Alcoholism Overview

Habitual intoxication; prolonged and excessive intake of alcoholic drinks leading to a breakdown in health and an addiction to alcohol such that abrupt deprivation leads to severe withdrawal symptoms. Alcohol problems vary in severity from mild to life threatening and affect the individual, the person's family, and society in numerous adverse ways. In teenagers, alcohol is the most commonly abused drug, and 14% of teens have been intoxicated. Studies have proved withdrawal, for those physically dependent on alcohol, is much more dangerous than withdrawal from heroin or other narcotic drugs. Alcohol abuse refers to excessive or problematic use with one or more of the following:
1. 2. 3. 4.

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.

Alcohol dependence refers to a more serious disorder and involves excessive or maladaptive use leading to three or more of the following:
1. 2.

3. 4. 5. 6. 7. 8.

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, 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 Continuing to drink despite knowing alcohol use has caused or worsened problems Binge drinking (consuming several drinks over a short period of time)

Causes of Alcoholism The cause of alcoholism is not well established. There is growing evidence for genetic and biologic predispositions for this disease, but this research is controversial. Studies examining adopted children have shown that children of alcoholic biological parents have an increased risk of becoming alcohol dependent as well. Relatively recent 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. Statistics show alcohol problems are highest among adults aged 18-29, and those who start drinking before age 21 are at higher risk for developing alcoholism. 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 (those are tolerance changes and withdrawal symptoms). Alcohol abuse and alcoholism are associated with a broad range of medical, psychiatric, social effects, legal, occupational, economic, and family problems. For example, parental alcoholism underlies many family problems such as divorce, spouse abuse, child abuse and neglect, welfare dependence, and criminal behaviors, according to government sources. 1. The great majority of individuals with alcoholism go unrecognized by physicians and health care professionals. This is largely because of the person with alcohol dependence 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. 2. 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 providers. 3. Individuals with alcoholism, 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. Therefore, signs of a drinking problem and symptoms often vary from person to person. There are, however, certain behaviors and signs that indicate someone may have a problem with alcohol. These behaviors and signs include 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. 4. Signs and symptoms of chronic alcohol abuse include medical conditions such as pancreatitis, gastritis, cirrhosis, neuropathy, anemia, cerebellar atrophy, alcoholic cardiomyopathy (heart disease), Wernicke's encephalopathy (abnormal brain functioning), Korsakoff's dementia, central pontine myelinolysis (brain degeneration), seizures, confusion, malnutrition, hallucinations, peptic ulcers, and gastrointestinal bleeding. Compared with children in families without alcoholism, children of alcohol dependent individuals are at increased risk for alcohol abuse, drug abuse, conduct problems, anxiety disorders, and mood disorders. Alcoholic individuals have a higher risk of psychiatric disorders and suicide. They often experience guilt, shame, 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 to Seek Medical Care People who drink alcohol to the point that it interferes with their social life, professional life, or 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 one in three motor-vehicle fatalities, 50% of drownings, nearly 20% of firerelated deaths, and up to 50% of homicides. It is imperative that emergency care be sought immediately when alcohol has contributed to an injury. This is very 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 that they have a fractured neck vertebra (broken neck) until it is too late (that is, 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: 1. During the tremulous stage, the person will exhibit a tremor 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. 2. Seizures often follow the tremulous stage. They are commonly generalized seizures during which the entire body shakes uncontrollably and the person loses consciousness. Seizures can occur in people withdrawing from alcohol. If you see someone having a seizure, attempt to lay the person on one side so they don't inhale any 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. 3. 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. 4. The most dangerous stage of alcohol withdrawal is called delirium tremens (DTs). 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, sweating, hallucinations, rapid heart rate, and high blood pressure. This is a true emergency. Studies have shown that death will

occur in about 35% of these people if they are not treated promptly. Even with appropriate medical treatment, this condition is associated with a 5%-15% death rate. Alcoholism is often associated with other psychiatric disorders such as anxiety, depression, and psychosis. This psychiatric illness, often combined with a reduced level of sound judgment while intoxicated, leads to suicides, suicide attempts, and suicidal gestures 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. Alcoholism Diagnosis The diagnosis of alcoholism is generally made by reviewing the person's behavior except when the person has symptoms of withdrawal or damage to organs as a result of alcohol consumption. Alcoholism, 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 alcohol dependency can be interpreted in different ways by different people. This often makes the diagnosis of alcoholism somewhat difficult. Several screening tests are routinely employed by many health care professionals 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. 1. The Michigan Alcoholism Screening Test (MAST) is a 22-question quiz often used in a clinical counseling setting. 2. 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)? 3. The TACE questionnaire is very 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. i. How many drinks does it Take to get you high? ii. Have people Annoyed you by criticizing your drinking? iii. Have you ever felt you ought to Cut down on your drinking? iv. Have you ever had a drink first thing in the morning to steady your nerves (Eye opener)? 4. The doctor may draw blood to evaluate your liver functions, 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.

5. 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).

Alcoholism Treatment
Self-Care at Home 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 disorders associated with alcoholism. In fact, 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 These skills include, but are not limited to, the following: 1. Learning to identify and manage what leads to cravings for alcohol ("triggers") 2. Resisting social pressures to engage in substance use 3. Changing health care habits and lifestyle (for example, improving diet and sleep hygiene, and avoiding high-risk people, places, and events) 4. Learning to challenge alcoholic thinking (thoughts such as, I need a drink to fit in, have fun, or deal with stress) 5. 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) 6. Learning to deal with emotions (anger, anxiety, boredom, depression) and stressors without reliance on alcohol 7. Identifying and managing relapse warning signs before alcohol is used 8. Anticipating the possibility of relapse and addressing high-risk relapse factors Medical Treatment 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, psychologists, family therapists, psychologists, 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: It is the treating doctor's responsibility to treat any medical conditions related or unrelated to alcoholism. Vast arrays of medical and surgical complications are associated with alcoholism, but only stabilization of alcohol withdrawal and alcoholic ketoacidosis are discussed here. 1. 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 are benzodiazepines. Commonly used medications in this class are 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. 2. 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 withdrawal and is then gradually tapered off until no withdrawal symptoms are evident. This usually requires a few days to a week. Recently, as physicianassisted, outpatient detoxification has become popular it may become more difficult to obtain coverage for in-hospital detoxification. 3. 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). a. 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. b. Outpatient counseling (individually, in groups, or with families) can be used as a primary treatment or as a "step-down" for people as they come out of a residential or structured day program. c. 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. 4. Several medications are available to assist the person in abstaining from alcohol consumption. a. 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. 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, which can lead to visual disturbances and eye pain. b. Other medications used in preventing relapse are naltrexone (ReVia), acamprosate (Campral), and a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).

Follow-up
The person suffering from alcoholism must first make the decision that he or she must stop using alcohol. Without such a resolve, achieving long-term sobriety is unlikely. 1. To avoid an impulsive relapse, the person's home should be alcohol-free. 2. The person should enroll in a social support group or counseling program. Also, social situations that encourage alcohol consumption should be avoided. 3. 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.

Prevention of 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 that you are at increased risk of becoming dependent on alcohol. Increased awareness of such a risk 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

Prognosis of Alcoholism
Remaining alcohol-free is a very difficult task for most people with alcohol dependency. Individuals who do not seek help after detoxification may have a relapse rate as high as 50%-60%. a. Four key factors may influence 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 b. 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. c. Alcoholism 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 illnesse.