Alcohol dependence and abuse

Alcohol dependence is a psychiatric disorder characterized by a maladaptive pattern of alcohol use involving serious behavioral and physical consequences and that may, in its most severe form, result in death.

Introduction

Pure ethyl alcohol is a colorless, mild-smelling liquid that boils at 79 degrees Celsius and evaporates quickly at room temperature. It is made either by fermentation of grain mashed and suspended in water or fruit juice, followed by the distillation (boiling) of the beer or wine that is produced, or by chemical synthesis from the petrochemical ethylene. Ethyl alcohol—usually simply called alcohol—has many uses, including the sterilization of surgical instruments and inclusion in the fuel gasohol; it is the liquid in which many medicines are dissolved, serves as the main component of perfumes and colognes, and is used in the manufacture of many useful chemicals. The best-known use of alcohol, however, is in alcoholic beverages, viewed by many as recreational beverages because of the mood-altering properties of the alcohol they contain.

It is believed that alcoholic beverages have been made since prehistoric times. The oldest records of widespread brewing of beer and production of wine have been found in what were ancient Babylon and Egypt, respectively. According to historians, the main reason for the preparation of alcoholic beverages by early civilizations was that their antimicrobial properties kept grape juice and other food sources from which they were prepared from spoiling. Drinking sparing amounts of fermented beverages was also thought to prevent many illnesses that people contracted from contaminated drinking water or from other unfermented beverages.

The misuse of alcoholic beverages has certainly occurred since their discovery; however, it became widespread during the Middle Ages, when the art of distillation became more universal, producing hard liquors (containing five to ten times the alcohol of beer and wine) that made it much easier to attain alcoholic euphoria and stupor. In the United States, it has been estimated that nearly 70 percent of men and 60 percent of women consume alcoholic beverages. At any given time, 5 percent qualify for a of alcohol dependence. People who abuse alcohol to the point of severe physical consequences and conditions such as alcohol dependence often suffer from the disease of alcoholism. They may exhibit problems with controlling their use of alcohol, despite its severe negative consequences on their health, behavior, daily functioning, time management, and relationships.

Continued drinking over a long period of time, despite alcohol dependence, affects many body organs. Among them is the brain, where related mental disorders include delirium tremens (also known as the DTs), acute alcoholic hallucinations, and Wernicke-Korsakoff syndrome. The DTs are a response to severe alcohol withdrawal that includes attacks, confusion, , delirium, tremor, and terrifying hallucinations and other symptoms of . Psychosis is a severe mental state characterized by partial or complete withdrawal from reality. Wernicke-Korsakoff syndrome is a degenerative brain disorder caused by a lack of thiamine, often produced by alcohol abuse, that causes disorientation, impaired , and the production of false to fill or make sense of memory gaps. It is a two-stage disease, with Wernicke’s encephalopathy being the acute phase and Korsakoff’s amnesic syndrome being the chronic phase. Both the DTs and Wernicke-Korsakoff syndrome may be accompanied by physical debility that can require hospitalization.

Alcoholic neuritis will develop when alcohol is the sole food consumed. In addition, alcohol dependence can lead to damage of the liver (causing cirrhosis that can be lethal), the kidneys, the heart, and the pancreas. Cirrhosis is a chronic liver disease characterized by the destruction of liver cells and their replacement by nonfunctional tissue. This ultimately causes blocked blood circulation, liver failure, and death. Furthermore, evidence suggests that severe alcohol dependence, combined with excessive cigarette smoking, greatly enhances the incidence of cancer of the mouth and throat.

There is no clear physical explanation for the development of alcohol dependence. Rather, it is most often proposed that alcohol dependence develops as the result of a genetic predisposition, social problems, and psychological stress. Much support is given to the high likelihood of alcohol dependence arising in the socioeconomic groups where consumption of alcoholic beverages is equated with manliness or sophistication. Other major bases proposed for the development of alcohol dependence include domineering or antisocial parents, adolescent peer pressure, personal feelings of inadequacy, loneliness, job pressures, and marital discord.

There is no known cure for alcohol dependence. However, treatments for alcohol problems for the majority of individuals entering treatment do demonstrate some benefit regardless of treatment orientations or treatment goals. Depending on the level of functioning of the individual before entering treatment for alcohol use disorders, rates of complete abstinence from drinking one year following treatment may range from 20 to 65 percent. Abstinence is only one treatment goal, however; relapse prevention and harm reduction approaches also are sometimes employed.

In relapse prevention, the goal is to have people manage high-risk situations and lapses, during which they are more likely to drink, so that they do not turn into relapses, or full-blown returns to pretreatment drinking. In harm reduction approaches, the goal might be to have patients refrain from drinking in risky situations, such as while driving or taking medication, or to decrease the or amount consumed, rather than quitting altogether. This latter approach is used to achieve some progress toward more adaptive behavior when, for whatever reasons, a client might not wish to abstain completely or might not be able to do so.

The recognition of alcohol dependence as a medical problem has led to the opening of many alcohol-rehabilitation treatment centers, where psychiatric treatment, medication, and physical therapy—in various combinations—provide valuable treatments. Furthermore, many experts believe that Alcoholics Anonymous (AA) programs are effective deterrents to a return to maladaptive alcohol use.

Changing Attitudes

As pointed out by Andrew M. Mecca, before 1935 the main opinion on alcohol dependence was that it was criminal behavior that merited punishment. Around 1935, the problem began to be identified as a disease. Crucial to the successful treatment of alcohol dependence was the advent of Alcoholics Anonymous, founded in that year. This organization operates on the premise that abstinence is the best course of treatment for alcohol dependence. The goal of the organization is sobriety: the permanent stoppage of a person’s drinking.

The methodology of Alcoholics Anonymous is psychosocial. It brings individuals with alcohol problems to the realization that they cannot use alcoholic beverages without succumbing to alcohol dependence. It identifies the need for help from a higher power, and it develops a support group of people with the same condition. As stated by Mecca, “Alcoholics Anonymous never pronounces the disease cured. . . . [I]t is arrested.” Estimates of the membership of the organization are between 1.5 million and 3 million, meaning that up to one-third of Americans with alcohol problems are affected by its tenets. These people achieve results ranging from discrete periods of sobriety (usually lasting longer and longer as membership in the organization continues) to lifelong sobriety. A liability of relying solely on Alcoholics Anonymous for treatment—according to many experts—is the lack of medical, psychiatric, and trained sociological counseling. This is especially true for the many individuals whose alcohol problems may accompany other psychiatric disorders.

As to medical treatment aiming at abstinence via therapeutic drugs, two well-known drugs for enforcing sobriety are disulfiram (Antabuse) and citrated calcium carbonate (Abstem). These drugs may be given to alcoholics who wish to avoid using any alcoholic beverages and who require a deterrent to help them stop drinking. Neither drug should ever be given in secret by well-meaning family or friends because of the serious danger they cause in the presence of alcoholic beverages. This danger is attributable to the biochemistry of alcohol utilization via the enzymes alcohol dehydrogenase and aldehyde dehydrogenase.

Normally, alcohol dehydrogenase converts alcohol to the toxic chemical acetaldehyde. Aldehyde dehydrogenase then quickly converts acetaldehyde to acetic acid, the main biological fuel of the body. Abstem and Antabuse turn off aldehyde dehydrogenase. This causes acetaldehyde buildup in the body when alcohol is consumed, quickly leading to violent headache, flushing, nausea, dizziness, heart palpitation, and vertigo.

Tranquilizers and related sedative hypnotics may also be used to treat alcohol dependence. However, this must also be done with great care, under the close supervision of a physician, for two main reasons. Many of these drugs can be addicting. Thus, an alcoholic may simply begin to abuse sedatives instead of alcohol if the former are used improperly. Moreover, some sedatives have additive effects that can be fatal if an alcoholic backslides during therapy.

The great value of therapists in alcohol dependence treatment has been identified by various sources. David H. Knott, in his book Alcohol Problems: Diagnosis and Treatment (1986), points out that while a psychotherapist cannot perform miracles, psychotherapy can be very valuable in helping the alcoholic patient by identifying factors leading to “destructive use of alcohol,” exploring and helping rectify problems associated with alcohol abstinence, providing emotional support that helps many patients rebuild their lives, and interfacing in referring patients to Alcoholics Anonymous and other long-term support efforts. The psychotherapist also has irreplaceable experience with psychoactive therapeutic drugs, behavioral modification techniques, and identifying whether a given individual requires institutionalization.

Knott also points out the importance of behavioral modification as a cornerstone of alcohol psychotherapy and makes it clear that a wide variety of choices are available to alcoholics desiring psychosocial help. An interesting point made by A. E. Bennett in Alcoholism and the Brain (1977) is that autopsy and a variety of sophisticated medical techniques, including computed tomography (CT) scans, identify atrophy of the of the brain in many alcoholics. This damage is viewed as a factor in the inability of alcoholics to stop drinking, as well as in loss of motor skills and eventual development of serious conditions such as Wernicke-Korsakoff syndrome.

Treating an Epidemic

The excessive use of alcoholic beverages, with resultant alcohol dependence, has occurred for many centuries. Modern efforts to deal with alcohol dependence are often considered to have begun in the early twentieth century, with the activities of the American temperance movement that culminated with Prohibition on the ratification of the Eighteenth Amendment. The idea behind Prohibition was that making liquor “impossible to get” would force sobriety on the nation. The measure turned out to be self-defeating, however, and several sources point out that it actually increased the incidence of alcohol dependence in the country. It was repealed in 1933.

The next, and much more useful, effort to combat alcohol dependence was the psychosocial approach of Alcoholics Anonymous, started in 1935 and still operating well. That organization does not reach the majority of individuals with alcoholic problems, however, so other efforts needed to evolve as treatment methodologies. Among these have been the wide use of psychiatric counseling, alcohol rehabilitation centers, family counseling, and alcohol management programs in the workplace. These options—alone or in various combinations—have had considerable success in reaching alcoholics, and combined alcohol dependence therapy seems to work best; however, it has not yet been possible to stem the tide of increasing alcohol dependence or to cure the disease. Instead, these techniques—like those of Alcoholics Anonymous—can only arrest it. Part of the reason for this is the fact that the basis for alcohol dependence is not clearly understood by those attempting to eradicate it. One hope for curing alcohol dependence is ongoing basic research into the biochemistry, pharmacology, and physiology of alcohol dependence.

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