Alcoholism I. INTRODUCTION Alcoholism, chronic and usually progressive illness involving ingesting inappropriately high levels of ethyl alcohol, whether in the form of familiar alcoholic beverages or as a constituent of other substances. Alcoholics will drink to such an extent that that they exhibit an emotional and often physical dependence on alcohol classified by the World Health Organization (WHO) in 1977 as alcohol dependence syndrome. This term continues to be included in the International Classification of Diseases (10th revision). The transition between continued excessive alcohol consumption and alcoholism is an individual behaviour and the condition of degrees rather than absolutes: low risk or sensible; increasing risk or hazardous; high risk or harmful. It is thought to arise from a combination of a wide range of physiological, psychological, social, and genetic factors. Alcoholism frequently leads to brain damage or early death. More men than women are directly affected by alcoholism. The heaviest drinkers have traditionally been men in their late teens or early twenties, but drinking among the young generally and among women is increasing. Peer pressure is likely to play an important role in encouraging the young to start drinking. In the developed world, male and female drinking patterns are converging. Binge drinking (heavy episodic drinking) among young women is a particular cause for concern. For various physiological reasons, besides smaller body-size, women are less able to tolerate alcohol. Consumption of alcohol is apparently on the rise in the United Kingdom and the United States, as is the total alcohol consumption and prevalence of alcohol-related problems in the former communist countries of Eastern Europe and the former Soviet Union (where alcohol is often produced at home). It is estimated that alcohol-use disorders reached 10 per cent of the adult male population in North America and Eastern Europe in 2000. This increase is paralleled in other countries, including developing nations, where home production is also common and therefore consumption is much more difficult to control through legislation. The WHO calculates that alcohol-related problems account for about 4 per cent of the global disease and injury burden. For comparison, tobacco use accounts for 4.1 per cent and high blood pressure 4.4 per cent. In the developed world, 9.2 per cent of disability-adjusted life years (DALYs) lost are due to alcohol. In the developing world, the figure is 6.2 per cent, but as a contribution to disease, injury, disability, and premature death, it is the single greatest risk factor. An excessive alcohol intake is frequently associated with other high-risk behaviours, for example, unsafe sex and the use of other psychoactive drugs. This pattern leads to co-morbidity with the ill health caused by other forms of drug dependence, sexually transmitted diseases, and, for women, unplanned pregnancy. In addition to the self-inflicted harm caused by alcoholism, an alcoholic presents a danger to those living in close contact. Rates of domestic violence are higher where there is an alcoholic in the family, and the general standard of living is frequently compromised. The social costs of heavy drinking also include death and injury caused by drink driving and the added burden on healthcare providers of dealing with accidents and intentional harm. The WHO estimated that in 2000, 1.8 million deaths (3.2 per cent) were due to the use of alcohol. In studies in the United Kingdom, United States, and Sweden it is estimated that the mortality rate among excessive drinkers is twice that otherwise expected. Among women aged between 15 and 39 years it may be as high as 17 times greater. II. DEVELOPMENT Until the 1960s, when a medical model of alcohol was strongly advocated and entered the mainstream, a moral view of excessive alcohol use predominated. This sought to punish rather than help the victim. While attitudes have changed considerably, blaming the victim is still part of society s purview of alcoholics and can affect legislation to control alcohol availability, for
instance those who drink and drive, and cause harm, are frequently demonized in the media for their alcohol intake. Among medical personnel, alcoholism, as opposed to merely excessive or irresponsible drinking, has been thought of as a symptom of psychological or social stress, or as a learned, maladaptive, coping behaviour. More recently, and probably more accurately, it has come to be viewed as a complex disease in its own right with a neurological model for alcohol reward, tolerance, and dependence. While the medicalization of alcoholism undoubtedly offers a more humane and effective treatment policy than the moral view, it does mean that only certain people are perceived to constitute the at risk group. In fact, anyone who drinks excessively over a long period of time has the potential to cross the boundary between this stage of drinking and alcoholism, where removing access to alcohol would result in alcohol dependence syndrome. A family history of alcoholism is one of the strongest predictors of risk. Heritability is estimated at between 45 and 65 per cent. It is thought that the genetic basis for alcoholism may include congenital abnormalities in the brain s neurotransmitter systems involving dopamine, opioid, and serotonin. Alcoholism usually develops over a period of years. Early and subtle symptoms include placing excessive importance on the availability of alcohol. Ensuring this availability strongly influences the person's choice of associates or activities. Alcohol comes to be used more as a moodchanging drug than as a foodstuff or beverage served as a part of social custom or religious ritual. Initially, the alcoholic may demonstrate a high tolerance to alcohol, consuming more and showing fewer adverse effects than others. Subsequently, however, the person begins to drink against his or her own best interests, as alcohol comes to assume more importance than personal relationships, work, reputation, or even physical health. The person commonly loses control over drinking and is increasingly unable to predict how much alcohol will be consumed on a given occasion or, if the person is currently abstaining, when the drinking will resume again. Physical addiction to the drug may occur, sometimes eventually leading to drinking around the clock to avoid withdrawal symptoms. III. EFFECTS Alcohol has direct toxic as well as sedative effects on the body, and failure to take care of nutritional and other physical needs during prolonged periods of excessive drinking may further complicate matters. Alcoholics frequently suffer from protein deficiency and lack of B vitamins. Advanced cases often require hospitalization for alcohol-related disabilities, and specialist psychiatric units may be necessary to deal with the withdrawal symptoms associated with the most severe aspects of alcohol dependence syndrome. Excessive alcohol consumption compromises virtually all the major organ systems of the body and the effects are cumulative. Among the primary causes of excess mortality resulting from alcohol abuse are liver disease, severe respiratory infections, cancer (most commonly of the digestive system and upper respiratory system), cardiovascular disease, suicide, and the effects of violence and accidents. A. Liver The liver is the body s primary site of alcohol metabolism and is supplied directly with blood from the intestines via the portal vein, which in heavy drinkers will contain large amounts of alcohol. The liver tissue is subject to two main types of damage resulting from this overexposure: inflammation (hepatitis) and scarring (cirrhosis). Women are more adversely affected than men, probably because of a harmful interaction of female sex hormones and the enzymes involved in alcohol metabolism. Genetic differences in enzyme metabolism may account for other individual differences in the severity of liver disease, but overall the risk of death from cirrhosis of the liver is ten times higher among alcoholics than the normal population.
B. Respiratory Infections The symptoms of pulmonary diseases, for example pneumonias, are increased in alcoholics due to the combined effects of decreased respiratory rate, airflow, and oxygen transport, and a reduction in efficacy of the defences of the pulmonary system. C. Cancer Cancers of the liver develop as further results of the damage caused by hepatitis and cirrhosis. Infection with hepatitis B and C further increases the risk of liver cancer associated with alcoholism. The incidence of oesophageal cancers increases because of the local action of alcohol-metabolizing enzymes and increased production of cytochromes in the mucus membrane. The combination of heavy smoking and drinking further increases the risk of oesophageal cancer. The risk of cancers of the skin, breast, thyroid, larynx, nose, and throat is elevated and may be due to alcohol s effects in depressing the immune system. D. Cardiovascular Disease Alcoholism increases the likelihood of arrhythmias, cardiomyopathy, and death from a sudden cardiac incident. There is also a 250-450 per cent increased risk of a stroke due to alcoholrelated hypertension. E. Suicide The second most frequent psychiatric disorder among suicides is alcoholism, occurring in at least 15-25 per cent of deaths. In a UK study among those who had received in-patient treatment for their alcoholism, the suicide rate was 80 times higher than in the general population. Those most at risk were older men who had been drinking heavily for many years, suffered from clinical depression, and had previously tried to commit suicide. The next most at-risk group included those with an alcohol-related physical illness, problems with a spouse, the workplace, or the law. This illustrates the complex nature of treating alcoholism, trying to disentangle the primary from the secondary causes of excessive drinking. F. Violence and Accidents The WHO statistics for global DALYs lost due to unintentional injuries associated with alcohol are 13 per cent, and almost 15 per cent for intentional injuries (suicide and homicide). Risk and severity of injury are positively correlated with the amount of alcohol consumed. Alcohol is implicated in between 15 and 63 per cent of fatal falls, between 33 and 61 per cent of fatal burns, and 44 per cent of fatal road traffic accidents. In studies from emergency rooms, half of those who enter and die from unintentional injuries have positive blood-alcohol levels. In addition to these major causes of mortality, alcohol-related morbidity includes digestive system disorders such as ulcers and inflammation of the pancreas. Alcoholics suffer from endocrine disorders, because of the direct toxic effects and the secondary effects of impaired liver function and malnutrition. Osteoporosis in women and men is more common, for instance, because of the impaired production of sex hormones. The central and peripheral nervous systems can be permanently damaged. Blackouts, hallucinations, and extreme tremors may occur. Alcoholics are subject to epileptic fits and cerebellar degeneration. Head injury is a common side effect of heavy bouts of drinking. Delirium tremens, the most serious aspect of alcohol withdrawal syndrome, appears 24-48 hours after ceasing drinking. Symptoms, which result from biochemical changes causing overactivation of the autonomic nervous system, include severely disordered mental activity,
disorientation, aberrant memory states, visual and other hallucinations, insomnia, headache, nausea, vomiting, shaking, restlessness, and seizures. The symptoms intensify and then decrease over two to three days. Delirium tremens can prove fatal despite prompt treatment, although fewer than 10 per cent of alcohol-dependent patients are at risk of death from these symptoms. By contrast, withdrawal from opiate drugs such as heroin, although distressing, rarely results in death. Recent evidence has shown that heavy and even moderate drinking during pregnancy can cause serious damage to the unborn child: physical or mental retardation, or both. At its most severe this damage is known as foetal alcohol syndrome, which is estimated to be present in 1 in 1,000 live births among the general obstetric population and in 4.3 in 100 live births among women who drink heavily. Less severe alcohol-related birth defects include lower birth weights, lower placental weights and heights, and smaller circumference of the head. There is a higher rate of stillbirth and neonatal death. Surviving children may go on to show decreased cognitive abilities and higher levels of attention deficit disorder. Women who continue to drink during pregnancy often frequently smoke and generally pay less attention to their nutritional status, repeating the usual pattern of alcohol abuse. IV. TREATMENT Treatment of the illness increasingly recognizes alcoholism itself as the primary problem needing attention, rather than regarding it as always secondary to another, underlying problem. The formal discipline of addiction medicine includes alcoholism along with other forms of drug dependence or substance abuse. The WHO prefers the non-pejorative term drug dependence over addiction, but societies of addiction medicine continue to function as professional organizations in many countries. Specialized residential treatment facilities offering detoxification, residential rehabilitation, and participation in a therapeutic community, as well as separate units within general or psychiatric hospitals, are rapidly increasing in number. However, many patients can be treated equally well on an outpatient basis. As the public becomes more aware of the nature of alcoholism, the social stigma attached to it decreases, alcoholics and their families tend to conceal it less, and diagnosis is not delayed as long. Earlier and better treatment has led to encouragingly high recovery rates. In addition to managing physical complications and withdrawal states, treatment involves individual counselling and group-therapy techniques aimed at complete and comfortable abstinence from alcohol and other mood-changing drugs of addiction. These approaches are now supported by successful clinical trials. It is also recognized that family support and community-based self-help groups can also materially affect a patient s ability to remain an abstainer. Such abstinence, according to the best current evidence, is the desired goal, despite some highly controversial suggestions that a safe return to social drinking is possible. A return to supposedly limited alcohol use is often quickly followed (sometimes in few days) by a return to the old pattern of excessive abuse. Addiction to other drugs, particularly to other tranquillizers and sedatives, poses a major hazard to alcoholics. Pharmacological therapies include the drug disulfiram (Antabuse), sometimes used after withdrawal. Disulfiram blocks the metabolism of acetaldehyde (the primary breakdown product of alcohol). If a person drinks while taking the drug, the subsequent build-up of toxic acetaldehyde in the body is extremely unpleasant. It is hoped that this negative reinforcement will help to prevent the patient from drinking. However, this therapy relies upon patient compliance. Naltrexone interferes with uptake of opiate drugs in the brain and prevents the reinforcing effects of these drugs in the brain. It also prevents the reinforcing effects of alcohol and may offer a better pharmacological solution to treating alcoholism. Alcoholics Anonymous (AA), a support group commonly used for those undergoing other treatment, in many cases helps alcoholics to recover without recourse to formal treatment. The motto of AA is One drink, one day at a time, and its members aim for abstinence. Public anonymity is respected. Attendees are supported by those who have themselves formerly been alcoholics and follow AA s 12-step plan to recovery. A buddy system provides additional
support outside meetings. Acknowledging that an individual has a problem underpins the recovery plan. V. PREVENTING EXCESSIVE ALCOHOL CONSUMPTION Acknowledging that alcoholism is a defined medical condition and working towards sustainable treatment have been important developments. Many specialists now consider that concentrating only on those whose drinking is severe enough to lead to alcohol dependence syndrome fails to reach those who engage in excessive alcohol consumption and that greater success in preventing alcoholism could result from recognizing and treating harmful or hazardous alcohol consumption either by reducing alcohol intake or abstaining. Patients with alcohol problems typically seek medical attention at the primary health care level nearly twice as often than those drinking little or nothing: gastrointestinal and psychiatric complaints and accidents being the most frequent reasons such people consult their doctor. In the United Kingdom, out of 2,000 general practitioner (GP) visits, 140 will be made by moderate and heavy drinkers. The GP is likely to be aware of the contributory effect of alcohol at best in only half of the drinkers. The figures for alcohol-related surgical and general medical inpatients are 30 per cent of male and 15 per cent of female admissions, with a similarly poor understanding of the contributing factor. In response to these statistics, primary care doctors have been encouraged to include questions about the amount of alcohol use as part of routine clinical encounters and then ask the four CAGE questions: Have your tried to Cut down on your drinking? Do you get Annoyed when people talk about your drinking? Do you feel Guilty about your drinking? Have you ever had an Eye-opener (a drink first thing in the morning)? If alcohol use is considered to be problematic, it is then possible to offer a brief intervention, which might range from a few minutes of structured advice to a series of counselling sessions from a trained professional (doctor, nurse, or counsellor). Trials of such brief interventions in clinical settings have proven positive in the developed world with heavy or problematic drinkers, especially males. A UK study reported a 13-per-cent-reduction in the proportion of heavy drinkers after such advice. Similarly, in Sweden, reduced absenteeism from work and fewer days in hospital followed the initiation of brief interventions, with a small but significant improvement in mortality reported. It may be a slow process that does not succeed the first time, but as a public health approach it appears to be valid and can be implemented in conjunction with other more traditional fiscal and legislative approaches. Increasing access to treatment services including working with lay-groups, such as AA, has measurable benefits at the population level, measured not least by a decline in deaths due to cirrhosis of the liver (data from Canada, the United States, and Sweden). A study of the range of national policies aimed at reducing alcohol consumption and preventing alcoholism rated the following ten most highly: A minimum legal age for purchasing alcohol most often it is 18 years, but where it exists varying between 16 and 21 years. A government monopoly for the sale of alcohol. Restricting sales by limited hours and/or days of sale. Controlling the number of places where alcohol is sold in a given area. Taxation most often successful among the young with lower disposable income, although evidence suggests this might need to be weighted more heavily at the cheaper end of the market. Checks for sobriety. Reducing the legal permitted level of alcohol in the blood. Suspension of driving licences for drink-driving.
Zero limit for alcohol in the blood of newly qualified drivers, raising after time to the generally permitted level. Use of brief interventions. The direct effect of such measures is most easily traced in reduced fatalities from road accidents involving the use of alcohol. Other policies include health warnings on alcohol containers and the limitation of advertising of alcoholic drinks. Television advertising for instance can be banned during those periods when it is anticipated that young people will form a substantial part of the viewing audience. The success of similar anti-tobacco legislation may be informative. These initiatives will necessarily have a greater effect in the developed world than the developing world since they rely upon a sophisticated infrastructure. In Europe, the European Alcohol Action Plan of the WHO is dedicated to reducing alcohol consumption. Globally, the WHO encourages its member states to continue to improve their monitoring of alcohol consumption and adopt country- and culture-specific programmes to prevent excessive alcohol and consumption and alcoholism. "Alcoholism," Microsoft Encarta Online Encyclopedia 2006