Alcohol
Nearly 8% of adults in the United States have some problem with alcohol use. Alcoholism is the most extreme alcohol use disorder. It is characterized by excessive drinking, unsuccessful attempts at stopping drinking, and continued drinking despite adverse social and occupational consequences. Men are 4 times more likely than women to become alcoholics.
Of the people who drink alcohol, about 10% become alcoholics. People who become alcoholics have been regularly using alcohol in excessive amounts over a prolonged period of time and are dependent on alcohol. The amount of drinking that takes place on an average day before a person becomes an alcoholic varies widely, but it may be as little as two drinks per day for women and three drinks for men (one drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1½ ounces of liquor, such as whiskey). Many alcoholics are also binge drinkers, meaning that they may drink five or more drinks on many days and little or none on a few days.
People of all ages are susceptible to alcoholism and other alcohol use disorders. Blood relatives of alcoholics have a higher rate of alcohol use disorders than do people at random, and alcohol use disorders are more likely to develop in biologic children of alcoholics than in adopted children. Increasingly, adolescents have alcohol problems, with especially disastrous consequences (see Section 23, Chapter 271). Older adults develop higher alcohol levels in the blood per amount of alcohol consumed compared with younger adults. This tendency is primarily due to a decrease in muscle tissue and an increase in fat tissue that occurs in most people as they age.
Alcoholism leads to many destructive behaviors. Drunkenness may disrupt family and social relationships; married couples often divorce. Extreme absenteeism from work can lead to unemployment. Alcoholics often cannot control their behavior, tend to drive while drunk, and suffer physical injury from falls, fights, or motor vehicle accidents. Some alcoholics become violent. Alcoholism in men is often associated with domestic violence against women (see Section 22, Chapter 253).
Other alcohol use disorders may fall just short of the definition of alcoholism. A person can have a significant problem with alcohol use but be able to fulfill work and family responsibilities. However, the excessive alcohol use involved in these alcohol use disorders still exacts a terrible toll on the person's body, leading to many physical and mental health problems.
Causes
Alcohol use disorders involve heredity to some extent. Some research suggests that people at risk of alcoholism are less easily intoxicated than nonalcoholics; that is, their brains are less sensitive to the effects of alcohol.
Aside from a possible hereditary risk, certain background and personality traits may predispose a person to alcohol use disorders. Alcoholics frequently come from broken homes, and relationships with their parents are often disturbed. Alcoholics tend to feel isolated, lonely, shy, depressed, or hostile. They may exhibit self-destructive behavior and may be sexually immature. Whether such traits are the cause of alcoholism or the result is not certain.
Symptoms and Complications
Because alcohol is absorbed faster than it is processed (metabolized) and eliminated from the body, alcohol levels in the blood rise rapidly. Effects can occur within a few minutes of drinking.
Small amounts (for example, ½ to 1½ ounces of pure alcohol, or one to three drinks--resulting in a blood level of about 0.05 grams per deciliter, or 0.05%) can act as a stimulant, often making the person giddy and talkative, and perhaps even boisterous and violent. Larger amounts (usually resulting in blood levels above 0.08 grams per deciliter or 0.08%) depress brain function, resulting in slowed, impaired movements, unsteadiness, and sleepiness. As the alcohol is slowly metabolized, the process may reverse, such that a sedated person once again becomes agitated and violent. Very large amounts (resulting in blood levels above 0.30 grams per deciliter, or 0.3%) can lead to coma and death.
Prolonged use of excessive amounts of alcohol damages many organs of the body, particularly the liver, brain, and heart. Like many other drugs, alcohol tends to induce tolerance, so that people who regularly have more than two drinks a day can drink more alcohol than nondrinkers without becoming intoxicated. People who drink excessively over longer periods also can become tolerant to other drugs that depress brain function, such as barbiturates or benzodiazepines.
If an alcoholic who has been drinking continually for a period of time suddenly stops drinking, withdrawal symptoms are likely. Alcohol withdrawal usually begins 12 to 48 hours after drinking stops. Mild symptoms include tremor, weakness, sweating, and nausea. Some people develop seizures (called alcoholic epilepsy or rum fits). Heavy drinkers who stop drinking may develop alcoholic hallucinosis, in which they hear voices that seem accusatory and threatening, causing apprehension and terror. Alcoholic hallucinosis may last for days and can be controlled with antipsychotic drugs, such as chlorpromazine or thioridazine.
 See the table Effects of Prolonged Alcohol Use.
Delirium tremens (DTs), a very serious set of symptoms, may result if alcohol withdrawal is left untreated. Delirium tremens usually does not begin immediately; rather, it appears about 2 to 10 days after the drinking stops. In delirium tremens, the person is initially anxious and later develops increasing confusion, sleeplessness, nightmares, excessive sweating, and profound depression. The pulse rate tends to speed up. Fever typically develops. The episode may escalate to include fleeting hallucinations, illusions that arouse fear and restlessness, and disorientation with visual hallucinations that may incite terror. Objects seen in dim light may be particularly terrifying, and the person becomes extremely confused. The floor may seem to move, the walls fall, or the room rotates. As the delirium progresses, the hands develop a persistent tremor that sometimes extends to the head and body, and most people become severely uncoordinated. Delirium tremens can be fatal, particularly when untreated.
Other problems are directly related to the toxic effects of alcohol on the brain and liver. Prolonged use of excessive amounts of alcohol can lead to alcoholic liver disease (see Section 10, Chapter 136). An alcohol-damaged liver is less able to rid the body of toxic substances, which can cause hepatic coma. A person developing hepatic coma becomes dull, sleepy, stuporous, and confused and usually develops an odd flapping tremor of the hands. Hepatic coma is life threatening and needs to be treated immediately.
Korsakoff's syndrome (Korsakoff's amnesic psychosis) usually occurs in people who regularly drink large amounts of alcohol, especially those who are malnourished and have a deficiency of B vitamins (particularly thiamin) (see Section 6, Chapter 82). A person with Korsakoff's syndrome loses memory for recent events. Memory is so poor that a person often makes up stories to try to cover up the inability to remember (confabulation). Korsakoff's syndrome sometimes follows a bout of delirium tremens. Korsakoff's syndrome can be fatal unless the thiamin deficiency is treated promptly. Some people with Korsakoff's syndrome also develop Wernicke's encephalopathy, which is due to a thiamin deficiency often resulting from prolonged heavy drinking. Symptoms occur suddenly and include abnormal eye movements, confusion, uncoordinated movements, and a decreased ability to sense pain.
Alcohol use disorders can lead to the development of a chronic tremor. Alcohol can damage the part of the brain that coordinates movement (cerebellum), leading to poorly controlled movement of the arms and legs (cerebellar degeneration). It can also damage the lining (myelin sheath) of nerves in the brain, resulting in a rare disorder called Marchiafava-Bignami disease. People with this disorder become agitated, confused, and demented. Some develop seizures and go into a coma before dying.
Drinking alcohol may worsen existing depression, and alcoholics have a higher likelihood of becoming depressed than do nonalcoholics. Because alcoholism, especially binge drinking, often causes deep feelings of remorse during dry periods, alcoholics are suicide-prone even when they are not drinking.
In a pregnant woman, alcohol use can cause severe birth defects in the developing fetus, including low birth weight, short body length, small head size, heart damage, muscle damage, and low intelligence or mental retardation (see Section 23, Chapter 265). Avoidance of alcohol is therefore recommended during pregnancy.
Screening and Diagnosis
Doctors may suspect an alcohol use disorder in a person with an unexplained change in behavior, or when behavior becomes self-destructive. Doctors may also suspect an alcohol use disorder when medical problems, such as high blood pressure or stomach inflammation (gastritis), do not respond to usual treatment.
Some doctors periodically screen their patients for alcohol-related problems by asking about their use of alcohol. Questions that the doctor might ask include:
- On average, how many days per week do you drink alcohol?
- On a typical day when you drink, how many drinks do you have?
- What is the maximum number of drinks you had on any given occasion in the past month?
Doctors may ask more specific questions about consequences of drinking of people they suspect may be alcoholics. Questions may include:
- Have you ever felt you should cut down on your drinking?
- Does criticism of your drinking annoy you?
- Have you ever felt guilty about drinking?
- Have you ever had an "eye opener" (a drink first thing in the morning) to steady your nerves or to get rid of a hangover?
Two or more "yes" answers to these questions indicate a probable diagnosis of alcoholism.
Measuring the amount of alcohol in the blood may help the doctor confirm suspicions that a person has an alcohol use disorder, especially if the person's breath smells of alcohol. Alcohol levels can be measured in the blood or estimated by measuring the amount in a sample of exhaled breath.
Treatment
Emergency Treatment: Emergency treatment may occur when a person comes for medical care for intolerable withdrawal symptoms. Alternatively, a person may be brought in for care because of symptoms related to high alcohol levels. Alcoholics who develop withdrawal symptoms generally treat themselves by drinking. Some people seek medical attention because they do not want to continue drinking or because withdrawal symptoms are too severe. Because vitamin deficiency causes potentially life-threatening symptoms, doctors in emergency departments generally give large intravenous doses of vitamin C and B complex vitamins, especially thiamin. Intravenous fluids, magnesium, and glucose are often given to prevent some of the symptoms of alcohol withdrawal and to avoid dehydration.
Often, doctors prescribe a benzodiazepine drug for a few days to calm agitation and help prevent withdrawal symptoms. Antipsychotic drugs are sometimes given to people with alcoholic hallucinosis. Delirium tremens can be life threatening and is treated more aggressively to control the high fever and severe agitation. Intravenous fluids, drugs that lower fever (such as acetaminophen), sedatives, and close supervision usually are needed. With such treatment, delirium tremens generally begins to clear within 12 to 24 hours of onset.
Detoxification and Rehabilitation: After the urgent medical problems are resolved, a detoxification and rehabilitation program should be started. In the first phase of treatment, alcohol is completely withdrawn. Then an alcoholic has to modify his behavior. Without help, most alcoholics relapse within a few days or weeks. Treatment should be tailored to the individual. Enlisting the support of family members may be important as well.
Sometimes the prescription drug disulfiram can help an alcoholic avoid drinking alcohol. This drug interferes with alcohol metabolism for 3 to 7 days, causing acetaldehyde, a substance that results from the breakdown of alcohol, to build up in the bloodstream. Acetaldehyde produces facial flushing, a throbbing headache, a rapid heart rate, rapid breathing, and sweating within 5 to 15 minutes after the person drinks alcohol. Nausea and vomiting may follow 30 to 60 minutes later. These uncomfortable and potentially dangerous reactions last 1 to 3 hours. The discomfort from drinking alcohol after taking disulfiram is so intense that few people risk taking alcohol--even the small amount in some over-the-counter cough and cold preparations or some foods.
Disulfiram is given only as part of an ongoing intensive counseling regimen. Pregnant women, people who have a serious illness, and older people should not use disulfiram. Naltrexone can help people become less dependent on alcohol if it is used as part of a comprehensive treatment program that includes counseling. Naltrexone alters the effects of alcohol on certain chemicals made by the brain (endorphins), which may be associated with alcohol craving and consumption. A big advantage compared with disulfiram is that naltrexone does not make people sick. However, a person taking naltrexone can continue to drink. Naltrexone should not be taken by people who have hepatitis or certain other liver diseases.
 See the sidebar Alcoholics Anonymous: A Path to Recovery.
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