Alcoholism

According to recent national surveys, most noninstitutionalized individuals in the United States who are 12 years of age or older drink beverages containing alcohol. In the year 2000 national survey, more than 60 percent of the respondents said that they drank alcohol in the last year and more than 46 percent said that they used it in the past month. However, “alcoholism” usually refers broadly to the use of alcohol that is associated with problems of various kinds, including health, legal, family, social, employment, or psychological. In the United States (and the rest of the Western world), although widely used, “alcoholism” is not a formally defined term. Instead, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), (American Psychiatric Association, 1994), which is the psychiatric diagnostic system followed most commonly in the United States, defines two “alcohol use disorders”: alcohol dependence and alcohol abuse. Most Americans who use alcohol do not meet the criteria for either of these disorders; in the United States, estimates of the prevalence of either current (last 12 months) alcohol abuse or alcohol dependence among adults who drink alcohol typically range around 10 percent, with the majority of diagnoses being alcohol abuse.

Alcohol dependence is most analogous to what traditionally has been called “alcoholism.” The DSM lists seven criteria for alcohol dependence, three or more of which must be met to make the diagnosis. The criteria refer to tolerance to alcohol, evidence of physical dependence on it, and cognitive and behavioral features that accompany the procurement of alcohol and its consumption. There are four criteria for alcohol abuse, and one or more of them must be met to make the diagnosis. The criteria focus on the negative consequences of alcohol use in different areas of life functioning. According to the DSM, dependence and abuse are mutually exclusive diagnostic categories, and a diagnosis of dependence preempts assigning a diagnosis of abuse.

Tolerance to and Dependence on Alcohol

Regular use of alcohol results in tolerance to it, which means that more alcohol must be consumed to experience an effect once reached with a lesser amount, or that a given dose of alcohol has less of an effect than it did earlier in the individual’s drinking history. With chronic, heavy drinking, physical dependence on alcohol may develop. This means that with a decline in the amount of alcohol in the blood or with the complete cessation of drinking, a pattern of physical and psychological symptoms appears that is associated with the passage of time. Alcohol withdrawal can be severe and may be fatal if not managed with established medical treatment protocols. The full train of symptoms that define the alcohol withdrawal syndrome may take 5-7 days to run its course.

Acute Effects of Alcohol

“Acute effects” refer to the physical, psychological, and social consequences experienced upon consuming a given amount (dose) of a drug. Alcohol is a drug that has pervasive effects on the body and thus has a variety of acute effects. Generally, alcohol is classified as a depressant drug, based on its action on the central nervous system (brain and spinal cord), and its effects are proportional to the amount of alcohol in the blood. Therefore, as the dose of alcohol consumed increases, its acute effects tend to increase in number and intensity. For example, for the “average” drinker who is not highly tolerant to alcohol, having one or two drinks typically is associated with feelings of warmth, well-being, relaxation, and happiness. Following the consumption of three or four drinks, these same effects become more noticeable, and there often are more exaggerated changes in emotion, judgment (more impaired), and inhibitions (lowered). Consumption of higher amounts of alcohol is associated with evidence of slowed reaction time, impaired muscle coordination, and further impairment in judgment. In the United States, the legal level of intoxication is 0.08 percent in 24 states and the District of Columbia and 0.10 percent in 25 states (one state does not have a “per se” legal level of intoxication). For a reference, if a 160-lb man had about five drinks (each containing the equivalent of 0.6 ounces of pure alcohol) in a 2-hr period, he would be legally intoxicated according to the 0.10 percent criterion; it would take slightly less than four drinks to be legally intoxicated according to the 0.08 percent criterion. If an individual who weighs 160 lb drinks about 25 ounces of hard liquor (e.g., gin, scotch, or vodka) that is 40 percent alcohol in 1 hr, there is a 50 percent chance that death will result.

In discussing alcohol’s acute effects, it is essential to comment on driving skills. The problem of driving while under the influence of alcohol has been a problem for many years, but it has been widely recognized in the United States as a major public health problem only in the last two decades. A strong case can be made that alcohol can be a causal factor in motor vehicle accidents; this becomes a major public health problem because fatal automobile crashes are the most common nonnatural cause of death among individuals aged 1-24 years. Although the rate of association of alcohol with fatal motor vehicle crashes has declined over the last two decades, it still approaches 40 percent. Indeed, in an individual who weighs 160 lb, driving skills may begin to show impairment after the consumption of about two drinks over a 2-hr period.

Chronic Effects of Alcohol

The effects of chronic, heavy drinking are the major reasons for the public’s concern about the alcohol use disorders. It is well known that a relatively long history of heavy alcohol use is associated with often severe impairment in psychological and social functioning. Furthermore, because alcohol’s effects on the body are so pervasive, chronic heavy alcohol use may have major damaging effects on a variety of body systems. Before describing these effects, it is important to say that “chronic, heavy use” of alcohol is difficult to define. However, it can be said with confidence that the chronic effects on the body that will be described here often take years to develop, and that people vary considerably in their susceptibility to alcohol’s chronic effects.

Chronic heavy alcohol use can affect the following body systems. Central nervous system functioning (reasoning, memory, judgment) may show specific and general impairments, which may be reversible, if there is no structural damage to the brain, with years of abstinence for alcohol. The liver is directly affected by alcohol because it is the primary site where the body metabolizes this drug. Damage to the liver may be reversible (“fatty” liver and alcohol hepatitis) or may be irreversible (cirrhosis, or scarring of the liver). The cardiovascular system may be affected, as there is increased mortality from coronary heart disease and increased risk for heart disease in general. Alcohol cardiomyopathy (alcohol-induced wasting of the heart muscle) also is a possible consequence. Alcohol can affect the endocrine system by altering the secretion of hormones in different hormone hierarchies or “axes.” These include the hypothalamic-pituitary-adrenal axis and the hypothalamic-pituitary-gonadal axis. The latter axis influences sexual behavior and reproductive function. The immune system may be compromised by alcohol, so that the individual has increased susceptibility to various diseases. Alcohol may affect the gastrointestinal system and lead to the development of gastritis and increase the risk of contracting pancreatitis. Finally, alcohol is associated with higher risk of contracting various cancers, including oral cavity, tongue, pharynx, larynx, esophagus, stomach, liver, pancreas, colon, and rectum cancer.

Before leaving this section, it is important to cite a chronic alcohol effect that does not focus on a specific body system or the drinker. Rather, the focus is alcohol’s effect on the fetus if the mother drinks during pregnancy. Because fetal alcohol syndrome has its own entry in this book, it is not discussed further here. However, it is essential to say that research has not established a “safe” level of alcohol consumption during pregnancy. As a result, the only guaranteed way to avoid fetal alcohol effects is not to use alcohol at all during pregnancy.

Moderate Drinking and Health

Despite the preponderance of evidence that drinking heavily over a long term can result in severe and sometimes fatal health consequences, there are data showing that a long-term pattern of “moderate” drinking is associated with better health. Here, “better health” has been defined as cardiovascular health, and “moderate” means one to three drinks a day. The association of moderate alcohol use and health has been researched fairly intensely for more than 10 years, and previously there was skepticism that the association is real. However, more recent, better-designed studies have provided support for the moderate alcohol use-cardiovascular health association. Alcohol appears to increase the production of high-density lipoproteins as well as alter other biological indicators of risk of cardiovascular disease.

Etiology of Alcohol Use Disorders

Given the major cost of alcohol use disorders in both human and financial terms (over $ 166 billion in the United States in 1995), it is not surprising that numerous theories about their development (etiology) have been proposed. Traditionally, these theories have reflected only one set of factors, either biological, psychological, or social/environmental. The research that these theories helped to generate typically could provide some support for a given theory, but also left many questions unanswered.

More recent theories of the etiology of the alcohol use disorders have been consistent with other areas of health-related behaviors in taking a “multivariate approach.” That is, research suggests that “single-factor” theories of the etiology of the alcohol use disorders are inadequate. Instead, biological, psychological, and social/environmental variables must be considered simultaneously if a theory that can explain the etiology of the alcohol use disorders is to be generated. For example, there is strong evidence that there is a genetic predisposition to some manifestations of alcohol use disorders, especially more severe types in males. However, whether such an inherited predisposition (“what” is inherited is a matter of considerable controversy and research) is expressed later as alcohol use disorder may depend on the existence of specific personality characteristics in the individual and the social environments reaction to them. An overarching factor is the attitudes and norms regarding alcohol consumption in the society or subculture that the individual lives in.

Treatment of Alcohol Use Disorders

Treatment of behavioral problems like the alcohol use disorders refers to systematic activities that are designed to change some pattern of behavior(s) of individuals or their families. In discussing the alcohol use disorders, the primary target of change is drinking behavior. However, because heavy alcohol use over a long period of time may affect an individual or his or her family in a number of areas of life functioning, treatment may target these other areas as well, depending on the individual’s needs and goals.

If there is recognition that there is need for modification of an individual’s drinking pattern, whether it comes from external pressures (such as an employer) or from within the individual himself or herself, then change may occur in a variety of ways. For example, a considerable number of people modify their patterns of alcohol use on their own, without the use of any kind of treatment. This has been referred to as “spontaneous remission.” In addition, people may attend peer self-help groups to help them change; probably Alcoholics Anonymous (AA) is the peer self-help group that is most widely known. Because there is a separate entry on AA in this book, it is not discussed further here. However, it does warrant mention that millions of people in the United States (and around the world) attend AA groups. It also is important to mention that, in recent years, alternative (to AA) self-help groups have become available to assist people in modifying their alcohol (or other drug) use. Some examples of these alternative groups include Women for Sobriety, Self-Management and Recovery Training (SMART), and Secular Organizations for Sobriety (SOS).

Before proceeding in this section, it should be mentioned that “modifying alcohol use” as a goal can mean stopping altogether (abstinence) or reducing alcohol use but not committing to abstinence. In the United States, by far the goal that is supported most in the professional and self-help (one exception is the self-help group called Moderation Management) treatment communities is abstinence. However, it is becoming more widely accepted in the United States that moderation to levels of use not associated with problems is a feasible goal for individuals who desire it, whose alcohol use disorder is not severe (e.g., abuse rather than dependence), and whose social life is relatively stable (employed, in a stable relationship, has a permanent residence). There also is support for a moderation treatment goal from those who follow a “harm reduction” model, which focuses on using treatment to reduce the negative consequences of alcohol use rather than targeting alcohol consumption. Typically, however, a focus of reducing negative consequences of use also means addressing amount of use because they are directly related. That is, as one increases, the other tends to as well.

The first consideration in professional treatment provision is whether the individual needs detoxification from alcohol, which is necessary if physical dependence is present. Established protocols are available to manage detoxification medically, and they may be delivered in some cases in the outpatient setting. If further professional treatment is sought, then the individual has a wide variety of options, depending on factors such as severity of his or her alcohol problem, presence of another psychiatric problem, such as depression or anxiety, desired level of treatment intensity or of treatment type, and financial resources. For example, treatment activities may occur in inpatient, outpatient, hospital, or residential settings, and may vary in their duration. By far the most common treatment setting is outpatient, as inpatient or residential settings typically are reserved for treatment of more severe problems. Treatment components may be “psychosocial” or pharmacological. Due to the number of areas of life functioning that may be affected in individuals with alcohol use disorder, psychosocial treatment components cover a wide variety of activities, and may be delivered in individual, couples/family, or group modalities. Professional treatment programs may also recommend self-help group attendance to complement their treatment services. Another option is the use of “brief interventions” for individuals whose problems are less severe. Pharmacological treatments involve the use of medication to help the individual abstain from alcohol use. The drug that has been used for the longest time in the treatment of alcohol use disorders and that is available in the United States is disulfiram (trade name Antabuse). The chemical action of disulfiram results in an increase in the blood level of acetaldehyde after alcohol consumption. The consequence of the heightened acetaldehyde depends on how much alcohol is drunk. For people on therapeutic doses of disulfiram, one or two drinks will produce flushing, tachycardia (excessively rapid heartbeat, usually a pulse rate of over 100 per min), tachypnea (excessively rapid respiration), sensations of warmth, heart palpitations, and shortness of breath. These effects usually last about 30 min and are not life threatening. However, if larger quantities of alcohol are consumed, the reaction may include intense palpitations, dyspnea (difficult or labored breathing), nausea, vomiting, and headache, all of which may last more than 90 min. The notion is that individuals will avoid alcohol to avoid these unpleasant consequences of drinking when a therapeutic level of disulfiram is in the blood.

In 1995, the Federal Drug Administration also approved the use of naltrexone in the treatment of alcohol use disorder. A considerable amount of research is in progress in the development or evaluation of additional medications. It is essential to note that medications are typically used in conjunction with psychosocial treatment components.

Effectiveness of Alcohol Treatment

An important question concerns whether alcohol treatment is effective. Overall, research has not identified a psychosocial treatment that generally is effective for everyone, but it has shown that staying involved in treatment is associated with better outcomes than is dropping out. It also appears that there are several treatment approaches that have shown promising results in controlled clinical research, and these include motivational enhancement therapies. It also appears that “matching” selection of treatment setting or content to the individual’s characteristics, such as marital or employment status or severity of co-occurring psychiatric problems, can be beneficial. Unfortunately, due to the principles of AA, particularly anonymity, it has proved extremely difficult to conduct controlled clinical trials of its effectiveness, so that no firm answers to that question are available.

Except for disulfiram, which has been available since the early 1950s, there are relatively little data on the effectiveness of pharmacotherapies. The findings on disulfiram effectiveness have been inconsistent, perhaps in part because the relevant studies have not always been done well. However, it does seem that disulfiram effectiveness can be enhanced considerably if part of the treatment consists of supervised administration of the required dose, say with the cooperation of the individual’s spouse. Naltrexone, the other approved pharmacotherapy for alcohol use disorders in the United States, has shown modest effectiveness. Research on this drug continues. Finally, the use of medications designed for treating depression and anxiety also has shown promise in the treatment of alcohol use disorders. This is especially the case in individuals who present with symptoms of anxiety or depression along with alcohol problems.

Relapse

A major problem for clinicians who treat alcohol use disorders (or other addictions) is relapse, which broadly refers to the reappearance of a problem following some period of its (voluntary) resolution. Although relapse is an aspect of alcohol treatment that clinicians have struggled with for many years, it has been only recently (last 20 years) that systematic relapse prevention methods have been developed and applied on a wide scale in clinical settings. The problem of relapse is common; if a return to alcohol use after a period of abstinence of more than 1 year following treatment is defined as relapse (other definitions are possible), then it can be expected that about 80 percent of individuals will relapse. Theories of relapse have been generated, and most relapse prevention methods involve application of principles of learning theory and cognitive psychology. In fact, relapse prevention typically is part of alcohol treatment and is not a stand-alone intervention because it concerns sustaining any changes made in treatment over the long-term.

Summary and Conclusions

This entry has provided an extremely brief overview of alcohol use, its acute and chronic effects, alcohol use disorders, and their treatment. Alcohol is a drug that is used by most American adults, and for a small but significant percentage of them, such use is associated with problems for the individual, for his or her interpersonal relationships, or in larger social contexts such as employment or the legal system. However, in the last 25 years, research has considerably improved our knowledge about what causes alcohol use disorders and about ways to modify alcohol use and related behaviors so that individuals who choose to change their drinking patterns have effective ways of doing so available to them.