practice coping skills, develop

supportive relationships, and engage in healthy alternative activities. In one study of patients with both depression and alcoholism, this therapeutic approach achieved 47% abstinence rates after six months compared to only 13% abstinence in patients who received standard treatments and relaxation techniques. It appears to be especially effective when used in combination with opioid antagonists, such as naltrexone.

Medications to Aid in Abstinence

Opioid Antagonists. Opioid antagonists are drugs that reduce the intoxicating effects of alcohol and the urge to drink. One of these agents, naltrexone (ReVia), has been found to be very effective for people with low- to moderate alcohol dependency when used with cognitive behavioral therapy. In one 1999 study, for example, 62% of patients taking naltrexone and undergoing such therapy did not relapse into heavy drinking compared with 40% of patients taking a placebo (a "dummy" pill). It does not appear to improve abstinent rates, however. Taking the drug consistently as prescribed by the doctor is very important for its success. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days. An oral form of nalmefene, an opioid antagonist currently available only by injection, is also proving to be effective in preventing relapse in heavy drinkers. Nalmefene blocks more opioid receptors than naltrexone does and may have less of an adverse effect on the liver. Aversion Medications. Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and last from half an hour to two hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for one to two weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. Studies have not shown the use of disulfiram to have any effect on staying abstinent, although it does reduce the frequency of drinking. One study indicated that the drug may be more effective in patients with spouses or other family members or caregivers, including AA "buddies," who are close by and vigilant to ensure that they take it. (Such support, however, probably improves the effectiveness of any treatment.) Another aversion drug, calcium carbimide, was withdrawn from the market. Acamprosate. Acamprosate (Campral) calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies in Europe indicate that it reduces the frequency of drinking. Although it is not clear whether it can improve abstinence, one study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use it cautiously. Combination therapy with naltrexone or disulfiram may be possible.

Antidepressant and Anti-Anxiety Drugs. Depression is common among alcohol-dependent people and can lead to a higher relapse rate. Antidepressants may be helpful, particularly for patients who suffer from both depression and alcoholism. Because of their effect on serotonin, the antidepressants selective serotonin reuptake inhibitors (SSRIs) were of particular interest. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopran (Celexa), and fluvoxamine (Luvox). Studies indicate they may be useful for reducing alcohol intake in heavy drinkers even if they are not depressed, although these drugs appear to have no significant affect on alcoholism itself. Another small study reported that people given the tricyclic antidepressant desipramine (Norpramin, Pertofrane), whether or not they exhibited other symptoms of depression, had fewer drinking days and a longer period between relapses than those not taking the drug. A unique anti-anxiety drug, buspirone (BuSpar), may also be beneficial for alcoholics, particularly if they also suffer from anxiety. The drug has few side effects and a low potential for abuse. It not only reduces anxiety, but also appears to have modest effects on alcohol cravings. In one study, alcoholics who took it had a slow return to alcohol consumption and fewer drinking days than those not on the drug. Another study, however, found no significant effect on alcoholism. Other Drugs. Under investigation are drugs that affect dopamine, the neurotransmitter (chemical messenger in the brain) that produces a sense of reward after drinking. Among these, tiapride, which blocks dopamine, is showing some modest benefits in small European studies. In one small study, isradipine, a calcium channel blocker, reduced cravings more effectively than naltrexone and the antidepressant paroxetine (Paxil). Calcium channel blockers are ordinarily used to treat high blood pressure and other medical conditions. Another drug being investigated for withdrawal and abstinence is gamma-hydroxybutyric acid (GHB). In one small study, 58% of subjects remained abstinent during a six-month period. It should be noted that GHB is sold illegally as a street drug because of its euphoric effects at high doses, which can have serious side effects, including seizures, coma, and respiratory arrest.

WHERE ELSE CAN HELP BE OBTAINED FOR ALCOHOLISM?

Alcoholics Anonymous, World Services, Inc., P.O. Box 459, New York, NY 10163. Call (212-870-3400) or on the Internet (http://www.alcoholics-anonymous.org/) Al-Anon Family Group Headquarters, Inc., 1600 Corporate Landing Pkwy, Virginia Beach, VA 23454-5617. Call (800-344-2666 in the US or 800-443-4525 in Canada) for meetings. Or call (800-356-9996 in the US or 800-714-7498 in Canada) for literature or on Internet (http://www.Al-Anon-Alateen.org/) Al-Anon was started by the wife of the founder of Alcoholics Anonymous to help families of alcoholics. They provide meetings and educational material established along the lines of those of AA. Also available through Al-Anon is Alateen, a support fellowship for adolescents affected by people with alcoholism. (This group is not for teenagers with drinking problems.) National Institute on Alcohol Abuse and Alcoholism, 6000 Executive Boulevard - Willco

Building, Bethesda, Maryland 20892-7003. On the Internet (http://www.niaaa.nih.gov/) National Clearinghouse of Alcohol and Drug Information, PO Box 2345, Rockville, MD 20852. Call (800-729-6686) or on the Internet (http://www.health.org/) Offers many publications on alcohol and substance abuse. Hazelden Foundation, PO Box 11, Center City, MN 55012-0011. Call (800-257-7800 or 1651-257-4010 outside the US) or on the Internet (http://www.hazelden.org/) Maintains chemical dependency treatment centers. Also provides educational materials for adults and adolescents. Their web site is very useful. National Council on Alcoholism, 12 West 21 Street, New York, NY 10010. Call (800NCA-CALL) or (212-206-6770) or on the Internet (http://www.ncadd.org/). Their 800 number is a hotline that requires a touch-tone phone. A recorded message provides local numbers for counseling, help, and information after the caller keys in their zip code. National Organization on Fetal Alcohol Syndrome, 18 C Street North East, Washington, DC 20002 Call (202-785-4585 ) or on the Internet (http://www.nofas.org/)

On the Internet:
Web of Addictions (http://www.well.com/user/woa/) has good links and keeps up with current research. Recovery (http://www.recovery.org/aa/) is a private web site with good links to other sites on alcoholism.

RECENT LITERATURE
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