Alcohol Use Disorder
Alcohol is commonly used to celebrate, relax, or socialize with others. When someone drinks in excess, however, or drinks as a way to cope with stressors or avoid problems, it can create physical and psychological risks.
Alcohol use disorder, more colloquially known as alcoholism­, refers to a problematic pattern of alcohol use that leads to significant impairment or distress. Because alcohol use varies greatly between people, it can be helpful to identify general signs of a problem, such as when drinking interferes with home life, school, or work. Drinking may be problematic if it creates interpersonal difficulties with family and friends or if it leads to a retreat from other activities. Age, family history, and how much or how often an individual drinks are other important variables when considering someone's relationship with alcohol.
Alcohol abuse cuts across gender, race, and ethnic lines. Nearly 14 million people—more men than women—in the United States have a problem with alcohol use. Issues surrounding alcohol are highest among young adults ages 18 to 29 and lowest among adults ages 65 and older. Defining and diagnosing alcohol use disorder can be complicated when working with young adults; the lifestyle of college students often includes excessive use of alcohol, making it difficult to ascertain when it is a legitimate disorder and when it isn't.
According to the U.S. Department of Health and Human Services and U.S. Department of Agriculture Dietary Guidelines for Americans, moderate drinking is up to one drink per day for women and up to two drinks per day for men. In the United States, one standard drink contains roughly 14 grams of pure alcohol, which is found in 12 ounces of regular beer (about 5 percent alcohol); 5 ounces of wine (typically about 12 percent alcohol); or 1.5 ounces of distilled spirits (about 40 percent alcohol).
Alcohol Use Disorder is defined by the DSM-5 as a problematic pattern of drinking that results in clinically significant impairment or distress, which takes the form of two or more of the following situations within a 12-month period:
- Drinking more than intended, or doing so for a longer period of time than intended
- Continually wanting or attempting unsuccessfully to cut down or stop drinking
- Spending a lot of time getting alcohol, drinking, or recovering from its effects
- Having a strong desire or urge to drink
- Failing to fulfill major work, school, or home responsibilities due to drinking
- Continuing to drink even though it is causing relationship troubles with family or friends
- Prioritizing drinking by giving up or cutting back important activities
- Drinking in situations in which it is physically dangerous
- Continuing to drink even though one has a persistent or recurrent physical or psychological problem that drinking has likely caused or made worse
- Needing much more than was once needed to get the desired effect from alcohol, or not experiencing the same effect when drinking the same amount
- Having withdrawal symptoms (trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, a seizure, or sensing things that are not there) or drinking to relieve or avoid such symptoms
Alcoholism, or alcohol dependence, had been considered the most severe form of alcohol abuse. The DSM-5 integrates alcohol abuse and alcohol dependence into a single disorder with mild, moderate, and severe sub-classifications.
Mild: The presence of two to three of the above symptoms
Moderate: The presence of four to five of the above symptoms
Severe: The presence of six or more of the above symptoms.
When someone has been drinking alcohol to excess regularly and suddenly stops, they may experience alcohol withdrawal. Symptoms include:
- Hand tremors
- Rapid heart rate
Various health consequences are associated with alcohol abuse, including:
- Increased incidence of cancer, particularly cancer of the larynx, esophagus, liver, and colon
- Acute and or chronic pancreatitis—an inflammatory disease of the pancreas
- Cirrhosis of the liver—fibrotic changes in the liver
- Alcoholic neuropathy—degenerative changes in the nervous system affecting nerves responsible for sensation and movement
- Alcoholic cardiomyopathy
- High blood pressure
- Nutritional deficiencies
- Erectile dysfunction
- Cessation of menses
- Fetal alcohol syndrome in the children of women who drink during pregnancy
- Alcohol-related dementia
- Wernicke-Korsakoff syndrome or Wernicke's encephalopathy—a syndrome of the central nervous system that results in confusion, loss of balance, and loss of vision
When does alcohol withdrawal develop?
Alcohol withdrawal is a serious condition that can become life-threatening if not treated. Symptoms typically develop within several hours to a few days after a person has stopped (or reduced) drinking. It is important for individuals who may have Alcohol Use Disorder to consult a doctor or other healthcare provider, to be honest and forthcoming to determine if they have a drinking problem and, if so, to collaborate on the best course of action.
While the specific cause of alcohol use disorder is unknown, there are environmental and genetic links. Another factor is the addictiveness of the substance itself. Excessive alcohol intake changes the chemical makeup of the brain in ways that can contribute to addiction. Drinking alcohol affects the physical and mental health of some people differently than others, and in some leads to alcohol-related disorders.
Alcohol abuse tends to run in families: The rate of the condition is three to four times higher in close relatives of alcoholics, and the risk increases with the closeness of the genetic relationship. Environmental factors include cultural attitudes about drinking, availability of alcohol, and substance abuse by peers.
The risk of abusing alcohol increases if individuals use drinking to numb themselves to their problems, to cope with anxiety, fears, or mood issues, or to enhance their creativity. Impulsivity is also linked to alcohol abuse.
Many people with alcohol problems don't recognize that their drinking has become problematic; others are not ready to get help with their drinking. It is important for each individual to consider the pros and cons of drinking and to decide whether cutting down (harm reduction) or quitting altogether (abstinence) is necessary.
Abstinence from alcohol is strongly recommended for those who:
- Have tried cutting down but could not stay within their set limits
- Have been diagnosed with an alcohol use disorder or are experiencing symptoms of one
- Have a physical or mental condition that is caused or worsened by drinking
- Are taking a medication that interacts with alcohol
- Are or may become pregnant
Others may benefit from the harm-reduction approach, aimed at helping individuals reduce the impact of the consequences associated with drinking.
When drinking is associated with problematic behavior caused by significant intoxication and or withdrawal symptoms (nausea, vomiting, agitation, insomnia, seizures, and/ or hand tremors) detoxification may be required to start the process of treatment.
Detoxification is done in a controlled, supervised setting in which medications relieve symptoms. Detoxification usually takes four to seven days. Examination for other medical problems (such as liver and blood-clotting) is necessary. A balanced diet with vitamin supplements is important.
Following detoxification, alcohol recovery or rehabilitation programs support the affected person in maintaining abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about alcoholism and its effects is part of the therapy. Many of the professional staff in rehabilitation centers are people who have recovered from an alcohol use disorder and who serve as role models. Programs can be either inpatient, with the person residing in the facility during the treatment, or outpatient, with the individual attending the program while living at home.
It is also important to remember that other psychiatric conditions, such as depression or bipolar disorder, may coexist with alcoholism. Therefore, coexisting or underlying disorders may also need to be treated. Individuals suffering from such conditions may have used alcohol as a form of self-medication. If this is the case, diagnosis of any coexisting condition is essential for guiding treatment.
Three oral medications—disulfiram (Antabuse), naltrexone (Depade, ReVia), and acamprosate (Campral)—are currently approved to treat alcohol dependence. In addition, an injectable, long-acting form of naltrexone (Vivitrol) is available. These medications have been shown to help people with dependence reduce their drinking, avoid relapse to heavy drinking, and achieve and maintain abstinence. Naltrexone acts to reduce the craving for alcohol in those who have stopped drinking. Acamprosate is thought to work by reducing symptoms, such as anxiety and insomnia, that may follow lengthy abstinence. Disulfiram discourages drinking by making individuals feel sick if they drink alcohol.
Other types of drugs are available to help manage the symptoms of withdrawal that may occur after someone with alcohol dependence stops drinking. Early recognition of these symptoms and immediate treatment can prevent some of them or drastically limit their severity.
While 12-step programs stick to abstinence as the cure for alcohol use disorder, the harm reduction approach is more individualized. A person who suffers may choose to use alcohol less, as opposed to full abstinence. The aim is to reduce the consequences of alcohol use. The idea of harm reduction also applies to other areas beyond alcohol abuse. For example, these various programs fall under harm reduction: Safe injection sites, dissemination of free condoms, and needle exchanges. In addition, psychotherapy is often part of the harm-reduction approach.
Alcoholics Anonymous (AA) describes itself as a "worldwide fellowship of men and women who help each other to stay sober." AA is generally recognized as an effective mutual-help program for people recovering from alcohol abuse, but even those who are helped by it usually find that AA meetings work best in combination with other forms of treatment, including counseling and medical care.
Seeking Help for Someone Who Is Unwilling
Someone with an alcohol problem can't be forced to get help except under certain circumstances, such as a violent incident that results in court-ordered treatment or a medical emergency. Many alcohol treatment specialists suggest the following steps to help a person with alcohol use disorder:
- Stop all "coverups." Family members often make excuses or try to protect someone with a drinking problem from the consequences of drinking.
- The best time to talk about drinking is shortly after an alcohol-related problem has occurred. Choose a time when the person is sober, both parties are fairly calm, and there is a chance to talk in private.
- Be specific. Tell the person that there are worries about the drinking. Use examples of the ways in which it has caused problems, including the most recent incident.
- Describe what happens next. Explain to the individual what will be done unless that person seeks help. This may range from the speaker refusing to go with the person to any social activity where alcohol will be served to moving out of the house. Do not make threats that won't or can't be carried out.
- Find options. Gather information in advance about treatment options in the community. If the person is willing to get help, call immediately for an appointment with a treatment counselor. Offer to go with the individual on the first visit to a treatment program and or to an Alcoholics Anonymous meeting.
- Call a friend. If the person still refuses to get help, ask a friend to talk with him or her using the steps described. A friend who is recovering from alcohol abuse may be particularly persuasive, but anyone who is caring and nonjudgmental may help.
- Find strength in numbers. With the help of a healthcare professional, some families join with other relatives and friends to help the alcoholic. This approach should be tried only under the guidance of a healthcare professional experienced in group intervention.
- Contact a support group. AA holds regular meetings for spouses and other significant adults in the life of a person with an alcohol problem. Alateen is geared toward children of such individuals. These groups help family members understand that they are not responsible for the alcohol abuse and that they need to take steps to take care of themselves.
Do treatment methods vary in different people?
Treatment for alcohol abuse works for many people. But as with any chronic condition, there are varying levels of success when it comes to treatment, as well as the type of treatment used. Some methods work for certain people, other methods do not. Some people stop drinking and remain sober. Others have long periods of sobriety with bouts of relapse. In many cases, the longer a person abstains from alcohol, the more likely it is that sobriety will be maintained.