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•	Highlights
•	Introduction
•	Causes
•	Risk Factors
•	Complications
•	Diagnosis
•	Treatment for Alcoholism...
•	Treatment for Alcohol Withd...
•	Therapy
•	Medications
•	Resources
•	References

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Alcoholism

Highlights

Anxiety and Alcoholism

Many people with alcoholism also suffer from anxiety disorders.

• In a 2005 study, 50% of alcohol-dependent patients with anxiety disorders started drinking again within 4 months of alcoholism treatment compared with 20% of patients without anxiety disorders.
• Social phobia and panic disorders were the two most common types of anxiety disorders found among patients with alcohol dependence.

In 2005, scientists identified a brain protein called CREB that may genetically link anxiety and alcoholism.

• The CREB protein controls the production of a brain chemical called NPY that affects anxiety and alcohol-drinking behaviors.
• Scientists discovered that levels of CREB and NPY were naturally lower in certain brain regions of rats bred to prefer alcohol.
• When these rats were given alcohol, their CREB function and NPY production increased, and their anxiety levels decreased.
• The scientists think that a hereditary lack of CREB protein may be associated with anxiety and alcoholism.

Therapy

Combining Alcoholics Anonymous (AA) sessions with professional treatment can increase a patient’s chance of quitting drinking. And, the earlier that patients enter AA, the better. According to a 2005 study, patients who entered an AA program within the first year of seeking professional help were more likely to stop drinking than those who only had medical treatment or only AA.

Drug Treatment

Patients who have to take the anticraving drug naltrexone (ReVia) every day may eventually have another option: Take the drug once a month by injection. Naltrexone can help reduce alcohol craving and consumption, but many patients fail to take it every day. A long-acting injectable form taken just once a month may make it easier for patients to receive this treatment. In a 2005 clinical trial published in the Journal of the American Medical Association, patients received monthly naltrexone injections for 6 months with good results.

Introduction

Alcoholism is a chronic, progressive, and often fatal disease. It is a primary disorder and not a symptom of other diseases or emotional problems. The chemistry of alcohol allows it to affect nearly every type of cell in the body, including those in the central nervous system. After prolonged exposure to alcohol, the brain becomes dependent on it. The severity of this disease is influenced by factors such as genetics, psychology, culture, and response to physical pain.

Alcoholism is a chronic illness marked by dependence on alcohol consumption. It interferes with physical or mental health, and social, family, or job responsibilities. This addiction can lead to liver, circulatory, and neurological problems. Pregnant women who drink alcohol in any amount may harm the fetus.

Alcoholism or alcohol dependence is associated with the following:

• The only indication of early alcoholism may be the unpleasant physical responses to withdrawal that occur during even brief periods of abstinence.
• Alcoholics have little or no control over the quantity they drink or the duration or frequency of their drinking.
• Alcoholics are preoccupied with drinking, deny their own addiction, and continue to drink even though they are aware of the dangers.
• Over time, some alcoholics become tolerant to the effects of drinking and require more alcohol to become intoxicated, creating the illusion that they can "hold their liquor."
• Alcoholics may have blackouts after drinking and have frequent hangovers that cause them to miss work and other normal activities.
• Alcoholics might drink alone and start their drinking early in the day.
• Alcoholics periodically quit drinking or switch from hard liquor to beer or wine, but these periods rarely last.
• Severe alcoholics often have a history of accidents, marital and work instability, and alcohol-related health problems.
• Episodic violent and abusive incidents involving spouses and children and a history of unexplained or frequent accidents are often signs of drug or alcohol abuse.

Alcoholism can develop insidiously, and often there is no clear line between problem drinking and alcoholism. Eventually alcohol dominates thinking, emotions, and actions and becomes the primary means through which a person can deal with people, work, and life.

Definition of Alcohol Use and Abuse

In addition to alcohol dependence, experts are now defining alcohol use by levels of harm that it may be causing. This information is useful to determine possible interventions at earlier stages. The following categories of alcohol use and abuse use a definition of one drink as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces (a jigger) of 90-proof liquor.

Moderate Drinking. Moderate drinking, particularly red wine, appears to offer health benefits. Moderate drinking is defined as equal to or less than two drinks a day for men and equal to or less than one drink a day for women.

Hazardous (Heavy) Drinking. Hazardous drinking puts people at risk for adverse health events. People who are heavy drinkers consume the following:

• More than 14 drinks per week, or 4 to 5 drinks at one sitting, for men
• More than seven drinks per week, or three drinks at one sitting, for women
• Frequent intoxication

Harmful Drinking. Drinking is considered harmful when alcohol consumption has actually caused physical or psychologic harm. This is determined by the following:

• There is clear evidence that alcohol is responsible for such harm.
• The nature of that harm can be identified.
• Alcohol consumption has persisted for at least a month or has occurred repeatedly for the past year.

Certain people are at much higher risk for harmful drinking, such as older individuals with high blood pressure or those taking medications for arthritis or pain.

Alcohol Abuse. People with alcohol abuse have one or more of the following alcohol-related problems over a period of one year:

• Failure to fulfill work or personal obligations
• Recurrent use in potentially dangerous situations
• Problems with the law
• Continued use in spite of harm being done to social or personal relationships

In a 2001 study, 55% patients continued to meet these criteria after 5 years, but only 3.5% developed dependency, the next stage.

Alcohol Dependence. People who are alcohol dependent have three or more of the following alcohol-related problems over a year:

• Increased amounts of alcohol are needed to produce an effect
• Withdrawal symptoms or drinking alcohol is used to avoid these symptoms
• Drinks more over a given period than intended
• Unsuccessful attempts to quit or cut down
• Gives up significant leisure or work activities
• Continues to drink in spite of the knowledge of its physical or psychological harm to oneself or others

In one long-term study, two-thirds of those with alcohol dependence continued to be dependent on alcohol after 5 years.

Causes

People have been drinking alcohol for about 15,000 years. Drinking steadily and consistently over time can produce dependence and cause withdrawal symptoms during periods of abstinence; this physical dependence, however, is not the sole cause of alcoholism. To develop alcoholism, other factors usually come into play, including biology, genetics, culture, and psychology.

Genetic Factors

Genetic factors play a significant role in alcoholism and may account for about half of the total risk for alcoholism. The disorder is so complex, however, that no single gene is likely to be a major culprit.

Researchers are investigating a number of inherited traits that make particular individuals susceptible to this disorder. Some examples are the following:

• The amygdala is an area of the brain thought to play a role in the emotional aspects of craving, which can lead to addiction. One study found that the amygdala is smaller in subjects with family histories of alcoholism, suggesting that inherited differences in brain structure may affect risk. Other studies suggest that certain brain chemicals (neurotransmitters) and proteins in the amygdala region may be involved in the link between anxiety and alcoholism.
• Because alcohol is not found easily in nature, genetic mechanisms to protect against excessive consumption may not have evolved in humans as they frequently have for protection against natural threats. Some evidence, then, indicates that a lack of genetic protection plays a major role in alcoholism. Such studies have found that people with a family history of alcoholism tend to "hold their liquor" better than those without such a history. Experts suggest some people may inherit a lack of those warning signals that ordinarily make people stop drinking. Research suggests this factor may contribute to between 40 - 60% of alcoholism cases related to genetic factors. (Even in the absence of genetic factors, repeated exposure to alcohol increases the ability to tolerate larger amounts before experiencing behavioral impairment.)
• Genes that regulate certain chemical byproducts of alcohol are under intense scrutiny. Alcohol is metabolized in a two-stage process: It is first converted to acetaldehyde (AcH), which is then converted into acetate. AcH is being researched because it plays a role in most actions of alcohol, including damaging effects on the liver and upper airway. It also may be protective. For example, some people, particularly in some Asian and Jewish populations, may be less likely to become alcoholic because of a genetic deficiency in AcH, which produces a buildup of acetate after drinking alcohol. Acetate is toxic and in high amounts causes flushing, dizziness, and nausea. Individuals with this genetic factor, then, are less likely to become alcoholic. (This deficiency is not completely protective against drinking, however, particularly if there is social pressure and high exposure to alcohol, such as among college fraternity members.)
• Some people with alcoholism may have an inherited dysfunction in the transmission of serotonin. This is an important brain chemical messenger known as a neurotransmitter. It is important for well-being and associated behaviors (e.g., eating, relaxation, sleep). Abnormal serotonin levels are associated with high levels of tolerance for alcohol. They are also linked to impulsive and aggressive behaviors, which can predispose people to drink and can increase the risk for dangerous behaviors and suicide in alcoholics. (Serotonin abnormalities can also develop from environmental pressures as well, such as early loss in childhood.)

Even if genetic factors can be identified, however, they are unlikely to explain all cases of alcoholism. It is important to understand that, whether they inherit the disorder or not, people with alcoholism are still legally responsible for their actions. Inheriting genetic traits does not doom a child to an alcoholic future. Environment, personality, and emotional factors also play a strong role.

Brain Chemical Imbalances After Long-Term Alcohol Use

Alcohol has widespread effects on the brain and can affect neurons (nerve cells), brain chemistry, and blood flow within the frontal lobes of the brain. Researchers are particularly interested in systems of neurotransmitters (chemical messengers) in the brain that are affected by alcohol. Some research is focusing on the way these neurotransmitters are employed in the brain after long-term alcohol use in order to adapt to the cravings and pain of withdrawal. Such chemical changes may lead to dependency or to relapse after quitting in two ways:

• They increase the need to reduce agitation; and
• They increase the desire to restore pleasurable feelings.

Reducing Agitation. When a person who is dependent on alcohol stops drinking, the following chemical responses create an overexcited nervous system and agitation:

• A drop in gamma-aminobutyric acid (GABA), a brain chemical that inhibits impulsivity
• An increase in glutamate, a brain chemical that excites nerve cells
• An increase in norepinephrine and corticotropin releasing factor, hormones linked to stress

High norepinephrine levels, in fact, may be the primary factor in withdrawal symptoms such as an increase in blood pressure and heart rate. This hyperactivity in the brain produces an intense need to calm down and to use more alcohol. One study suggested that the need to relieve agitation may be the more important factor in causing a relapse than restoring mood.

Restoring Pleasure. Alcohol stimulates the release of neurotransmitters and other chemicals that produce the following pleasurable feelings:

• Dopamine produces euphoria and a sensation of being rewarded. Repeated alcohol use increases sensitivity to dopamine.
• Serotonin produces feelings of well-being.
• Opioid peptides are important for well-being.

Over time, however, heavy alcohol use appears to deplete the stores of dopamine and serotonin. Persistent drinking, therefore, eventually fails to restore mood, but by then the drinker has been conditioned to believe that alcohol will improve spirits (even though it does not).

Social and Emotional Causes of Alcoholic Relapse

Between 80 - 90% of people treated for alcoholism relapse, even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. According to one study, three factors placed a person at high risk for relapse:

• Frustration and anger
• Social pressure
• Internal temptation

Another study suggests that impaired sleep is also an important predictor of relapse.

Mental and Emotional Stress. Alcohol blocks out emotional pain and is often perceived as a loyal friend when human relationships fail. It is also associated with freedom and with a loss of inhibition that offsets the tedium of daily routines. When the alcoholic tries to quit drinking, the brain seeks to restore what it perceives to be its equilibrium. The brain's best weapons to achieve this are depression, anxiety, and stress (the emotional equivalents of physical pain), which are produced by brain chemical imbalances. These negative moods continue to tempt alcoholics to return to drinking long after physical withdrawal symptoms have abated.

Even intelligence is no ally in this process, for the over-agitated brain will use all its powers of rationalization to persuade the patient to return to drinking. According to a 1999 study, having a high or low IQ has little effect on quitting. However, according to this study, a high verbal ability may aid the alcoholic in remaining sober.

It is important to realize that any life change, even changes for the better, may cause temporary grief and anxiety. With time and the substitution of healthier pleasures, this emotional turmoil weakens and can be overcome.

Co-dependency. Many aspects of the ex-drinker's relationships change when drinking stops, making it difficult to remain abstinent:

• One of the most difficult problems that occur is being around other people who are able to drink socially without danger of addiction. A sense of isolation, a loss of enjoyment, and the ex-drinker's belief that pity, not respect, is guiding a friend's attitude can lead to loneliness, low self-esteem, and a strong desire to drink again.
• Friends may not easily accept the sober, perhaps more subdued, ex-drinker. Close friends and even intimate partners may have difficulty in changing their responses to this newly sober person and, even worse, may encourage a return to drinking.
• To preserve marriages, spouses of alcoholics often build their own self-images on surviving or handling their mates' difficult behavior and then discover that they are threatened by abstinence.

In such cases, separation from these "enablers" may be necessary for survival. It is no wonder that, when faced with such losses, even if they are temporary, a person returns to drinking. The best course in these cases is to encourage close friends and family members to seek help as well. Fortunately, groups such as Al-Anon exist for this purpose.

Social and Cultural Pressures. The media portrays the pleasures of drinking in advertising and programming. The medical benefits of light to moderate drinking are frequently publicized, giving ex-drinkers the spurious excuse of returning to alcohol for their health. These messages must be categorically ignored and acknowledged for what they are: an industry's attempt to profit from potentially great harm to individuals.

Risk Factors

About 90% of adults in the U.S. drink alcohol. Every day, more than 700,000 Americans are being treated for alcoholism. In addition, up to half of American men have problems that are caused by alcohol.

Categories of Alcoholic Types

Some researchers have categorized people with alcoholism as Type 1 or Type 2.

• Type 1 individuals are more often women. They typically become alcoholic at a later age, have less severe symptoms or fewer psychiatric problems, and have a better outlook on life than those classified as type 2.
• Type 2 people are more likely to be male. They tend to become alcoholic at an early age and have a high family risk for alcoholism, more severe symptoms, and a negative outlook on life.

Not only do these two groups tend to respond differently to psychotherapeutic approaches, but they may also respond differently to medications.

Age

Drinking in Adolescence. About half of under-age Americans have used alcohol. Currently 1.9 million people between the ages of 12 and 20 are considered heavy drinkers and 4.4 million are binge drinkers. Anyone who begins drinking in adolescence is at risk for developing alcoholism. Young people at highest risk for early drinking are those with a history of abuse, family violence, depression, and stressful life events. People with a family history of alcoholism are also more likely to begin drinking before the age of 20 and to become alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges or driving after drinking, than young drinkers without a family history of alcoholism. Binge drinking, in fact, is now on the risk among this group, particularly among young men.

Drinking in the Elderly Population. Although alcoholism usually develops in early adulthood, the elderly are not exempt. In fact, doctors may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process. A survey of adults over 60 reported that 15% of men and 12% of women were hazardous drinkers, and 9% of men and 3% of women were alcohol dependent. In another study, the prevalence of problem drinking was as high as 49% among nursing home patients.

Alcohol also affects the older body differently. People who maintain the same drinking patterns as they age can easily develop alcohol dependency without realizing it. It takes fewer drinks to become intoxicated, and older organs can be damaged by smaller amounts of alcohol than those of younger people. Also, up to one-half of the 100 most prescribed drugs for older people react adversely with alcohol. Medications used for arthritis or pain pose a particular danger for interaction with alcohol.

Gender

Most alcoholics are men, but the incidence of alcoholism in women has been increasing over the past 30 years. Studies indicate that 9.3% of men and 1.9% of women are heavy drinkers, and 22.8% of men are binge drinkers compared to 8.7% of women. In general, young women who are problem drinkers follow the drinking patterns of their partners, although they tend to engage in heavier drinking during the premenstrual period.

Women tend to become alcoholic later in life than men, and it is estimated that 1.8 million older women suffer from alcohol addiction. Even though heavy drinking in women usually occurs later in life, the medical problems women develop because of the disorder occur at about the same age as men, suggesting that women are more susceptible to the physical toxicity of alcohol.

Genetics and Family History

Alcoholism often runs in families. The risk for alcoholism in sons of alcoholic fathers is 25%. The family link is weaker for women, but is still a factor in many cases. Genetics certainly play a role in many people with alcoholism, but negative alcoholic behaviors by the parents can also be significant contributors in the risk for alcoholism in the children. They often play off each other in a perpetuating and tragic spiral. A 2002 study, for example, reported that alcoholic parents have a higher risk for being separated from their children, and such children then face a higher risk for alcoholism in adulthood. (A stable family and psychological health, however, cannot fully protect a person with a genetic risk.) Unfortunately, there is no way to predict which members of alcoholic families are most at risk for alcoholism.

History of Abuse

Individuals who were abused as children have a higher risk for substance abuse later on. In a 2003 study, for example, 72% of women and 27% of men with substance abuse disorders reported physical or sexual abuse or both. They also had worse response to treatment than those without such a history.

Ethnicity

Overall, there is no difference in alcoholic prevalence among African Americans, Caucasians, and Hispanics. Some population groups, however, such as Irish and Native Americans, have an increased incidence of alcoholism while others, such as Jewish and Asian Americans, have a lower risk. Although the biological or cultural causes of such different risks are not known, certain people in these population groups may have a genetic susceptibility or invulnerability to alcoholism because of the way they metabolize alcohol.

Psychiatric and Behavioral Disorders

Psychiatric Disorders. Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. In a major study of alcohol-dependent people, 78% of men and 86% of women also suffered from an accompanying psychiatric or substance abuse disorder. Either anxiety or depression may increase the risk for self-medication with alcohol.

Depression is the most common psychiatric problem in people with alcoholism or substance abuse. Estimates of depression in people with alcoholism are as high as 67%. Studies have reported depression accompanies about one-third of all cases of alcoholism. According to a 2000 study, for instance, the risk for heavy drinking in women who are depressed was 2.6 times greater than the risk in women who are not depressed.

Depression is less reported in the male population, but this may be caused by male tendency to mask emotional disorders with behavior such as alcohol abuse.

Specific anxiety disorders, such as panic disorders and social phobia, may pose particular risks for alcohol and substance abuse. Social phobia causes an intense fear of being publicly scrutinized and humiliated. Panic disorders cause intense anxiety and panic attacks. People with these disorders may use alcohol as a way to become less inhibited in public situations or to calm feelings of panic. While anxiety disorders are found in about 15% of all adults, over 50% of people with alcohol abuse problems suffer from these conditions. A 2005 study suggested that people who have anxiety disorders are more likely to resume drinking after treatment for alcohol dependence. [For more information, see In-Depth Report #28: Anxiety.]

Long-term alcoholism itself may cause chemical changes that produce anxiety and depression. In fact, a study on elderly people with depression reported that when even moderate drinkers reduced consumption, their mood improved. It is not always clear, then, whether people with emotional disorders are self-medicating with alcohol, or whether alcohol itself is producing mood swings.

Behavioral Disorders and Lack of Impulse Control. Studies are also finding that alcoholism is strongly related to impulsive, excitable, and novelty-seeking behavior, and such patterns are established early on. Children who later become alcoholics or who abuse drugs are more likely to have less fear of new situations than others, even if there is a greater risk for harm than in nonalcoholics. Specifically, children with attention deficit hyperactivity disorder (ADHD), a condition that shares these behaviors, have a higher risk for alcoholism in adulthood. The risk is especially high in children with ADHD and conduct disorder.

Socioeconomic Factors

Alcoholism is not restricted to any social or economic levels. For example, a thorough 1996 study reported that no higher prevalence of alcoholism among adult welfare recipients than in the general population (about 7%). There was also no difference in prevalence between African Americans and Caucasians in low-income groups. On the other hand, people in low-income groups who drank did display some tendencies that differed from the general population of drinkers. For instance, in one study as many women as men were heavy drinkers in lower income groups. Excessive drinking may also be more dangerous in lower income groups. One study found that alcohol was a major factor in the higher death rate of people, particularly men, in lower socioeconomic groups compared with those in higher groups.

Geographic Factors

Although 54% of urban adults use alcohol at least once a month compared to 42% in nonurban areas, living in the city or the country does not affect the risks for bingeing or heavy alcohol use. One study reported that people in the north central US are at highest risk for heavy drinking (6.4% heavy use and 19% binge drinking), and those in the Northeast have the lowest risk (4.5% heavy use and 13% binge drinking).

Complications

Alcoholism reduces life expectancy by 10 to 12 years. Next to smoking, it is the most common preventable cause of death in America. Although studies indicate that adults who drink moderately (about one drink a day) have a lower mortality rate than their nondrinking peers, their risk for untimely death increases with heavier drinking. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Once one becomes dependent on alcohol, it is very difficult to quit.

Alcoholism and Early Death

Alcohol can affect the body in so many ways that researchers have a hard time determining exactly what the consequences are from drinking. Interestingly, although heavy drinking is associated with earlier death, studies suggest it is not from a higher risk of the more common serious health problems, such as heart attack, heart failure, diabetes, lung disease, or stroke. It is well known, however, that chronic consumption leads to many problems that can increase the risk for death:

• In general, people who drink regularly have a higher rate of death from injury or violence.
• Alcohol overdose can lead to death. This is a particular danger for adolescents who may want to impress their friends with their ability to drink alcohol but cannot yet gauge its effects. It is important to note that alcohol overdose doesn't only occur from any one heavy drinking incident, but may also occur from a constant infusion of alcohol in the bloodstream.
• Severe withdrawal and delirium tremens. Delirium tremens occurs in about 5% of alcoholics. It includes progressively severe withdrawal symptoms and altered mental states. In some cases, it can be fatal.
• Frequent, heavy alcohol use directly harms many areas in the body and produce dangerous health conditions (e.g., liver damage, pancreatitis, anemia, upper gastrointestinal bleeding, nerve damage, and impotence).
• Alcohol abusers who require surgery have an increased risk of postoperative complications, including infections, bleeding, insufficient heart and lung functions, and problems with wound healing. Alcohol withdrawal symptoms after surgery may impose further stress on the patient and hinder recuperation.

The Effects of Hangover

Although not traditionally thought of as a medical problem, a 2000 review of studies found that hangovers have significant consequences that include changes in liver function, hormonal balance, and mental functioning and an increased risk for depression and cardiac events. Hangovers can impair job performance, increasing the risk for mistakes and accidents. Interestingly, hangovers are generally more common in light to moderate drinkers than heavy and chronic drinkers, suggesting that binge drinking can be as threatening as chronic drinking. Any man who drinks more than five drinks or any woman who has more than three drinks is at risk for a hangover.

Accidents, Suicide, and Murder

Alcohol plays a large role in accidents, suicide, and crime.

• In a 2002 study, nearly half of all drunken drivers were alcohol dependent, and alcohol plays a major role in more than half of all automobile fatalities.
• Alcohol-related automobile accidents are the leading causes of death in young people.
• Less than two drinks can impair the ability to drive. 
• One study of emergency room patients found that having had more than one drink doubled the risk of injury, and more than four drinks increased the risk eleven times.
• Another study reported that among emergency room patients who were admitted for injuries, 47% tested positive for alcohol and 35% were intoxicated. Of those who were intoxicated, 75% showed evidence of chronic alcoholism.
• Alcoholism is the primary diagnosis in one-quarter of all people who commit suicide.
• Alcohol is implicated in 67% of all murders.

Domestic Violence

Alcoholic households are less cohesive and have more conflicts, and their members are less independent and expressive than households with nonalcoholic or recovering alcoholic parents. Domestic violence is a common consequence of alcohol abuse.

Effect on Women. Research suggests that for women, the most serious risk factor for injury from domestic violence may be a history of alcohol abuse in her male partner.

Effect on Children. Alcoholism in parents also increases the risk for violent behavior and abuse toward their children. Children of alcoholics tend to do worse academically than others, have a higher incidence of depression, anxiety, and stress and lower self-esteem than their peers. One study found that children who were diagnosed with major depression between the ages of six and 12 were more likely to have alcoholic parents or relatives than were children who were not depressed. In addition to their own inherited risk for later alcoholism, one study found that 41% of children of alcoholics have serious coping problems that may last their entire life.

Adult children of alcoholic parents are at higher risk for divorce and for psychiatric symptoms. One study concluded that the only events with greater psychological impact on children are sexual and physical abuse.

Increased Risk for Other Addictions

Researchers are finding common genetic factors in alcohol and nicotine addiction, which may explain, in part, why alcoholics are often smokers. Alcoholics who smoke compound their health problems. More alcoholics die from tobacco-related illnesses, such as heart disease or cancer, than from chronic liver disease, cirrhosis, or other conditions that are more directly tied to excessive drinking.

Liver Disorders

Alcoholic Hepatitis and Cirrhosis. Alcohol is absorbed in the small intestine and passes directly into the liver, where it becomes the preferred energy source. The liver, then, is particularly endangered by alcoholism. In the liver alcohol converts to toxic chemicals, notably acetaldehyde, which trigger the production of immune factors called cytokines. In large amounts, these factors cause inflammation and tissue injury.

Cirrhosis is a chronic liver disease that causes damage to liver tissue, scarring of the liver (fibrosis; nodular regeneration), progressive decrease in liver function, excessive fluid in the abdomen (ascites), bleeding disorders (coagulopathy), increased pressure in the blood vessels (portal hypertension), and brain function disorders (hepatic encephalopathy). Excessive alcohol use is the leading cause of cirrhosis.

Even moderate alcohol intake can produce pain in the upper right quarter of the abdomen--a possible symptom of liver involvement. In many cases, such symptoms may be an indication of fatty liver or alcohol hepatitis, which are reversible liver conditions.

Between 10 - 20% of people who drink heavily (five or more drinks a day) develop cirrhosis, a progressive and irreversible scarring of the liver that can eventually be fatal. Alcoholic cirrhosis (also sometimes referred to as portal, Laennec’s, nutritional, or micronodular cirrhosis) is the primary cause of cirrhosis in the US. It is estimated to be responsible for between 44 - 80% of deaths from cirrhosis in North America. [See In-Depth Report #75: Cirrhosis.]

Not eating when drinking and consuming a variety of alcoholic beverages increase the risk for liver damage. Nevertheless, the amount of alcohol consumed and the patterns of drinking are only weak predictions of risk. Up to 90% of heavy drinkers do not develop advanced irreversible liver disease. Other risk factors have been identified that may increase the danger to the liver in heavy drinkers:

• Obesity is a major factor for all stages of liver disease.
• Women develop liver disease at lower quantities of alcohol intake than men.
• Genetic factors that regulate the immune responses also play role.

Viral Hepatitis B and C. People with alcoholism tend to have lifestyles that put them at higher risk for viral hepatitis B and C, which are caused by viruses. Chronic forms of viral hepatitis pose risks for cirrhosis and liver cancer, and alcoholism significantly increases these risks. People with alcoholism should be immunized against hepatitis B; they may need a higher-than-normal dose of the vaccine for it to be effective. There is no vaccine for hepatitis C. [See In-Depth Report #59: Hepatitis.]

Gastrointestinal Problems

Alcoholism can cause many problems in the gastrointestinal tract. Violent vomiting can produce tears in the junction between the stomach and esophagus. Alcoholism poses a high risk for diarrhea and hemorrhoids. It increases the risk for ulcers, particularly in people taking the painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. It can also cause inflammation of the esophagus (esophagitis), which can lead to bleeding in heavy drinkers.

Click the icon to see an image of Ulcer emergencies.

Alcohol can contribute to serious and chronic inflammation of the pancreas (pancreatitis) in people who are susceptible to this condition. There is some evidence of a higher risk for pancreatic cancer in people with alcoholism, although this higher risk may occur only in people who are also smokers.

Click the icon to see an image of the pancreas.

Effect on Heart Disease and Stroke

Benefits of Moderate Drinking. The effects of alcohol on heart disease and stroke vary depending on consumption. Evidence strongly suggests that light to moderate alcohol consumption (one or two drinks a day, especially of red wine) protects the heart and also helps prevent stroke. The benefits are strongest in people at high risk for heart disease and may be fairly small in those at low risk.

Adverse Effects of Heavy Drinking. It should be strongly noted that heavy drinking harms the heart. In fact, cardiovascular disease is the leading cause of death in alcoholics. The following are negative effects on the heart and the circulatory system from high alcohol consumption.

• Evidence suggests that people who consume more than three drinks per day have abnormal blood clotting factors.

Click the icon to see an image of blood clot formation.

• Heavy drinking was associated with atherosclerosis (hardening of the arteries) in a 2003 study.

Click the icon to see an image of atherosclerosis.

• Between 5 - 10% of cases of hypertension are due to alcoholism. Heavy alcohol consumption can raise blood pressure even in people with no history of heart disease. The more alcohol someone drinks, the greater the increase in blood pressure, with binge drinkers (people who have nine or more drinks once or twice a week) being at greatest risk.

Click the icon to see an image of untreated hypertension.

• One study found that binge drinkers had two and half times the risk for heart-related emergencies than nondrinkers.

Click the icon to see an image of heart attack symptoms.

• Heavy alcohol use, particularly a recent history of drinking, is associated with a higher risk of both ischemic and hemorrhagic stroke.

Click the icon to see an image of an intracerebral hemorrhage.

• Large doses of alcohol can trigger potentially dangerous irregular heartbeats, most often those called atrial fibrillation, which is a common heart rhythm problem in people with alcoholism.

Click the icon to see an image of the heart.

• Alcohol abuse has also been associated with, and may actually be a cause of, idiopathic dilated cardiomyopathy, a condition in which the heart enlarges and its muscles weaken, putting the patient at risk for heart failure. Scientists have identified a genetic factor that appears to be responsible for this condition in certain people with alcoholism. Not all heavy drinkers develop heart failure and, in fact, moderate drinking can be protective.

Click the icon to see an image of alcoholic cardiomyopathy.

Cancer

As with heart disease, light to moderate consumption of alcohol, particularly red wine, may protect against cancer. Cancer, however, is the second leading cause of death in alcoholics (after cardiovascular disease), and alcoholics have a rate of carcinoma 10 times higher than that of the general population. Alcohol is probably not the direct cause of cancer in such cases, but most likely it increases the effects of other factors that contribute to certain cancers. The following are some examples:

• Alcohol produces enzymes in saliva that may be carcinogenic and increase the risk of upper digestive cancers in certain individuals.
• Studies suggest that alcohol, in combination with tobacco smoke, causes genetic damage that is associated with the development of cancer in the upper airways, the esophagus, the pancreas, and the liver.
• Use of alcohol has also been associated with a higher risk for breast cancer, possibly because of increased estrogen levels or because the liver overproduces certain carcinogenic growth factors in response to alcohol. The more a woman drinks, the higher the risk. Even moderate drinking poses a higher risk, although it is modest compared to heavy drinking. (Women who drink and are also taking hormone replacement therapy are at the highest risk.)
• Alcoholism is also highly associated with invasive cervical and vaginal cancers. This high risk, however, may be due to behaviors associated with both alcoholism and these cancers (e.g., smoking, promiscuity, use of hormonal contraception, and dietary deficiencies).

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Effects on the Lung

Pneumonia. Alcoholism is strongly associated with very serious pneumonia. Over time, chronic alcoholism can cause severe reductions in white blood cells, which increase the risk for infections, particularly those in the lung. One study on laboratory animals suggests that alcohol specifically damages the bacteria-fighting capability of lung cells. (Chronic alcoholism also causes changes in the immune system, although in people without any existing medical problems these changes do not appear to be significant.)

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Acute Respiratory Distress Syndrome. One study indicated that intensive care patients with a history of alcohol abuse have a significantly higher risk for developing acute respiratory distress syndrome (ARDS) during hospitalization. ARDS is a form of lung failure that can be fatal. It can be caused by many of the medical conditions common in chronic alcoholism, including severe infection, trauma, blood transfusions, pneumonia, and other serious lung conditions.

Skin, Muscle, and Bone Disorders

Severe alcoholism is associated with osteoporosis (loss of bone density), muscular deterioration, skin sores, and itching. Alcohol-dependent women seem to face a higher risk than men for damage to muscles, including muscles of the heart, from the toxic effects of alcohol. Peripheral neuropathy, damage to the nerves in the limbs, occurs in 5 - 15% of people with alcoholism. Such injuries cause tingling, pain, and numbness in the hands, feet, arms, and legs.

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Effects on Reproduction and Fetal Development

Effects Sexual Function and Fertility. Alcoholism increases levels of the female hormone estrogen and reduces levels of the male hormone testosterone, factors that possibly contribute to impotence in men and infertility in women. Such changes may also be responsible for the higher risks for absent periods and abnormal uterine bleeding in women with alcoholism.

Drinking During Pregnancy and Effects on the Infant. Even moderate amounts of alcohol can have damaging effects on the developing fetus, including low birth weight and an increased risk for miscarriage. High amounts can cause fetal alcohol syndrome, a condition that can cause mental and growth retardation. One study indicated a significantly higher risk for leukemia in infants of women who drank any type of alcohol during pregnancy. A 2003 study also suggested that children of mothers who drink during pregnancy have a higher risk for alcohol dependence as they grow older.

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Effect on Weight and Diabetes

Moderate alcohol consumption may help protect the hearts of adults with type 2 diabetes. Heavy drinking however is associated with obesity, which is a risk factor for this form of diabetes. In addition, alcohol can cause hypoglycemia, a drop in blood sugar, which is especially dangerous for people with diabetes who are taking insulin. Intoxicated diabetics may not be able to recognize symptoms of hypoglycemia, a potentially hazardous condition.

The Effect on Central Nervous System and Mental Functioning

Drinking too much alcohol can cause immediate mild neurologic problems in anyone, including insomnia and headache. Long-term alcohol use may even physically affect the brain. Except in severe cases, however, any neurologic damage is not permanent, and abstinence nearly always leads to eventual recovery of normal mental function.

Effect on Mental Functioning. Studies have reported less blood flow in the frontal lobes of the brain, which may reflect links to deeper levels. In a 1999 study, even recent high alcohol use (i.e., within the last 3 months) was associated with some loss of verbal memory and slower reaction times. Researchers are also interested in the effects on the hippocampus. This region in the brain is associated with learning and memory and the regulation of emotion, sensory processing, appetite, and stress. One 2000 study suggests that during adolescence the hippocampus is particularly vulnerable to the adverse effects of alcohol.

Moreover, a 2002 report indicated that over time chronic alcohol abuse can impair so-called "executive functions," which include problem solving, mental flexibility, short-term memory, and attention. These problems are usually mild to moderate and can last for weeks or even years after a person quits drinking. In fact, such persistent problems in judgment are possibly one reason for the difficulty in quitting. Alcoholic patients who have co-existing psychiatric or neurologic problems are at particular risk for mental confusion and depression.

Wernicke-Korsakoff Syndrome. Wernicke-Korsakoff syndrome is a serious consequence of severe thiamin (vitamin B1) deficiency in alcoholism. Symptoms of this syndrome include severe loss of balance, confusion, and memory loss. Eventually, it can result in permanent brain damage and death. Once the syndrome develops, oral supplements have no effect, and only adequate and rapid intravenous vitamin B1 can treat this serious condition.

Peripheral Neuropathy. Vitamin B1 deficiencies can also lead to peripheral neuropathy, a condition that causes pain, tingling, and other abnormal sensations in the arms and legs.

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Vitamin and Mineral Deficiencies

People with alcoholism should be sure to take vitamin and mineral supplements. Even apparently well-nourished people with alcoholism may be deficient in important nutrients. Deficiencies in vitamin B are particularly health risks in people with alcoholism. Other vitamin and mineral deficiencies, however, can also cause widespread health problems.

Folate Deficiencies. Alcohol interferes with the metabolism of folate, a very important B vitamin, called folic acid when used as a supplement. Folate deficiencies can cause severe anemia. Deficiencies during pregnancy can lead to birth defects in the infant. Folate deficiencies and alcoholism have also been associated with a higher risk for cancer and heart disease, particularly in women under 60.

Vitamin B1 Deficiencies. Many of the B vitamins are essential for nerve protection. Severe deficiencies are common in alcoholism and can have serious consequences on the central nervous system, notably peripheral neuropathy and, in very severe cases, Wernicke-Korsakoff syndrome.

Drug Interactions

The effects of many medications are strengthened by alcohol, while others are inhibited. Of particular importance is alcohol's reinforcing effect on anti-anxiety drugs, sedatives, antidepressants, and antipsychotic medications. Alcohol also interacts with many drugs used by diabetics. It interferes with drugs that prevent seizures or blood clotting. It increases the risk for gastrointestinal bleeding in people taking aspirin or other nonsteroidal inflammatory drugs (NSAIDs) including ibuprofen and naproxen. Chronic alcohol abusers have a particularly high risk for adverse side effects from consuming alcohol while taking certain antibiotics. These side effects include flushing, headache, nausea, and vomiting. In other words, taking almost any medication should preclude drinking alcohol.

Diagnosis

Even when people with alcoholism experience withdrawal symptoms, they nearly always deny the problem, leaving it up to co-workers, friends, or relatives to recognize the symptoms and to take the first steps toward encouraging treatment. Denial, in fact, may be an important warning signal for alcoholism.

Family members cannot always rely on a doctor to make an initial diagnosis. Although 15 - 30% of people who are hospitalized have alcoholism or alcohol dependence, doctors often fail to screen for the problem. In addition, doctors themselves often cannot recognize the symptoms. In one study, alcohol problems were detected by the doctor in less than half of patients who had them. Even when doctors identify an alcohol problem, however, they are frequently reluctant to confront the patient with a diagnosis that might lead to treatment for addiction.

Screening Tests for Alcoholism

A doctor who suspects alcohol abuse should ask the patient questions about current and past drinking habits to distinguish moderate from heavy, or hazardous, drinking. Screening tests for alcohol problems in older people should account for possible medical problems or medications that might place them at higher risk for hazardous drinking than younger individuals.

A number of short screening tests are available, which a person can even take on his or her own. Because people with alcoholism often deny their problem or otherwise attempt to hide it, the tests are designed to elicit answers related to problems associated with drinking rather than the amount of liquor consumed or other specific drinking habits.

CAGE Test. The CAGE test is an acronym for the following questions and is the quickest test:

• Attempts to CUT (C) down on drinking
• ANNOYANCE (A) with criticisms about drinking
• GUILT (G) about drinking
• Use of alcohol as an EYE-OPENER (E) in the morning

This test and another called the Self-Administered Alcoholism Screening Test (SAAST) appear to be most useful in detecting possible alcoholism in white, middle-aged males. They are not very accurate for identifying alcohol abuse in older people, white women, and African and Mexican Americans.

T-ACE Test. The T-ACE test is a four-question test that appears to be quite accurate in identifying alcoholism in both men and women. It asks the following questions:

• Does it TAKE (T) more than three drinks to make you feel high?
• Have you ever been ANNOYED (A) by people's criticism of your drinking?
• Are you trying to CUT DOWN (C) on drinking?
• Have you ever used alcohol as an EYE OPENER (E) in the morning?

A positive response to two of these four questions is considered to indicate possible alcohol abuse or dependence.

AUDIT Test. A more effective and important test for most people may be the Alcohol Use Disorders Identification Test (AUDIT), which is the only test specifically designed to identify hazardous or harmful drinking. It asks three questions about amount and frequency of drinking, three questions about alcohol dependence, and four questions about problems related to alcohol consumption.

A Single-Question. One simple question may be as sensitive as the CAGE or AUDIT: "When was the last time you had more than five drinks (for men) or four drinks (for women) in one day?" An answer of "within three months" accurately identified about half of people who were problem drinkers. Problem drinking is defined as hazardous drinking within the last month or some alcohol-use disorder during the past year.

Other Screening Tests. Other short screening tests are the Michigan Alcoholism Screening Test (MAST) and the Alcohol Dependence Scale (ADS).

Ruling Out Other Problems

Some symptoms of alcoholism may be attributed to other disorders, particularly in the elderly, where symptoms of confusion, memory loss, or falling may be attributed to the aging process alone. Heavy drinkers may be more likely to complain to their doctors about so-called somatization symptoms, which are vague ailments, such as joint pain, intestinal problems, or general weakness, that have no identifiable physical cause. Such complaints should signal the doctor to follow-up with screening tests for alcoholism.

Alcoholism is particularly less likely to be recognized in elderly women. In fact, only 1% of older women who need treatment for alcoholism are diagnosed accurately and treated appropriately. Instead, they are often diagnosed with depression and may even be prescribed anti-anxiety drugs or antidepressants that can have dangerous interactions with alcohol.

Tests for Related Medical Problems

Physical Examination. A physical examination and other tests should be performed to uncover any related medical problems.

Laboratory Tests. Tests for alcohol levels in the blood are not useful for diagnosing alcoholism because they reflect consumption at only one point in time and not long-term usage. Certain blood tests, however, may provide biologic markers that suggest medical problems associated with alcoholism or indications of alcohol abuse:

• Carbohydrate-deficient transferrin (CDT). This compound is a marker for heavy drinking and can be helpful in monitoring patients for progress towards abstinence.
• Gamma-glutamyltransferase (GGT). This liver enzyme is very sensitive to alcohol and can be elevated after moderate alcohol intake and in chronic alcoholism.
• Aspartate (AST) and alanine aminotransaminases (ALT). These are liver enzymes and are markers for liver damage.
• Testosterone. Male hormone levels in men with alcoholism may be low. (Such results sometimes persuade men with alcoholism to seek help.)
• Mean corpuscular volume (MCV). This blood test measures the size of red blood cells, which increase with alcohol use over time.

Treatment for Alcoholism

Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. One study reported that the main reasons alcoholics do not seek treatment are the following:

• Lack of confidence in successful therapies
• Denial of their own alcoholism
• Social stigma attached to the condition and its treatment

The alcoholic patient and everyone involved should fully understand that alcoholism is a disease. Furthermore, the responses to this disease (e.g., need, craving, fear of withdrawal) are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as are treatments for other life-threatening diseases, such as cancer, but that treatment is the only hope for a cure.

Interventions by family members, employers, and therapists can be very effective in motivating a person to quit and in reducing drinking over the short term. Even brief interventions from a primary care doctor and self-help information can be helpful in reducing harmful drinking. Studies report, however, that only regular follow-up and reinforcement will sustain quit rates and possibly even improve survival rates.

Personal Intervention Meetings. The best approaches for motivating a patient to seek treatment are interventional group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this approach, each person affected offers a compassionate but direct and honest report describing specifically how he or she has been hurt by their loved one's alcoholism. The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and consistently demand that the patient seek treatment. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation.

Employer Intervention. Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if he or she does not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers. Studies suggest that such interventions are effective at helping the worker at least to cut back on drinking.

Overall Treatment Goals

The ideal goals of long-term treatment by many doctors and organizations such as Alcoholics Anonymous are total abstinence. Patients who secure total abstinence have better survival rates, mental health, and marriages, and they are more responsible parents and employees than those who continue to drink or relapse. To achieve this, the patient aims to avoid high-risk situations and replace the addictive patterns with satisfying, time-filling behaviors.

Because abstinence is so difficult to attain, however, many professionals choose to treat alcoholism as a chronic disease. In other words, patients should expect and accept relapse but should aim for as long a remission period as possible. Even merely reducing alcohol intake can lower the risk for alcohol-related medical problems.

Alcoholics Anonymous (AA) and other alcoholic treatment groups are greatly worried by treatment approaches that do not aim for strict abstinence, however. Many people with alcoholism are eager for any excuse to start drinking again. There is also no way to determine which people can stop after one drink and which ones cannot.

Evidence strongly suggests that seeking total abstinence and avoiding high-risk situations are the optimal goal for people with alcoholism.

Inpatient Versus Outpatient Treatment

A number of treatment options now exist for alcoholism. It is first important to determine whether inpatient or outpatient care would best benefit the individual. Inpatient care is performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. It is recommended for the following people:

• Those with a coexisting medical or psychiatric disorder
• Those with delirium tremens
• Those who may harm themselves or others
• Those who have not responded to conservative treatments
• Those who have a disruptive home environment

Some -- but not all -- studies have reported better success rates with inpatient treatment of patients with alcoholism. In the positive reports, patients who were hospitalized for treatment had fewer complications and re-hospitalizations and longer abstinence rates than patients treated as outpatients. Other studies, however, have shown no difference in results between inpatient and outpatient programs. Given the ambiguity in results and high expense of inpatient treatment, most care providers do not choose inpatient treatment for alcoholics who are not a threat to others or to themselves.

Inpatient Treatment Options. A typical inpatient regimen may include the following stages:

• A physical and psychiatric work-up for any physical or mental disorders
• Detoxification --this phase involves initiating abstinence, managing withdrawal symptoms and complications, and ensuring that the patient remains in treatment
• On going treatment with medications in some cases
• Psychotherapy, usually cognitive-behavioral therapy
• An introduction to Alcoholics Anonymous (AA)

Outpatient Treatment Options. People with mild to moderate withdrawal symptoms are usually treated as outpatients. Treatments are similar to those in inpatient situations and include the following:

• Psychotherapy or counseling
• Medications that target brain chemicals involved in addiction
• Social support groups such as Alcoholics Anonymous
• Cognitive therapies
• Quitting smoking

After-Care and Work Therapy. After-care employs services that help alcoholics maintain sobriety. For example, in some cities, sober-living houses provide residences for people who are trying to stay sober. They do not offer formal treatment services, but the people living there offer each other support and maintain an abstinent environment. A 2002 study reported that work therapy improved the outcome for homeless veterans who were being treated for substance abuse.

Factors That Predict Success or Failure After Treatment

A 2001 analysis of studies reported that 25% of people were continuously abstinent following treatment, and another 10% used alcohol moderately and without problems. Even among the remaining group, alcohol consumption was reduced by an average of 87%. Most studies strongly suggest that intensive and prolonged treatment is important for successful recovery, whether the patient is treated within or outside a treatment center.

Certain factors play a role in success or failure. Patients from low-income groups tend to have worse results in general. Their difficulties are often intensified by lack of insurance, low self-esteem, and minimal social support.

Treating People Who Have Both Alcoholism and Health Problems

Severe alcoholism is often complicated by the presence of serious medical illnesses. People with alcoholism should try at least to maintain a healthy diet and take vitamin supplements. Such deficiencies are a major cause of health problems in people with alcoholism. Women are particularly endangered.

A program called integrated outpatient treatment (IOT) may be specifically helpful for medically ill alcoholics. The patient visits a clinic once a month and receives both intensive alcohol treatment and a physical check-up, which includes tracking factors, such as liver function, that are affected by drinking. One study showed that IOT significantly increased abstinence and the number of treatment visits. IOT may even improve survival rates. Interestingly, however, drinking also significantly decreased in a comparison group of patients who were treated only for their medical conditions.

Treating People Who Have Both Alcoholism and Mental Illness

Treatment for patients with both alcoholism and mental illness is particularly difficult. The greater the psychiatric distress a person is experiencing, the more he or she is tempted to drink, particularly in negative situations.

There has been some concern that self-help programs, such as Alcoholics Anonymous (AA), are effective for patients with dual diagnoses of mental illness and alcoholism, because the focus of the organization is on addiction, not psychiatric problems. Studies, however, have reported that they are also effective in many of these patients. (AA may not be as helpful for people with schizophrenia and schizoaffective disorder.) In one interesting study, individuals with a dual diagnosis achieved better abstinence rates after being treated only for alcoholism compared to patients treated for the mental disorder as well. (Cognitive-behavioral therapy was used for both groups.)

Newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are proving to be very useful complements to AA or counseling sessions. Anti-anxiety medications are also available for people with anxiety.

People with alcoholism and more severe problems such as schizophrenia or severe bipolar disorder probably need more intense help. One 2002 study also suggested that women and men with dual diagnoses may need different treatment approaches. Women were more bothered by their psychiatric problems and with social relationships than men were and were more likely to have a history of abuse. Women also had fewer episodes of criminal activity.

Treatment for Alcohol Withdrawal

When an alcoholic stops drinking, withdrawal symptoms begin within 6 to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are overproduced and the central nervous system becomes overexcited. Common symptoms include:

• Anxiety
• Irritability
• Agitation
• Insominia

Additional symptoms may include:

• Extremely aggressive behavior
• Fever
• Rapid heartbeat
• Changes in blood pressure (either higher or lower)
• Mental disturbances
• Seizures occur in about 10% of adults during withdrawal, and in about 60% of these patients, the seizures are multiple. The time between the first and last seizure is usually 6 hours or less.
• Delirium tremens (DTs) are withdrawal symptoms that become progressively severe and include altered mental states (hallucinations, confusion, severe agitation) or generalized seizures. DTs are potentially fatal. They develop in up to 5% of alcoholic patients, usually 2  to 4 days after the last drink, although it may take 2 or more days to peak.

It is not clear if older people with alcoholism are at higher risk for more severe symptoms than younger patients. However, several studies have indicated that they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Initial Assessment

Upon entering a hospital due to alcohol withdrawal, patients should be given a physical examination for any injuries or medical conditions. They should be treated, if possible, for any potentially serious problems, such as high blood pressure, anemia, liver damage, or irregular heartbeat.

Treatment for Withdrawal Symptoms

The immediate goal of treatment is to calm the patient as quickly as possible. Patients should be observed for at least two hours to determine the severity of withdrawal symptoms. Doctors may use assessment tests, such as the Clinical Institute Withdrawal Assessment (CIWA) scale, to help determine treatment and whether the symptoms will progress in severity.

About 95% of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15 - 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients often can be treated as outpatients. After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms increase in severity. If possible, a family member or friend should support the patient through the next few days of withdrawal.

Benzodiazepines. Anti-anxiety drugs known as benzodiazepines inhibit nerve-cell excitability in the brain and are considered to be the treatment of choice. They relieve withdrawal symptoms, help prevent progression to delirium tremens, and reduce the risk for seizures. Long-acting drugs, such as chlordiazepoxide (Libritabs, Librium), oxazepam (Serax), and halazepam (Paxipam) are preferred. They pose less risk for abuse than the shorter-acting drugs, which include diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan).

Assessing symptoms frequently and administering benzodiazepine doses as needed (compared giving to a fixed dose at regular intervals) may reduce the incidence of withdrawal symptoms and other adverse events, including delirium, seizures, and transfer to the intensive care unit.

Some doctors question the use of any anti-anxiety medication for mild withdrawal symptoms, since these drugs are subject to abuse. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe and frequent seizures with possible brain damage. In any case, benzodiazepines are usually not prescribed for more than 2 weeks or administered for more than 3 nights per week. Problems with benzodiazepines include the following:

• Side Effects. Common side effects of benzodiazepines are daytime drowsiness and a hung-over feeling. In rare cases, they actually cause agitation. Respiratory problems may be exacerbated. The drugs appear to stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet), antihistamines, and oral contraceptives. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although very rarely fatal. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. Benzodiazepines are associated with birth defects and should not be used by pregnant women or nursing mothers.
• Loss of Effectiveness and Dependence. The primary problem with these drugs is their loss of effectiveness over time with continued use at the same dosage. As a result, patients may increase their dosage level to prevent anxiety. Patients then can become dependent. In fact, some evidence suggests that people with alcoholism, or even a family history of alcoholism, may be more susceptible to benzodiazepine abuse than nonalcoholics. This is a common danger and can occur after as short a time as 3 months. (These drugs do not cause euphoria, a so-called "high," so such drugs are not addictive in the same way as are narcotics.)
• Withdrawal Symptoms. People who discontinue benzodiazepines after taking them for even four weeks can experience mild rebound symptoms. The longer the drugs are taken and the higher the dose, the more severe the symptoms. They include sleep disturbance and anxiety, which can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms, including stomach distress, sweating, and insomnia, that can last from 1 to 3 weeks. Sleep changes, in fact, can persist or months or years after quitting and may be a major factor in relapse.

Antiseizure Medications. Antiseizure drugs, such as carbamazepine (Tegretol) or divalproex sodium (Depakote) may be useful for reducing the requirements of a benzodiazepine. In two comparison 2002 studies, carbamazepine alone was superior to the benzodiazepine lorazepam in reducing withdrawal symptoms, including anxiety and sleep disturbances. Reduction in post-treatment drinking was also reported in one of the studies. Studies are also showing good results with divalproex. When used by themselves, however, they do not appear to reduce seizures or delirium associated with withdrawal.

Other Supportive Drugs. Beta-blockers, such as propranolol (Inderal) and atenolol (Tenormin), are sometimes used in combination with benzodiazepines. They slow heart rate and reduce tremors. They may also reduce cravings.

Note on Treating Alcohol Withdrawal with Alcohol. Some medical centers give patients alcohol to help with withdrawal. Experts do not recommend this approach. There is no evidence that this approach is safe or effective, while there is substantial evidence on the safety and effectiveness of benzodiazepines.

Specific Treatment for Severe Symptoms

Treating Delirium Tremens. People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. Treatment usually involves intravenous anti-anxiety medications. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to the patient or to others.

Treating Seizures. Seizures are usually self-limited and treated with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or in those with ongoing seizures. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe for reducing agitation and seizures.

Psychosis. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Korsakoff's psychosis (Wernicke-Korsakoff syndrome) is caused by severe vitamin B1 (thiamine) deficiencies, which cannot be replaced orally. Rapid and immediate injection of the B vitamin thiamin is necessary. One study reported benefits from a combination of fluvoxamine (Prozac) and clonidine (Catapres), a drug used for Tourette’s syndrome.

Therapy

The two standard forms of therapy for alcoholism are the following:

• Cognitive-behavioral therapy
• Interactional group psychotherapy based on the Alcoholics Anonymous (AA) 12-step program

Some comparison studies have reported that these approaches are equally effective when the program was competently administered. One 2001 study suggested that in general, AA may have a better abstinence rate than cognitive-behavioral therapy. It is also less expensive. Specific people, however, may do better with one program than another. One study, for example, examined the differences in success rates on type 1 or type 2 alcoholics:

• People in the type 1 group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy. (Type 1 individuals become alcoholic at a later age, have less severe symptoms or fewer psychiatric problems, and have a better outlook on life than those classified as type 2. They are more likely to be women.)
• The people in the type 2 group tend to do better with cognitive-behavioral therapy. (Type 2 people are more likely to be male, become alcoholic at an early age, have a high family risk for alcoholism, have more severe symptoms, and have a negative outlook on life.)

This difference in response to the two forms of treatment held up after two years. Other studies have also reported that people with fewer psychiatric problems do best with the AA approach.

Interactional Group Psychotherapy (Alcoholics Anonymous)

Alcoholics Anonymous (AA), founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well known program for helping people with alcoholism. It offers a very strong support network using group meetings open seven days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation.

AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) uses a structured teaching approach and may be better than AA for people with severe alcoholism. Patients are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. The following are examples of approaches:

• Patients might write a history of their drinking experiences and describe what they consider to be risky situations.
• They are then assigned activities to help them cope when exposed to "cues" (places or circumstances that trigger their desire to drink).
• Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team; this gave them the opportunity to practice coping skills, develop supportive relationships, and engage in healthy alternative activities.

CBT may be especially effective when used in combination with opioid antagonists, such as naltrexone. CBT that addresses alcoholism and depression also may be an important treatment for patients with both conditions. Interestingly, however, in one study patients with alcoholism and social phobias had a poorer outcome with a CBT program that addressed both problems.

Motivational Interviewing

A technique known as motivational interviewing is aimed at motivating people with alcoholism to change their own behavior. Studies suggest that it is very helpful in encouraging people to quit, even including those with mental illnesses. With this technique, the therapist uses empathy and a nonargumentative approach to encourage patients to make their own changes and to solve their own problems.

Behavioral Therapies for Partners

Partners of people with alcoholism can also benefit greatly from behavioral approaches that help them cope with their mate. Of note, children of an alcoholic mother or father may do better if both parents participate in couples-based therapy, rather than just treating the parent with alcoholism.

Treating Sleep Disturbances

Nearly all patients who are alcohol dependent suffer from insomnia and sleep problems, which can last months to years after abstinence. Sleep disturbances may even be important factors in relapse. Available therapies include sleep hygiene, bright light therapy, meditation, relaxation methods, and other nondrug approaches. Many medications for inducing sleep are not recommended in people with alcoholism. [For more information, see In-Depth Report #27: Insomnia.]

Alternative Methods

Some people try alternative methods, such as acupuncture or hypnosis. Such approaches are not harmful. In one study acupuncture reduced the desire for alcohol in nearly half of people, although it was not significantly more helpful than conventional treatments.

Medications

In the US, three drugs are specifically approved to treat alcohol dependence:

• naltrexone (ReVia)
• acamprosate (Campral)
• disulfiram (Antabuse)

Naltrexone and acamprosate are categorized as anticraving drugs. Disulfiram is an aversion drug. Other types of medications, such as antidepressants, may also be used to treat patients with alcoholism.

Anticraving Medications

Anticraving drugs are opioid antagonists. These drugs reduce the intoxicating effects of alcohol and the urge to drink

Naltrexone. Naltrexone (ReVia) is approved for the treatment of alcoholism and is effective for reducing alcohol dependence in the short term for people with low to moderate alcohol dependency. For best results, it should be used with cognitive behavioral therapy but it may also help many alcohol-dependent people without access to psychologic support. The drug does not work in all patients. A 2003 study suggested that people with a specific genetic variant called ASn40 respond better to the drug than those without the gene. The gene regulates receptors that affect the response to opioids. A 2005 study indicated that naltrexone works best for patients who have a family history of alcoholism, began drinking at an early age, and abuse other drugs. Another study reported that naltrexone offered no advantages for men with chronic, severe alcohol dependence, particularly if they have no social support.

Research is being conducted on the effects of combining naltrexone with acamprosate (Campral), particularly for individuals who have not responded to single drug treatment. Naltrexone is currently approved as a pill that is taken daily by mouth. Researchers are investigating an injectable form of naltrexone that would be given on a monthly basis. A 2005 study in the Journal of the American Medical Association reported that patients who received monthly injections of naltrexone for 6 months were more likely to reduce their heavy drinking than patients who received placebo. In this study, patients also received psychotherapy.

Naltrexone is often prescribed along with psychotherapy. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses can cause liver damage. The drug should not be given to anyone who has used narcotics within a week to 10 days. It is important that patients follow their doctors’ orders and take the pill on a daily basis.

Acamprosate. Acamprosate (Campral) is the newest drug to be approved for treatment of alcoholism. Acamprosate calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies indicate that it reduces the frequency of drinking and, in concert with psychotherapy, improves quality of life even in patients with severe alcohol dependence. One study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use acamprosate cautiously. For some patients, combination therapy with naltrexone or disulfiram may provide greater benefit than acamprosate alone.

Nalmefene. Nalmefene (Revex) is an injectable opioid antagonist that is similar to naltrexone. It is generally used to reverse the effects of narcotics that are given during surgery. It is being investigated as an anticraving drug for alcohol dependence.

Aversion Medications

Disulfiram. Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and may last from half an hour to 2 hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for 1 to 2 weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. The drug is more effective if patients have family or social support, including AA "buddies," who are close by and vigilant to ensure that they take it. A 2004 study that compared naltrexone with disulfiram during the course of one year found that 86% of patients treated with disulfiram remained abstinent compared with 44% of patients treated with naltrexone. However, patients treated with naltrexone had lower levels of alcohol craving.

Antidepressants

Depression is common among alcohol-dependent people, and it can be a significant problem in people who quit drinking. In fact, one 2002 study found that quitting drinking was associated with a fourfold increase in the risk for major depression. Antidepressants may be helpful, particularly for patients who have a history of depression. Experts reporting on the study suggested that treating these individuals with antidepressants as soon as they quit drinking may help prevent relapse. A 2004 review of clinical trials found that antidepressants had a limited effect on alcohol dependence and should be prescribed in combination with behavioral or pharmacologic therapies that directly address the addiction itself.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) target the neurotransmitter serotonin and are of particular interest in the treatment of alcoholism. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox). Studies indicate that these antidepressants may reduce cravings and desire for alcohol, even in selected people who are not depressed. Studies report reductions in alcohol ranging from 10 - 70% in people with alcoholism who take SSRIs. Research is under way to determine which individuals with alcoholism might best respond to SSRIs. For example, one study suggested that they may be more effective for men than women. Some may be specifically helpful for people with both alcoholism and certain anxiety disorders, such as social anxiety.

Designer Antidepressants. A number of drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron). Some research suggests they may have some benefits for treating alcoholism. However, nefazodone has been linked to increased risk for liver damage and should be used with caution by people with alcohol dependence.

Other Drugs

Topiramate. Topiramate (Topamax) is an anti-seizure drug used to treat epilepsy. It also helps control impulsivity. Early studies indicate it might reduce craving in patients with alcoholism, and may also help them stop smoking. Most side effects are mild to moderate and include mood swings and behavioral problems, dizziness, fatigue, visual disturbances, tremor, impaired concentration and thinking, weight loss and diarrhea, and a higher risk for kidney stones.

Odansetron.Ondansetron (Zofran) is ordinarily used to prevent nausea and vomiting due to chemotherapy. It also has actions that affect serotonin, a neurotransmitter that helps regulate alcohol's effects. In one study, ondansetron helped reduce drinking in people with early-onset alcoholism, although not in people who began drinking after age 25. These results suggest that this drug is helpful in patients with genetically related alcoholism, although not with alcoholism caused by other factors.

Resources

• www.niaaa.nih.gov -- National Institute on Alcohol Abuse and Alcoholism
• www.samhsa.gov -- Substance Abuse and Mental Health Services Administration
• www.health.org -- National Clearinghouse of Alcohol and Drug Information
• www.aca-usa.org -- American Council on Alcoholism
• www.ncadd.org -- National Council on Alcoholism
• www.alcoholics-anonymous.org -- Alcoholics Anonymous
• www.al-anon-alateen.org -- Al-Anon Family Group Headquarters
• www.nofas.org -- National Organization on Fetal Alcohol Syndrome

References

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Garbutt JC, Kranzler HR, O'Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA. 2005;293(13):1617-1625.

Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097-1106.

Johnson BA, Ait-Daoud N, Akhtar FZ, Javors MA. Use of oral topiramate to promote smoking abstinence among alcohol-dependent smokers: a randomized controlled trial. Arch Intern Med. 2005;165(14):1600-1605.

Kushner MG, Abrams K, Thuras P, Hanson KL, Brekke M, Sletten S. Follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients. Alcohol Clin Exp Res. 2005;29(8):1432-1443.

Pandey SC, Zhang H, Roy A, Xu T. Deficits in amygdaloid cAMP-responsive element-binding protein signaling play a role in genetic predisposition to anxiety and alcoholism. J Clin Invest. 2005;115(10):2762-2773.

Rubio G, Ponce G, Rodriguez-Jimenez R, Jimenez-Arriero MA, Hoenicka J, Palomo T. Clinical predictors of response to naltrexone in alcoholic patients: who benefits most from treatment with naltrexone? Alcohol Alcohol. 2005;40(3):227-233.

Scott LJ, Figgitt DP, Keam SJ, Waugh J. Acamprosate: a review of its use in the maintenance of abstinence in patients with alcohol dependence. CNS Drugs. 2005;19(5):445-464.

Williams SH. Medications for treating alcohol dependence. Am Fam Physician. 2005;72:1775-1780.

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