Alcohol abuse and alcoholism: In depth

Alcohol abuse is a disorder characterized by a desire for alcohol and the continuation of drinking despite alcohol-related occupational, legal, health, or family problems. Alcohol abuse can progress to alcohol dependence or alcoholism. Alcoholism is a condition in which a person becomes physically dependent on alcohol and drinks to avoid withdrawal symptoms.

Many health professionals use the term "alcohol use disorder (AUD)" to include various forms of alcohol abuse, alcohol dependence, and hazardous or problem drinking (including binge drinking). Several factors can contribute to alcohol abuse and alcoholism, including genetics, brain chemistry, social pressure, emotional stress, chronic pain, depression or other mental health problems, and problem drinking behaviors learned from family and friends. There are several recommended treatment options, including behavioral therapies and medications, that have been shown to be highly effective. Nevertheless, alcohol abuse remains a common condition in many populations, with wide-ranging social impacts.

Risk Factors

A risk factor is anything that increases one’s likelihood of getting or developing a disease or condition. It is possible to develop alcohol abuse disorder without any of the risk factors listed below. However, the more risk factors an individual has, the greater the likelihood of developing the condition. The following factors can increase the risk of alcoholism:

Family history. Alcohol abuse tends to run in families. Adult children of alcoholics may have learned problematic drinking habits from observing their parents’ behavior or they may inherit a genetic vulnerability to developing an alcohol use disorder. While the potential genetic factors involved are not fully understood, studies suggest that there may be heritable differences in the way a person’s body processes and responds to alcohol.

Cultural and social factors. Alcohol abuse is more of a problem in some cultures than in others. For example, rates of alcohol abuse are high in Europe and the United States where alcohol consumption is common and socially acceptable. In American culture, alcohol is often used as a social lubricant and a means of reducing tension. Among religious groups that abstain from drinking alcohol, such as Mormons or Muslims, the incidence of alcohol abuse is minimal. Higher rates of alcohol abuse are also related to peer pressure and easy access to alcohol. Individuals with long working hours also have elevated incidence rates of alcohol abuse.

Psychological vulnerability. Researchers have found that certain psychological factors increase an individual’s risk for alcohol abuse. These factors include having high self-expectations, having a low frustration tolerance, feeling inadequate and unsure of one’s roles, needing an inordinate amount of praise and reassurance, and having a tendency to be impulsive and aggressive. Military personnel with combat exposure are also at a greater risk of developing an alcohol use disorder compared to nondeployed personnel, likely due to the trauma experienced in combat.

Psychiatric disorders. Researchers have found high rates of alcohol abuse disorders among people with anxiety disorders, post-traumatic stress disorder, depression, antisocial and other personality disorders, schizophrenia, and other substance use disorders, such as smoking and illicit drug use. People with attention deficit hyperactivity disorder also have a higher rate of alcohol use disorders (and other substance use disorders). People suffering from psychological disorders may begin using alcohol to manage their symptoms; repeated use can then develop into dependence.

Symptoms

According to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), individuals who meet two or more of eleven criteria over the past twelve-month period qualify for alcohol use disorder. The diagnostic criteria include:

• Drinking more or for longer than intended.
• Wanting or trying to cut down or stop drinking but not being able to.
• Spending a lot of time drinking or recovering from the effects of drinking.
• Experiencing cravings for alcohol.
• Drinking or being sick from drinking that interferes with taking care of home or family or causing problems at work or school.
• Continuing to drink even though it has caused problems with family or friends.
• Giving up or cutting back on activities that were once important, interesting, or pleasurable in order to drink.
• Getting into situations while or after drinking that increase the chances of getting hurt, such as drunk driving or engaging in unsafe sex.
• Continuing to drink even though it has caused feelings of depression or anxiety or exacerbated another health problem.
• Needing to drink much more than once was needed in order to feel the same effect (tolerance).
• Experiencing withdrawal symptoms such as sleep disturbances, irritability, anxiety, depression, or restlessness when cutting back or stopping drinking.

The severity of the disorder is determined by the number of criteria met. Two to three criteria is considered mild, four to five is moderate, and six or more is severe. Denial that an alcohol problem exists is also common.

Alcohol misuse can progress to alcohol dependence. Alcohol use disorder involves a craving, or a powerful, uncontrollable desire for alcohol. This craving overrides the desire to stop drinking. Symptoms of alcohol dependence include craving a drink of alcohol, the inability to stop or limit drinking of alcohol, and the need for greater amounts of alcohol to feel the same effect. Withdrawal symptoms if alcohol is stopped include nausea, sweating, shaking, anxiety, and increased blood pressure. Seizures are an extreme symptom of withdrawal.

Alcohol use disorder may also lead to physical symptoms caused by the destructive effects of alcohol on the body. Symptoms include high blood pressure, yellowing of the whites of the eyes and/or skin (jaundice), flushed face, spidery veins showing through the skin around the umbilicus and on the face, enlarged liver, dyspepsia and ulcers, and easy bruising or bleeding. Other physical symptoms that may result include general shakiness, weakness of the wrists and ankles, numbness and tingling, impaired memory, fast heart rate, shrunken testicles and erectile dysfunction, and increased susceptibility to infections and cancer.

There are a myriad of risks associated with alcohol use disorder. Alcohol abuse can increase the risk of accidents and injury, including motor vehicle accidents and falls; domestic violence, murder, and suicide; family dysfunction and failed relationships; lost jobs and earnings; problems with the law, including drunk driving; and depression.

Drug interactions are also of concern when dealing with alcohol, especially if the individual is diagnosed with certain cancers. These include cancer of the liver, esophagus, throat, larynx, and pancreas. Other concerns are pancreatitis, diabetes, or hepatitis. Gastrointestinal problems, such as bleeding, diarrhea, hemorrhoids, ulcers, and inflammation of the esophagus, are also affected and caused by alcohol abuse.

The excessive use of alcohol also increases the risk of nerve damage; sexual disorders, including impotence and reproductive problems; postoperative complications (infections, bleeding, and delayed healing); neurological problems and brain damage (in long-term use); liver damage, including cirrhosis; heart and circulatory problems; pneumonia and acute respiratory distress syndrome; osteoporosis; peripheral neuropathy; hormonal problems in both sexes; fetal alcohol syndrome (in the babies of women who drank during pregnancy); malnutrition; disorders of the immune system; and increased risk of infection.

Screening and Diagnosis

It is often difficult for people to accept the fact that they need help with an alcohol problem. Nevertheless, the sooner help is provided, the better the chances for a successful recovery. Some people may perceive alcohol problems as a sign of moral weakness. As a result, one may feel that to seek help is to admit some type of shameful defect in oneself. However, taking steps to identify a possible drinking problem has an enormous payoff: a chance for a healthier, more rewarding life.

The purpose of screening is early diagnosis and treatment of alcohol use disorder. Screening tests are usually administered to people without current symptoms but who may be at high risk for certain diseases or conditions. Screening tests for alcohol abuse usually involve simple questionnaires, either verbally administered by a doctor or given in written form. Several of the most commonly used tests include the CAGE questionnaire, the Michigan Alcoholism Screening Test (MAST), Self-Administered Alcoholism Screening Test (SAAST), the Alcohol Dependence Scale (ADS), the Alcohol Use Disorders Identification Test (AUDIT), and the T-ACE Test.

Some health care providers use a single question for screening: “When was the last time you had more than five drinks (for men) or four drinks (for women) in one day?” About 50 percent of all individuals who have a problem with drinking alcohol will answer “within three months” to this question.

A diagnosis of alcohol abuse is often based on an initial assessment, physical examination, and psychological evaluation. Typically, a doctor will ask a number of questions about alcohol use to determine whether the patient is experiencing problems related to drinking. A physical examination may include blood tests to determine the size of red blood cells; to check for a substance called carbohydrate-deficient transferrin (CDT), a measure of alcohol consumption; and to check for alcohol-related liver disease and other health problems, such as gamma-glutamyltransferase (GGT).

A patient may also be evaluated for psychiatric disorders that often co-occur with alcohol use disorder, such as anxiety disorders and depression. They may be evaluated by a doctor or be referred to a mental health professional.

Treatment and Therapy

The type of treatment one receives depends on the severity of the alcohol use disorder and the resources that are available in the community. Treatment may be on an inpatient or outpatient basis and may include detoxification (the process of safely getting alcohol out of one’s system), medications to help prevent a relapse once drinking has stopped, individual or group counseling, and referral to community resources, including support groups.

To manage the disease, a patient will have to make some permanent lifestyle changes. The following strategies can help an individual stay away from alcohol and reduce the risk of relapse: socializing without alcohol, including avoidance of bars; refraining from keeping alcohol in the home; avoiding situations and people that encourage drinking; befriending nondrinking individuals and engaging in activities that do not involve alcohol consumption; attending support groups such as Alcoholics Anonymous; identifying potential relapse triggers; and developing coping strategies for difficult situations. Eating a healthful diet and learning stress reduction techniques, such as deep breathing, meditation, and yoga, are also helpful, along with basic rest and relaxation.

Certain medications can help alleviate symptoms of alcohol withdrawal and help to prevent relapse. Medications are usually prescribed alongside counseling or other psychosocial treatment. Also, alcohol abuse is usually treated with a combination of medications, rather than just one medication. Treatment will vary on a case-by-case basis.

Naltrexone is used to help an individual stay away from alcohol, but it is not a cure for addiction. It may work by blocking the cravings for alcohol. It will not, however, prevent one from experiencing the effects of alcohol. Naltrexone is available as a pill (ReVia) and an injection in the muscle (Vivitrol).

Disulfiram (Antabuse) helps overcome a drinking problem by making the individual very sick if they drink alcohol. However, it is not a cure for alcohol use disorder. While this medicine is being taken, and for fourteen days before an individual begins taking it, the patient should not drink even the smallest amount of alcohol. They should also not use any foods, products, or medicines that contain alcohol, nor should they come into contact with any chemicals that contain alcohol while using this medicine. When alcohol is ingested while an individual is using this medication can cause nausea and vomiting, chest pain, dizziness or fainting, sweating and flushing, difficulty breathing, confusion and weakness, rapid heartbeat, and drowsiness.

Acamprosate (Campral) reduces the craving for alcohol by inhibiting a chemical in the brain called gamma aminobutyric acid (GABA). Several studies have indicated that it may help a patient remain abstinent. Possible side effects include diarrhea and headache.

In addition to medications, alcoholism treatment programs use counseling and group therapy to help a person stop drinking. Most people with an alcohol use disorder need help to recover from their disease. With support and treatment, many people are able to stop drinking and rebuild their lives.

Self-help groups are the most commonly sought source of help for alcohol-related problems. Alcoholics Anonymous (AA) is one of the most well-known self-help groups. AA emphasizes person-to-person relationships, group support, and commitment to recovery. Meetings consist mainly of discussions about the participants’ problems with alcohol and testimonials from those who have recovered. AA outlines twelve consecutive activities, or steps, that an individual should achieve during the recovery process.

Psychotherapy is also an option, as a number of cognitive and behavioral therapies may be beneficial in the treatment of alcohol abuse. These approaches target thoughts and behaviors that may contribute to the abuse of alcohol. Cognitive-behavioral interventions have been shown to improve mood and reduce substance abuse. In addition, aversive conditioning is a behavioral approach in which the consumption of alcohol is associated with a wide range of noxious stimuli. Another approach, self-control training, can help to reduce the intake of alcohol without totally abstaining. A variety of coping skills and stress management techniques may also be used.

Motivational enhancement therapy (MET) is based on the assumption that one has the responsibility and capacity for change. A therapist begins by providing individualized feedback about the effects of drinking. Working closely together, the patient and the therapist will explore the benefits of abstinence, review treatment options, and design a plan to implement treatment goals. Often, it is helpful to involve a spouse or significant other in a treatment program. This can increase the likelihood that the patient will complete therapy and continue to abstain after treatment ends.

Behavioral-marital therapy (BMT) combines a focus on drinking with efforts to strengthen marital relationships. BMT involves shared activities and the teaching of communication and conflict evaluation skills. Couples therapy may also be combined with learning and rehearsing a relapse prevention plan. Among those with severe marital and drinking problems, the combination approach produces improved marital relations and higher rates of abstinence.

Brief interventions involve counseling from primary care doctors or nursing staff during five or fewer standard office visits. In brief interventions, the patient will receive information on the negative consequences of alcohol abuse. They will also learn about strategies and community resources to help achieve moderation or abstinence. Most brief interventions are designed to help individuals if they are abusing alcohol and are at risk for developing alcoholism. They are designed to help reduce alcohol consumption. If they are already alcohol-dependent, however, they are encouraged to enter specialized treatment with the goal of complete abstinence.

There are no surgical treatments indicated for the treatment of alcoholism.

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