Alcoholism

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Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to the extent that this behavior interferes with the drinker's normal personal, family, social, or work life, and may lead to physical, or mental harm. The resulting chronic use can result in many psychological and physiological disorders. Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

Epidemiology

According to the Treatments of Psychiatric Disorders, 3rd Ed, substance use disorders are the major public health problem facing the United States today. More than 15 million Americans suffer from alcoholism. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol." Satal, Kosten, and Schuckit noted in 1993 that it is likely that individuals will not reach an optimal level of function until substance free for three to six months. Those with the condition are classified by the APA as either actively using alcohol, or being in early or sustained remission. The latter two groups may be further identified as being partial or full depending upon the patient's symptom profile.

The disease hypothesis

Below are arguments for ("pro") and against ("con") alcoholism as a disease.

Pro

Drunkenness was often viewed as a moral lapse and a sinful choice until the disease hypothesis of alcoholism was proposed in the early 1800's. In the present day the American Society of Addiction Medicine and the American Medical Association both maintain extensive policy regarding alcoholism. The American Psychiatric Association recognizes the existence of "alcoholism" as the equivalent of alcohol dependence. The American Hospital Association, the American Public Health Association[1], the National Association of Social Workers, and the American College of Physicians classify "alcoholism" as a disease.

The AMA's policies, formed through consensus of the federation of state and specialty medical societies within their House of Delegates, state, in part: "The AMA endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice." This policy was developed in 1987 in part due to the lack of parity between addictive disease and other chronic disease states with respect to third party reimbursement. In 1991, The AMA further endorsed the dual classification of alcoholism by the International Classification of Diseases under both psychiatric and medical sections. In 1980, the AMA's Council on Scientific Affairs (now the Council on Science and Public Health) noted that "alcoholism is in and of itself a disabling and handicapping condition."

Although medication has been developed to assist in the treatment of alcoholism, the research has not yet demonstrated long term efficacy. Of importance is that frequency and quantity of alcohol use are not related to the presence of the condition (definition, as per 1992 JAMA article cited above); that is, individuals can drink a great deal without necessarily being alcoholic, and alcoholics may drink minimally and/or infrequently. Alcohol is cross-tolerant with other sedatives such as Valium, Phenobarbital, and Soma. These other sedative agents are therefore generally not prescribed to individuals with alcoholism.

Con

Whether or not alcoholism is a biological disease remains controversial. The hypothesis has yet to be supported to the satisfaction of the alcoholism research community (Research Society on Alcoholism; American Psychological Association), although it is widely believed by AA members, therapists, many practicing physicians, and others. Some argue that the disease concept is promoted by those with a vested interest: if alcoholism is not considered a disease, third-party payments to physicians and hospitals for its treatment might cease. In a 1988 U.S. Supreme Court decision on whether alcohol dependence is a condition for which the U.S. Veterans Administration should provide benefits (Traynor v. Turnage), Justice Byron R. White's statement echoed the District of Columbia Circuit's finding that "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility." He also wrote, "Indeed, even among many who consider alcoholism a "disease" to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary." [2] The US Social Security Administration no longer makes disability payments to individuals for whom substance use disorders are a material aspect of their disability.

Programs such as Rational Recovery reject the "disease model" and Stanton Peele has devoted a significant portion of his web site to disputing many assertions made by many in the alcoholism treatment community including the AMA, APA and NIAAA[3].

Diagnosis

The DSM IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism, one more closely based on specifics than the 1992 JAMA article. In part this is to assist in the development of research protocols in which findings can be compared with one another, but the DSM definition is the one in general use from a diagnostic standpoint. That definition is: maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Biological mechanism

The biological mechanism of alcoholism is unknown. Alcohol itself, according to the Lowinson text, is not a factor in the development of this condition, however, or one would be able to turn a non-alcoholic into an alcoholic through the provision of alcohol.

Terminology

There are many terms which are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, addiction, abuse and dependence are all commonly in use, but are not always used with an understanding of the associated medical conditions and therefore have acquired highly varying and sometimes non-standard meanings.

Use refers to simple use of a substance. An individual who drinks a beer is using alcohol.

Misuse and heavy use do not have standard definitions, but generally refer to the consumption of alcohol beyond the point where it causes physical, social, or moral harm to the drinker. Social and moral harm are highly subjective and therefore have no clinical definition.

Abuse and Dependence have standard medical diagnosis definitions in the DSM-IV-TR, but this terminology is now under discussion for change as DSM-V is being prepared. The American Psychiatric Association (APA) welcomes input regarding proposed terminology.

Addiction has a separate entry.

Effects

See also: Effects of alcohol on the body and Alcohol consumption and health

Long term physical health effects

The long term health effects caused by the consumption of large amounts of alcohol (both by alcoholics and non-alcoholics) may include:

• death from many sources, primarily alcohol toxemia
• pancreatitis, or inflammation of the pancreas (both the acute and chronic form)
• heart disease, including dilated cardiomyopathy
• polyneuropathy, or damage to the nerves leading to poor sensation of pain and impaired mobility
• cirrhosis of the liver, a chronic disease characterized by destruction of liver cells and loss of liver function, and its numerous complications, including bleeding from esophageal varices
• depression, insomnia, anxiety, and suicide
• increased incidence of many types of cancer, including breast cancer, head and neck cancer, esophageal cancer and colorectal cancer
• nutritional deficiency of folic acid, thiamine (vitamin B1) and several others
• Wernicke-Korsakoff syndrome, a neuropsychiatric disorder caused by thiamine deficiency that results from poor nutrition in alcoholics
• sexual dysfunction

Social Effects

The social problems arising from alcoholism can include loss of employment, financial problems, marital conflict and divorce, convictions for crimes such as drunk driving or public disorder, loss of accommodation, and loss of respect from others who may see the problem as self-inflicted and easily avoided. Alcohol dependence affects not only the addicted but can profoundly impact the family members around them. Children of alcohol dependents can be affected even after they are grown; the behaviors commonly exhibited by such children are a topic of research. Adult Children of Alcoholics (ACoA) World Service provides support for such individuals.

Alcohol Withdrawal

There are several distinct but not mutually exclusive alcohol withdrawal syndromes caused by alcohol withdrawal:

• Tremulousness - "the shakes"
• Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure.
• Seizures - acute grand mal seizures can occur in alcohol withdrawal in patients who have no history of seizure or any structural brain disease.
• Hallucinations - usually visual or tactile in alcoholics
• Delirium tremens - can be severe and often fatal.

Unlike withdrawal from opioids such as heroin, which can be unpleasant but never fatal (Lowinson), alcohol withdrawal can kill (by uncontrolled convulsions or delirium tremens) if it is not properly managed. The pharmacological management of alcohol withdrawal is based on the fact that alcohol, barbiturates, and benzodiazepines have remarkably similar effects on the brain and can be substituted for each other. Since benzodiazepines are the safest of the three classes of drugs, alcohol consumption is terminated and a long-acting benzodiazepine is substituted to block the alcohol withdrawal syndrome. The benzodiazepine dosage is then tapered slowly over a period of days or weeks.

Screening

Several tools may be used to detect the habitual abuse of alcohol. The CAGE questionnaire, developed by Dr. John Ewing and named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Another screening questionnaire is the Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization.

The Alcohol Dependence Data Questionnaire [4] is a more sensitive diagnostic test than the CAGE test. The Alcohol Dependence Data Questionnaire serves to distinguish a diagnosis of alcohol dependence from one of alcohol abuse.

The CAGE questionairre, among others, has been extensively validated for use in identifying alcoholism. Its use has not been validated for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.

Blood tests

Although there is no blood test specific for alcohol abuse or alcohol dependence (alcoholism), prolonged heavy alcohol consumption may lead to several abnormalities, including:

• Macrocytosis (enlarged MCV)¹
• Elevated GGT²
• Moderate elevation of AST and ALT and an AST:ALT ratio of 2:1.
• High carbohydrate-deficient transferrin²

Treatments

Goals of treatment involve "1) helping the patient achieve a substance-free life, 2) maximizing multiple aspects of life functioning, and 3)preventing relapse," according to the 3rd Edition of Treatments of Psychiatric Disorders. This is generally accomplished in a majority of patients entering treatment through a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism therefore supports an abstinence-based approach, unlike the harm-reduction approach that is supported for opioid dependence. However, there are those individuals and programs that disagree with this approach.

Group Therapy and Psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues leading to alcohol dependence, and also to provide the recovering addict with relapse prevention skills. Aversion therapies may be supported by drugs like Disulfiram, which causes a strong and prompt sensitivity reaction whenever alcohol is consumed. Naltrexone or Acamprosate may improve compliance with abstinence planning by treating the physical aspects of cravings to drink. The standard pharmacopoeia of antidepressants, anxiolytics, and other psychotropic drugs treat underlying mood disorders, neuroses, and psychoses associated with alcoholic symptoms.

In the mid-1930s, the mutual-help group-counseling approach to treatment began and has become very popular. Alcoholics Anonymous is the best-known example of the support group movement. Other groups that provide similar self-help and support without AA's spiritual focus include LifeRing Secular Recovery, Smart Recovery, Women For Sobriety, and Rational Recovery.

Rationing

Some programs attempt to help problem drinkers before they become dependents. These programs focus on harm-reduction and reducing alcohol intake as opposed to cold-turkey approaches. Since one of the effects of alcohol is to reduce a person's judgment faculties, each drink makes it more difficult to decide that the next drink is a bad idea. As a result, rationing or other attempts to control use are increasingly ineffective as pathological attachment to the drug develops. Use may continue despite serious adverse health, personal, legal, work-related, and financial consequences.

Nonetheless, this form of treatment is initially effective for some people, and it may avoid the physical, financial, and social costs that other treatments result in, particularly in the early phase of recovery. Professional help can be sought for this form of treatment from programs such as Moderation Management.

Detoxification

This is not a treatment for alcoholism per se, but is rather a treatment to make the alcohol withdrawal process safer than it would be otherwise. Unlike withdrawal from some drugs (e.g. opioids), withdrawal from alcohol carries risks of significant morbidity and mortality.

Medications

The use of medications for alcoholism is to supplement a person's willpower and encourage abstinence. Antabuse (disulfiram), for instance, prevents the elimination of chemicals which cause severe discomfort when alcohol is ingested, effectively preventing the alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on Antabuse can result in severe illness and death. Naltrexone has also been used because it helps curb cravings for alcohol while the person is on it. Both of these, however, have been demonstrated to cause a rebound effect when the user stops taking them. These do allow a person to resist psychological addictions to alcohol, but they do not treat the neurochemical addiction. As noted above, the use of medications for the treatment of alcoholism remains controversial.

Pharmacological Extinction

In recent studies[5] it has been demonstrated that the use of endorphin antagonists [e.g. naltrexone] combined with normal drinking habits can result in long term elimination of the craving to consume alcohol. Over a period of roughly three months the alcoholic, while continuing to drink, loses interest in drinking alcohol and can eventually just give it up as being sensibly unbeneficial. This technique is used to good effect in Finland[6], Pennsylvania[7], and Florida[8]. This particular form of treatment is sometimes referred to as the Sinclair Method.

There is a lot of professional bias against this treatment for two reasons. Pendery et al in 1982 demonstrated that controlled drinking by alcoholics was clearly not a useful treatment technique. Many studies have also been done which demonstrate naltrexone to be of questionable value in supporting abstinance. For those who don't understand the mechanism involved, these results have been falsely assumed to reflect the effectiveness of the two treatments in combination.

The Finn study indicated, "Naltrexone was not better than placebo in the supportive groups, but it had a significant effect in the coping groups: 27% of the coping/naltrexone patients had no relapses to heavy drinking throughout the 32 weeks, compared with only 3% of the coping/placebo patients. The authors' data confirm the original finding of the efficacy of naltrexone in conjunction with coping skills therapy. In addition, their data show that detoxification is not required and that targeted medication taken only when craving occurs is effective in maintaining the reduction in heavy drinking."

Nutritional therapy

Not a treatment of alcoholism itself, but rather a treatment of the difficulties that can arise after years of heavy alcohol use: Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be treated by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, resulting in poor treatment outcomes. See: [9]

Return to normal drinking

It has long been argued that alcoholics cannot learn to drink in moderation. The literature is heavy with research that has demonstrated the long-term failure of programs with such goals; despite this, research by the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates that about 18% of such individuals in the US whose dependence began more than one year earlier are now drinking in moderation.

Societal Impact

Today, alcohol abuse and alcohol dependence are major public health problems in North America, costing the region's inhabitants, by some estimates, as much as US$170 billion annually. Alcohol abuse and alcohol dependence sometimes cause death, particularly through liver, pancreatic, or kidney disease, internal bleeding, brain deterioration, alcohol poisoning, and suicide. Heavy alcohol consumption by a pregnant mother can also lead to fetal alcohol syndrome, an incurable and damaging condition.

Additionally, alcohol abuse and alcohol dependence are major contributing factors for head injuries, motor vehicle accidents (MVA), violence and assaults, neurological, and other medical problems (cirrhosis, etc.).

Of the one half of the North American population who consume alcohol, it has been estimated by some that 10% are alcohol abusers and alcohol dependents, and 6% consume more than half of all alcohol.

Stereotypes of alcohol abusers and alcohol dependents are often found in fiction and popular culture: for example the "town drunk," or the stereotype of Russians and the Irish as alcoholics. In modern times, the recovery movement has led to more realistic portraits of abusers and dependents and their problems, such as in Charles R. Jackson's The Lost Weekend, or the films Days of Wine and Roses, and My Name is Bill W or the extreme Leaving Las Vegas. Charles Bukowski describes honestly his alcohol addiction in the movie Barfly and in his other writings.

Politics and public health

Because alcohol use disorders impact society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

Organizations working with those suffering from alcohol use disorders include:

• Alcoholics Anonymous (AA)
• International Organisation of Good Templars (IOGT)
• LifeRing Secular Recovery (LifeRing)
• Men For Sobriety (MFS)
• Moderation Management (MM)
• Rational Recovery (RR)
• Secular Organizations for Sobriety (SOS)
• Smart Recovery (Self Management And Recovery Training - SMART)
• Women For Sobriety (WFS)
• Narcotics Anonymous (NA), Alcohol is a drug.

Miscellaneous

• The disease model of alcoholism was first proposed by Dr. Benjamin Rush of Philadelphia in the early 1800's, who also promoted his theory that the dark skin of blacks was caused by a congenital disease called "Negritude" [10].
• E. M. Jellinek, who has been called the father of the modern theory of alcoholism as a disease, may not actually have received any earned university degree [11]. There is also considerable controversy over his claim that he ever received an earned doctoral degree and he has been called a liar and a fraud [12].

See also

• Addiction
• Alcohol-related traffic crashes
• Alcohol tolerance
• Alcoholics Anonymous
• Beer
• Beer belly
• Delirium tremens
• Drug addiction
• Drunkenness
• E. Morton Jellinek
• List of famous deaths through alcohol
• List of fictional alcoholics
• List of iconic drinkers
• Public house
• Substance abuse
• Wernicke-Korsakoff syndrome
• Drug test
• medical diagnostic tests used in alcoholism: liver function tests, full blood count and other
• films about alcoholism: Leaving Las Vegas (1995), When a Man Loves a Woman (1994)

External links

• National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• Stanton Peele Addiction Website A web site dedicated to exploring popular myths and controversies regarding alcoholism and addiction treatment, prevention and research.
• Baldwin Research Institute Independent Research on Alcoholism and Drug Addiction
• Alcoholics Anonymous
• Online Screening Test for Alcohol Abuse
• Psych Forums: Alcohol Addiction Forum
• Alcohol Tolerance May Be Genetic health.dailynewscentral.com
• CAGE Questionnaire (PDF)
• Articles and information pertaining to alcohol and drug rehabilitation
• Drink Too Much? by David J. Hanson
• Alcoholics can Drink in Moderation
• Invited Interview from the Oxford Journal of Medicine on the use of Naltrexone to treat alcoholism

References

1. Tonnesen H, Hejberg L, Frobenius S, Andersen JR. Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics. Acta Med Scand. 1986;219(5):515-8. (Medline abstract)
2. Schwan R, Albuisson E, Malet L, Loiseaux MN, Reynaud M, Schellenberg F, Brousse G, Llorca PM. The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach. Drug Alcohol Depend. 11 June 2004 ;74(3):273-9. (Medline abstract)
3. Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984
4. U.S Supreme Court, Traynor v Turnage, 485 U.S 353 (1988) at 535-550
5. McKelvey v. Turnage, 792 F.2d 194 (D.C. Cir. 1986) and Traynor v. Walters, 791 F.2d 226 (2d. Cir. 1986)
6. Heavy Drinking: The Myth Of Alcoholism As a Disease, Herbert Fingarette, PhD (University of California Press, 1988)
7. The Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control, Stanton Peele, PhD (Jossey-Bass, 1999)

• Hobbs, M.D., Ph.D., T. R. Managing alcoholism as a disease. Physician’s News Digest, February, 1998 [13]
• Meyer, Roger E. The disease called addiction: emerging evidence in a 200-year debate. Lancet, 1996, 347, 162-166. [14]
• Kolata, G. Alcoholic genes or misbehavior? The Supreme Court is due to decide whether alcoholism is a disease or a character flaw. Psychology Today, May, 1988 [15]
• Korhonen, M. Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ottawa: National Aboriginal Health Organizations, 2004 [16]
• Nackerud, L. The disease model of alcoholism: a Khunian paradigm. Journal of Sociology and Social Welfare, 2002 [17]
• Kelly, D. Understanding the Nature of Alcoholism (2001). Discusses the disease controversy. [18]
• Schaler, J. A. Thinking about drinking: the power of self-fulfilling prophecies. The International Journal of Drug Policy, 1996, 7(3), 187-191 [19]
• Doweiko, H. E. Concepts of Chemical dependency. NY: Brooks-Cole, 1996.
• Levy, M.S. The disease controversy and psychotherapy with alcoholics. Journal of Psychoactive Drugs, 1992, 24(3), 251-256. [20]
• Maltzman, I. Is alcoholism a disease? A critical review of a controversy. Integrative Physiological and Behavioral Science: The Official Journal of the Pavlovian Society, 1991, 26(3), 200-210 {

[21].

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