Alcohol Addiction
Alcoholism encompasses two distinct conditions: alcohol abuse and alcohol dependence. Abuse is formally defined as a maladaptive pattern of use leading to impairment in one of several sociobehavioral domains for a 1-year period. Dependence is formally defined as a maladaptive pattern of use characterized by at least three of seven symptoms that include tolerance, withdrawal, preoccupation with and recurrent use of alcohol despite adverse consequences in important areas of life. Most problem drinkers are employed, employable, or in families, indicating that the scope of the problem extends far beyond those who meet formal diagnostic criteria.
Screening for alcohol problems long before they become disabling and more difficult to manage should be a routine part of every primary care practice. One first identifies and then helps the patient understand and acknowledge the consequences of drinking, the presence of a problem, and the need for intervention. The objective then shifts to negotiating and carrying out an acceptable treatment plan, one that is personalized and multifaceted.
The etiology of alcohol abuse remains incompletely understood but is clearly multifactorial. Biogenetic, sociocultural, psychologic, and behavioral elements have been elucidated. No single model accounts for all manifestations, but each is helpful in understanding the problem.
Biogenetic Model. Genetic factors appear to influence the metabolism of alcohol and the effects of alcohol on neurotransmitters, receptors, and cell membranes. The A1 allele at the D2 dopamine receptor gene and the G1 allele of the GABAAA receptor b3 have been identified as independent contributors, with a more robust risk for disease when combined. Alcohol abuse is clearly multigenetic in origin and more genetic risk factors are likely to be characterized.
Sociocultural Model. External factors such as poverty, socialization patterns, and cultural differences in the rules governing alcohol use are emphasized. Parental and peer values, attitudes, and behaviors regarding alcohol all contribute. This model may explain the increasing use of alcohol among women and youth and use patterns of ethnic minorities, despite an overall national decline in consumption.
Psychologic-Psychodynamic Model. In this model, underlying psychopathology (e.g., dependency conflict, depression, excessive need for power or sensation seeking, gender identification problems) is viewed as predisposing a person to drink excessively, either to mask or solve a psychologic problem. Drinking is viewed merely as a symptom.
Learning Theory/Behavioral Model. Alcoholism is seen as a learned behavior that is reversible, time limited, on a continuum with normal drinking behavior and established by a series of learning and reinforcement experiences. Social interactions, emotional stress, guilty or negative thoughts, and need for sleep or pain relief serve as precipitants and maintainers of drinking behavior. Any of these precipitants coupled with learned expectations about the effects of alcohol or deficits in social skills will initiate and maintain the drinking behavior.
Use of alcohol in moderation is characterized by varying consumption and beverage according to internal cues and external circumstances. If one chooses to drink, one does so in drinking-appropriate circumstances and rarely exceeds one or two drinks. The moderate drinker is neither likely to drive under the influence (might have a drink on arrival at a party and switch to something nonalcoholic later) nor likely to drink in order to deal with problems, escape, or get drunk.
With the caveats that a given dose of alcohol affects different people differently and that average daily consumption neglects the pattern of drinking, drinking in moderation may be defined quantitatively as two or less drinks per day for men and one or less for women and the elderly. The figure is lower in women and the elderly because they experience a higher blood alcohol level per drink due to smaller volume of distribution and decreased first-pass metabolism of alcohol. (A standard drink is assumed to contain roughly 12 g, 15 mL, or 0.5 oz of alcohol, which is the approximate content of 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor.)
Alcohol misuse ranges from social drinking with a tendency for occasional excess to constant intoxication. Orderly progression is not assumed. The most commonly encountered presentations include
Groups at increased risk include professionals; executives; young people; women, especially those of childbearing age; and the elderly as are those presenting with depression, other drug use, or a family history positive for alcoholism. Seemingly high functioning executives and professionals who manage their own schedules have ready access to both alcohol and drugs, the use and consequences of which remain hidden until serious sequellae become obvious. Eighty percent of young people drink as high school seniors and 24% binge drink, a pattern that continues and increases to 34% among college students. Adults who began drinking or smoking regularly in their early teens suffer the most serious alcohol, drug, and psychiatric problems and often manifest the greatest proportion of familial alcohol problems. Women, as a result of social change, are consulting clinics at double the former rates. Elderly patients may begin to use alcohol excessively for stress, especially in reaction to loss of a loved one or because of sleep difficulties. A peak period for onset for new alcohol-related problems is 65 to 74 years of age.
Natural History and Clinical Course. There is considerable individual variation. Onset ranges from an initial phase of social drinking to immediate heavy drinking. Prognosis remains relatively favorable until dependence sets in. Once the addiction becomes psychologic or physiologic, it is difficult to break in the absence of treatment and the clinical course is often progressive. (This makes it imperative to detect alcohol misuse long before the patient meets formal criteria for diagnosis of alcohol abuse.) At the point of addiction, continued drinking may punctuated by periods of abstinence or controlled drinking but followed by relapse and progression, especially if there is no expert intervention. Controversy continues regarding whether or not total abstinence is required to halt progression.
Medical Complications. The risk of organ damage is related in part to the dose and duration of alcohol exposure, with some conditions (e.g., alcoholic cardiomyopathy, fatty liver) manifesting reversibility with abstinence, and others (e.g., cirrhosis) seeming to progress inexorably once severe hepatocellular damage has occurred. Risk appears to be a function of a genetic predisposition and alcohol dosage and chronicity of exposure. Although cardiovascular benefits may accrue from up to two drinks a day in white men (one in women and black men), consumption of more than three drinks a day is associated with increased risk for hypertension, among other risk factors for more serious disease.
Persistent impotence and loss of libido reflect impaired gonadotropin release and accelerated testosterone metabolism that occur as consequences of chronic alcohol excess; they predate end-stage liver disease. Alcoholic hepatitis, pancreatitis, and gastritis may follow binge drinking. Fatty liver and esophagitis ensue from chronic use. Late-stage complications include cirrhosis, oral cancers, cardiomyopathy, Wernicke’s encephalopathy, and Korsakoff’s dementia.
Fetal alcohol syndrome occurs in infants born to mothers who drink heavily during pregnancy. Features include permanently stunted growth, mental retardation, musculoskeletal abnormalities, poor coordination, and cardiac malformations. Incidence approaches 33% among pregnant women who drink more than 150 g (6.25 oz) of alcohol per day. Another third of children born to such women will have mental retardation or severe behavior disorders. Serious maternal and infant health problems and increased infant and fetal deaths accrue among women who report drinking even as little as one drink a week during pregnancy.