Worldwide, alcoholism is a leading preventable cause of morbidity and mortality. The chronic effects of alcohol overuse are destructive to bodily organs, families, and communities alike. Although the numbers of persons consuming alcohol is great, constituting a majority of the population in certain cultures, a small minority of these will develop problems with alcohol.
Alcoholism is defined by the U.S. National Council on Alcoholism and the American Society of Addiction Medicine as a “primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.” The criteria for alcoholism, as defined by this group, are as follows:
impaired control over drinking
preoccupation with the drug alcohol
use of alcohol despite adverse consequences
distortion of thinking, most notably denial
The term alcoholism encompasses the Diagnostic and Statistical Manual, 4th edition (DSM-IV) definitions of alcohol abuse and dependence, terms used to more clearly define types of alcoholism. Both are characterized as maladaptive patterns of alcohol abuse, with separate criteria. Alcohol abuse involves one or more of the following:
failure to fulfill work, school, or social obligations;
recurrent substance use in physically hazardous situations;
recurrent legal problems related to substance use;
continued use despite alcohol-related social or interpersonal problems.
substance taken in larger quantity than needed
persistent desire to cut down or control use
time is spent obtaining, using, or recovering from the substance
social, occupational, or recreational tasks are sacrificed
use continues despite physical and psychological problems
The three definitions—alcoholism, alcohol abuse, and alcohol dependence—all represent maladaptive use of alcohol that compromise the ability to function and fulfill obligations. While the distinctions between the three are useful in research, they are often indistinguishable in the clinical setting. Moreover, because they are treated similarly, health professionals will often focus on developing an individualized treatment plan based more on individual needs, rather than the diagnostic category. In addition, while the three overlap in many individuals, a unique feature of alcohol dependence is worth mentioning. In contrast to alcohol abuse, alcohol dependence involves signs of physiological dependence on alcohol characterized by an inability to quit or decrease usage of alcohol, despite a desire to do so. This article will use the convention chosen by many and will define alcoholism to be the disease of alcohol abuse and/or dependence, as outlined by the DSM-IV criteria.
Although many societies treat “alcohol use” as a socially accepted norm, making it commonplace, the abuse of alcohol is often found concentrated in specific segments of the population. Data from primary care patients suggest that prevalence rates of alcohol abuse/dependence can approach 10 percent of the population. Persons at the youngest and oldest ends of the age spectrum appear to be the most at risk for alcohol problems. For young adults 18–25 years of age, the group for whom binge and heavy drinking rates are the highest in the United States, the risks and costs of alcoholism throughout their lifetime are both acute and long term. Acute risks for this age group include alcohol-related motor vehicle crashes and violence. Longer-term effects are also great owing to their young age, and the fact that they are still developing physically and emotionally.
One study in the United States, where laws require persons to be 21 years of age to consume alcohol, revealed that young persons who initiated alcohol use before the age of 21 were four times more likely to become alcoholics over their lifetime when compared to those who began drinking alcohol at age 21. For older patients, unique problems associated with alcoholism include comorbid medical conditions and drug–alcohol interactions.
Two other populations known to have high rates of alcoholism are smokers and those with mental illness. In the case of smokers, 30 percent of those who smoke suffer from alcoholism, while 90 percent of alcoholics smoke. Different studies in the United States have shown that those with mental illness are more likely to have problems with alcohol, and vice versa. Current evidence suggests that approximately 40 percent with one of the two problems will also have the other (e.g., 40 percent of those diagnosed with mental illness will have problems with alcohol, while 40 percent of those with alcohol disorders will have diagnosable mental illness).
Long before there was rigorous science to back up a mechanism for alcoholism, it was clear that this condition had both a biological and social aspect. It is now known that alcohol is an antagonist to NMDA receptors, and an agonist at GABA receptors. Downstream from these receptors, alcohol affects many pathways, including the dopamine reward pathways. Recently, a molecule involved in stress responses, CRF, has been implicated as a mediator in the alcohol–GABA relationship, suggesting a biological mechanism connecting stress and alcoholism.
Beyond our ever-increasing understanding of the mechanisms behind alcohol addiction, there is also increasing evidence for a genetic basis to the disease. First-degree relatives of alcoholics have a relative risk for alcoholism three- to fourfold that of those without alcoholic relatives. In addition, a large population-based twins study found that identical twins have greater rates of concordance with regard to alcoholism than do fraternal twins; the authors estimate that approximately 50 to 64 percent of the variation between twins was explained by differences in addictive genetic factors.
Alcoholism is a costly societal condition. Estimates from Europe suggest an excess annual cost of €1,431 in 2003 for those with alcoholism, mostly due to decreased production. Another study estimated the cost to the United States in 1998 for alcoholism to be $185 billion, a result of the lost productivity, treatment, and comorbidities associated with alcoholism. Although these numbers are staggering, there are many costs to alcoholism that cannot be quantified, including the suffering of family members and the lost potential of the alcoholic. In addition, even though the statistics linking alcohol use with crime, violence, motor vehicle crashes, suicide, and drowning are direct indicators of alcohol’s societal costs, it is certain that alcoholism puts persons at risk to themselves and others through a perpetual overuse of alcohol.
Alcohol also has devastating effects on the body of the alcoholic. Chronic alcohol overuse affects nearly all of the body’s organs and organ systems. The nervous system effects of alcoholism are particularly devastating. Wernicke’s encephalopathy (WE), a condition seen in alcoholics due to low thiamine levels causes confusion, disorientation, and other signs of encephalopathy, oculomotor dysfunction, and gait ataxia. Korsakoff’s amnestic syndrome is often seen in patients who have already experienced WE, especially WE due to alcohol. It is marked by selective memory deficits (retrograde and anterograde), apathy, and an intact sensorium.
Beyond these specific deficits, there are also global changes found in alcoholics, with more than half showing deficits on neuropsychological testing; this corresponds with widespread changes to the brain, namely the enlargement of the ventricles, that is seen with chronic alcohol abuse. Other categories of nervous system dysfunction found disproportionately in alcoholics include cerebellar degeneration, damage to the corpus callosum, peripheral neuropathy, and myopathy.
The gastrointestinal (GI) system is also vulnerable to damage from alcohol. Most prominently affected are the liver and pancreas. Inflammation of the liver due to alcohol, known as alcoholic hepatitis, causes symptoms of nausea, vomiting, and abdominal pain. Over years of such inflammation, this will lead to permanent scarring and necrosis of the liver, a condition known as alcoholic cirrhosis. At this point, the functional capacity of the liver is decreased, and the patient is at risk for liver failure and hepatocellular carcinoma (HPC), not to mention the various sequelae from the liver’s inability to process and eliminate toxins from the body. Chronic ethanol use, even in moderate amounts, is also known to enhance the risks for HPC in carriers of hepatitis B and C.
The pancreas is also affected by chronic alcohol use, leading to a similar acute and chronic inflammatory response as is seen in the liver. One in 10 alcoholics will develop acute pancreatitis, with the majority of them progressing to chronic pancreatitis. In addition, cancers of the GI tract also rise with increasing rates of alcohol consumption, and are, therefore, found disproportionately in alcoholics.
While the bodies of alcoholics suffer greatly, fetuses exposed to ethanol are especially susceptible to long-term damage. The range of effects from maternal alcohol use vary from severe (fetal death, fetal alcohol syndrome) to mild or nonexistent, depending on many factors. Worldwide, rates of fetal alcohol syndrome, the disorder at the severe end of the spectrum of alcohol-related effects, range from 1 in 100,000 to 1 in 100. Its characteristics include facial abnormalities and central nervous system deficits. Other alcohol-related effects from fetal exposure include low birth weight, sleep disorders during infancy, learning disabilities, hyperactivity, and low IQ.
There are other conditions clearly associated with alcoholism, a few of which are mentioned below. Those conditions for which evidence is unclear (e.g., dementia or lung cancer) are not discussed here.
Breast cancer: Those who drink more alcohol have higher rates of breast cancer, with a dose-dependent curve between the two, beginning at one to two drinks per day. Hormone replacement therapy appears to further enhance alcohol’s effect of breast cancer risk, while high folic acid intake lessens alcohol’s effect.
Cancer of the oral cavity, larynx, pharynx, and esophagus: The rates of these cancers rise linearly with increased alcohol use. In addition, smoking has a synergistic effect on cancer risk in those who also use alcohol.
Osteoporosis: Alcoholism is related both to more falls and decreased bone mineral density.
Diabetes: Through pancreatic damage and the chronic inflammation associated with alcohol, those with drinking problems are at higher risk for diabetes.
Alcoholism, with the vast aforementioned risks to both individual patients and to the society around them, requires aggressive treatment. There are many options, some of which have been validated in studies of their effectiveness, to treat those with alcohol problems. First, however, the patient must recognize his or her illness, a process that involves both the diagnosis being made and the patient overcoming denial. The medical community has turned to behavioral approaches as primary interventions for alcoholics, recognizing that the behavior patterns associated with this condition must be broken before abstinence from alcohol can be achieved.
Alcoholics Anonymous (AA) and similar support groups operate across the world, providing large numbers of alcoholics with “treatment” for their disease. More recently, medications have become available as alternative treatment for alcoholism, with naltrexone currently recommended for patients who need help to maintain abstinence. Two components of all treatment plans for alcoholics deserve mention. First, there is a risk for alcohol withdrawal in those who have developed high levels of alcohol dependence, and therefore, measures are taken to ensure a safe cessation of alcohol. Second, there is no level of alcohol considered “safe” for alcoholics, and therefore, complete abstinence from alcohol is necessary to achieve remission.
Alcohol and Youth; Alcohol Consumption; American Academy of Addiction Psychiatry (AAAP).
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