Alcohol Use Disorder
Alcohol is commonly used to celebrate, relax, or socialize with others, and drinking in moderation is typically seen as a reasonable behavior. When we drink in excess or drink as a way to cope with stressors or avoid problems, it can lead to physical, behavioral, and emotional risks. Age, family history, and how much or often we drink are important variables to keep in mind when considering our relationship with alcohol.
According to the U.S. Department of Health and Human Services and U.S. Department of Agriculture, Dietary Guidelines for Americans 2015–2020, 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, which is usually about 5 percent alcohol; 5 ounces of wine, which is typically about 12 percent alcohol; 1.5 ounces of distilled spirits, which is about 40 percent alcohol.
Alcohol-use disorder—also known as alcoholism—refers to a problematic pattern of alcohol use leading 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.
Alcohol abuse cuts across gender, race, and ethnic lines. Nearly 14 million people—more men than women—in the United States are dependent on alcohol or have alcohol problems. 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.
Short-term effects include memory loss, hangovers, and blackouts. Long-term problems associated with heavy drinking include stomach ailments, heart problems, cancer, brain damage, memory loss, and liver cirrhosis. Heavy drinkers also markedly increase their chances of dying from automobile accidents, homicide, and suicide. Alcohol use and abuse is also linked to a higher incidence of unemployment, domestic violence, and legal issues.
Other alcohol related problems can include alcohol intoxication and alcohol withdrawal. Alcohol intoxication refers to recent ingestion of alcohol with problematic behavioral or psychological changes developed during, or shortly after, drinking. Alcohol withdrawal refers to the symptoms that may develop when a person who has been drinking excessive amounts of alcohol on a regular basis suddenly stops drinking.
In general, the body is able to metabolize approximately one alcoholic drink per hour. Mild alcohol intoxication can be seen in most people after approximately two standard-size drinks. When an individual first starts drinking, symptoms of intoxication typically include talkativeness, a feeling of well-being, and bright mood. In addition to problematic behavior, symptoms of alcohol intoxication include slurred speech, lack of physical coordination, unsteady walk, involuntary eye movements, poor attention or memory, and even stupor or coma. At very high blood-alcohol levels, a person is likely to fall asleep and, depending on how severe the alcohol intoxication is, may experience inhibited respiration and pulse.
Signs of alcohol use disorder include strong cravings for alcohol, drinking alcohol in spite of problems it causes in one’s life, an inability to cease drinking, and needing to drink more and more alcohol to feel its effects.
Alcohol use disorder is defined as a problematic pattern of drinking that results in two or more of the following situations within a 12-month period:
- Drinking more or for a longer period than intended
- On more than one occasion feeling the need or attempting to cut down or stop drinking
- Spending a lot of time drinking, or recovering from the aftereffects of alcohol
- Craving or thinking about wanting a drink or having the urge to use alcohol
- Failing to fulfill major work, school, or home responsibilities due to drinking
- Continuing to drink even though it is causing relationship troubles with your family or friends
- Prioritizing drinking by giving up or cutting back activities that were important to you, or gave you pleasure
- Drinking before or during situations that are physically dangerous—while driving a car, operating machinery, swimming, or having unsafe sex
- Continuing to drink even though drinking is making you feel depressed or anxious, is linked to another health problem, or results in having memory blackouts
- Developing a tolerance for drinking—needing much more than you once did to get the desired effect from alcohol, or not experiencing the same effect when drinking the same amount of alcohol
- Withdrawal, as characterized by having withdrawal symptoms (trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, a seizure, or sensing things that are not there)
Alcoholism, or alcohol dependence, used to be considered the most severe form of alcohol abuse. The DSM-V integrates alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD) with mild, moderate, and severe sub-classifications.
Mild: The presence of two to three symptoms
Moderate: The presence of four to five symptoms
Severe: The presence of six or more symptoms.
Answering the following four questions can help you find out if you or a loved one has an alcohol use disorder:
- Have you ever felt you should cut down on your drinking?
- Have people been annoyed by or criticized your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
One answer of yes suggests a possible problem; more than one indicates that a problem likely exists. Those who answer 'no' to the above questions may still need help. It is important to consult a doctor or other health-care provider and to be honest and forthcoming to determine if you have a drinking problem and, if so, to collaborate on the best course of action.
Health hazards that may indicate problematic drinking habits or alcohol abuse:
- Increased incidence of cancer, particularly cancer of the larynx, esophagus, liver, and colon
- Alcoholic hepatitis, an acute syndrome reported by patients who have ingested about 100 grams of alcohol (about eight ounces of 100-proof whiskey, 30 ounces of wine, or eight 12-ounce cans of beer) daily for over one year. Symptoms can include fever, jaundice, and enlarged liver
- Acute and/or chronic pancreatitis—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—vitamin B12, folate, and thiamine
- 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 caused by thiamine deficiency that leaves permanent brain damage, resulting in the individual becoming confused, losing balance while walking, and showing loss of vision.
When someone has been drinking alcohol to excess on a regular basis and suddenly stops, they may experience hand tremors, sweating, insomnia, rapid heart rate, anxiety, depression, fatigue, irritability, and even hallucinations or seizures. 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.
While the specific cause of alcohol-use disorder is unknown, there are social, cultural, environmental, psychological, 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 lead 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 according to the closeness of the genetic relationship. Environmental factors include cultural attitudes about drinking, availability of alcohol, stress levels, substance abuse by peers, positive expectations about the use of alcohol, and maladaptive ways of coping. Impulsivity as a personality variable is also linked to high alcohol use and abuse.
The risk of abusing alcohol also increases if individuals use drinking to numb themselves to their problems, to cope with anxiety, fears, or mood issues, or to enhance their creativity.
Many people with alcohol problems don't recognize that their drinking has become problematic, and 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 such
- 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 to help individuals reduce the impact of the consequences associated with drinking.
When drinking is associated with problematic behavior caused by significant intoxication and/or with withdrawal symptoms (nausea, vomiting, agitation, insomnia, seizures, and/or hand tremors), detoxification may be required to start the process of treatment.
Detoxification, entailing withdrawal from alcohol, is done in a controlled, supervised setting in which medications relieve symptoms. Detoxification usually takes four to seven days. Examination for other medical problems is necessary. For example, liver and blood-clotting problems are common. A balanced diet with vitamin supplements is important. Complications associated with the acute withdrawal from alcohol, such as delirium tremens (DT's), which could be fatal, may occur. Depression or other underlying mood disorders should be evaluated and treated as alcohol abuse often develops from efforts to self-treat an illness.
Following detoxification, alcohol recovery or rehabilitation programs support the affected person to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centers are recovering alcoholics 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, dual 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 in the brain to reduce the craving for alcohol in those who have stopped drinking. Acamprosate is thought to work by reducing the 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, such as shakiness, nausea, and sweating, 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.
Virtually all alcohol use disorder treatment programs also include support groups such as Alcoholics Anonymous (AA). AA describes itself as a "worldwide fellowship of men and women who help each other to stay sober." Although AA is generally recognized as an effective mutual-help program for recovering alcoholics, not everyone responds to AA's style or message. Even people who are helped by AA usually find that the meetings work best in combination with other forms of treatment, including counseling and medical care.
Seeking Help for an Unwilling Alcoholic
An alcoholic 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 the alcoholic from the results of his or her drinking. It is important to stop covering for the alcoholic so that he or she experiences the full consequences of drinking.
- The best time to talk to the drinker about his or her drinking is shortly after an alcohol-related problem has occurred—a serious family argument or an accident. Choose a time when he or she is sober, both of you are fairly calm, and you have a chance to talk in private.
- Be specific. Tell the person that you are worried about his or her drinking. Use examples of the ways in which the drinking has caused problems, including the most recent incident.
- State the results. Explain to the drinker what you will do if he or she doesn't seek help. What you say may range from refusing to go with the person to any social activity where alcohol will be served to moving out of the house. Do not make any threats you are not prepared to carry out.
- Get help. Gather information in advance about treatment options in your 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 an Alcoholics Anonymous meeting.
- Call a friend. If a family member still refuses to get help, ask a friend to talk with him or her using the steps just described. A friend who is a recovering alcoholic may be particularly persuasive, but anyone who is caring and nonjudgmental may help.
- Find strength in numbers. With the help of a health-care professional, some families join with other relatives and friends to help the alcoholic. This approach should be tried only under the guidance of a health-care professional experienced in group intervention.
- Get support. It is important to remember that you are not alone. Support groups offered in most communities include Al-Anon, which holds regular meetings for spouses and other significant adults in an alcoholic's life, and Alateen, which is geared toward children of alcoholics. These groups help family members understand that they are not responsible for an alcoholic's drinking and that they need to take steps to take care of themselves, regardless of whether the alcoholic family member chooses to get help.
Treatment for alcohol use disorder works for many people. But as with any chronic disease, there are varying levels of success when it comes to treatment. Some people stop drinking and remain sober. Others have long periods of sobriety with bouts of relapse. And still others cannot stop drinking for any length of time. With treatment, one thing is clear, the longer a person abstains from alcohol, the more likely he or she will stay sober.
Some people find they are able to quit on their own, or at least drink less alcohol once they realize it has become a problem. Many others find they need help. Outpatient treatment for mild or moderate alcohol withdrawal symptoms typically includes sedative medications to help ease withdrawal symptoms and counseling to promote healthier habits. Behavioral interventions, including recovery programs (such as harm reduction) and support groups (such as AA) can help diminish cravings and other symptoms of withdrawal and improve the likelihood of quitting. Severe alcohol withdrawal may be treated in an inpatient setting where symptoms can be closely monitored.
- National Institute of Mental Health
- National Institute of Alcohol Abuse and Alcoholism
- Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
- National Institutes of Health (NIH) - National Library of Medicine
Last reviewed 02/01/2018