Alcoholism — The Dana Guide

by Charles P. O'Brien, M.D., Ph.D.

June, 2009

sections include: who becomes an alcoholic?, alcohol and the braindiagnosis and treatment 

Alcoholism is a disease that is defined by the compulsive use of alcohol to the point that it interferes with work or personal life or impairs health. A popular myth holds that alcoholics drink on a daily basis and are usually unemployed and unsuccessful. In truth, most alcoholics are successful, intelligent, educated citizens who are able to function normally but become incapacitated gradually due to excessive use of alcohol. Many alcoholics may not even drink every day.

Alcoholism symptoms include the following:

  • The person shows increasing tolerance to alcohol. Either the person has to drink much more to become as intoxicated as he or she desires, or the same amount of alcohol has a much less potent effect.
  • Withdrawal symptoms (sweating or high pulse rate, hand tremors, insomnia, nausea or vomiting, shakiness, hallucinations, anxiety, and seizures) appear several hours or days after the person has stopped using alcohol following a period of heavy drinking.
  • The person drinks larger amounts or over a longer time than he or she intended.
  • The person persistently wants to cut down or control his or her drinking, but can’t.
  • The person spends a great deal of time buying alcohol, drinking, and recovering from hangovers.
  • The person gives up or cuts back on important social, professional, or recreational activities in order to drink.
  • The person continues to drink despite evidence of alcohol’s adverse effects, such as depression, blackouts, or liver disease.

Most, if not all, alcoholics report that they crave alcohol, and that they spend a great amount of time thinking about it. Other symptoms of alcoholism specific to the brain include personality changes, forgetfulness, moodiness with gradual progression to carelessness, and depression. Long-term alcoholics may suffer a gradual onset of forgetfulness that can be misdiagnosed as Alzheimer’s disease. Indeed, alcohol always impairs memory during intoxication, and some people’s memories are very sensitive to its long-term effects.

In the most severe cases, drinking alcohol damages multiple nerves in both the central and peripheral nervous systems. In affecting the brain, it impairs memory and such cognitive skills as problem solving and learning. The most distinguishing symptom of this syndrome, known as Wernicke-Korsakof syndrome, is that sufferers will make up detailed, believable stories about their experiences or situations to cover the gaps in their memories. Alcoholic neuropathy is another disorder that can be caused by the toxic effect of alcohol on nerve tissue. It can affect the autonomic nerves that regulate internal body functions as well as the nerves that control movement and sensation. Damage is usually permanent, and may become progressively worse if the person does not stop using alcohol. Symptoms vary from mild discomfort to severe disability.

Alcoholism is a form of substance use disorder that focuses specifically on ethyl alcohol. Alcohol abuse is considered to be a less severe form of alcohol dependence but the symptoms often gradually worsen to include all the symptoms of alcohol dependence as defined in DSM IV, the current classification of the American Psychiatric Association. Failing to fulfill major work, school, or home responsibilities; drinking in dangerous situations; having recurrent legal problems related to alcohol, such as being arrested for driving drunk; or continuing drinking despite any persistent relationship problems it exacerbates are all symptoms of an alcohol use disorder.

There is also a separate, unofficial category called binge drinking, which applies to the consumption of five or more drinks on a single occasion for a male, and four or more drinks for a female. Very often adolescents and college students are binge drinkers, some of whom go on to develop full-blown alcoholism.

Who Becomes an Alcoholic?

More than 90 percent of adult Americans have consumed alcohol at some time in their lives. About 70 percent continue using it during adulthood. Most adults can drink moderate amounts of alcohol—up to two drinks a day for men, and one drink a day for women—and avoid alcohol-related problems. However, of those exposed to alcohol, 10 percent to 15 percent develop alcohol abuse or dependence, making this a very common disorder. 

We do not know what causes alcoholism, but there is strong evidence from adoption studies that it can be inherited. People whose biological parents are alcoholic have a greatly increased risk of alcoholism even when they are adopted and raised by nonalcoholics. Conversely, people whose biological parents are nonalcoholics do not have an increased risk of alcoholism in adulthood, even when raised in homes where there is at least one alcoholic.

There is also an increased risk of alcoholism for people born with a high tolerance for alcohol. Some people report little effect from relatively large amounts of alcohol when they are quite young, even on their first exposure to alcohol. In a study involving young men tested for sensitivity to alcohol, those with a family history of alcoholism tended to have a higher tolerance compared with those with a similar drinking history but no family history of alcoholism. At follow-up, the men who were very tolerant at age 20 had a much higher incidence of alcoholism by age 30. Thus, it appears that some people may inherit tolerance to alcohol and that this tolerance increases the risk for developing alcoholism.

Beyond biological factors for alcoholism, some psychological and social factors may play a role. These may include anxiety, stress, or low self esteem; the widespread availability of alcohol and acceptance of its use; and peer pressure, especially among teenagers. 

Alcohol and the Brain

Alcohol is a complex, water-soluble drug that distributes itself throughout the body. It affects the central nervous system as a depressant, which in most people results in an initial “high” of stimulation and euphoria and in a decrease of anxiety, tension, and inhibitions. Larger amounts of alcohol result in sedation, unconsciousness, and, in toxic quantities, death. Beyond those basic facts, however, there is much that scientists do not know. Research is under way to move us from educated guesses to solid knowledge.

In one promising avenue of research, scientists are taking a closer look at some of the receptors in the brain—the sites where neurons receive their chemical messages. At one time alcohol was thought to have only a general effect on nerve cells, but research now suggests that alcohol may fit into specific places in many different receptors. This action would differ from that of other addictive drugs, such as heroin, which fit into a few particular receptors. It may explain why alcohol addiction is so complex.

Alcohol seems to affect the specific brain pathways for gamma-aminobutyric acid (GABA), the brain’s major inhibitory neurotransmitter, or “off” signal. Some studies suggest that alcohol intensifies the effects of this chemical by acting on one type of GABA receptor. Such sedatives as Valium also work on these receptors, which may explain alcohol’s ability to lessen anxiety. Individuals who are tolerant to large doses of alcohol also have high GABA inhibition. If these individuals suddenly stop drinking, they lose this inhibition all at once and experience withdrawal seizures.

Alcohol also affects the general central nervous system through the receptors for N-methyl- D-aspartate (NMDA), which is an important excitatory neurotransmitter (or “on” signal). NMDA is also thought to be involved in some forms of learning and memory, as well as motor control. When alcohol inhibits this receptor, nerve cells may fire less rapidly, which may explain alcohol’s sedative action on the central nervous system.

Another major effect of alcohol is to enhance dopamine activity in the reward pathways of the brain, the same effect that cocaine, nicotine, and opioids have. Alcohol appears to increase this neurotransmitter by releasing endogenous opioids (naturally occurring hormones with sedative effects), which results in more dopamine being released in important brain reward areas. If the opioid receptors are blocked, alcohol does not increase dopamine and the reward from alcohol is significantly less. This mechanism appears to be an important factor in the success of opioidantagonist medication in treating alcoholism.

Serotonin, which is involved in regulating moods, is yet another neurotransmitter affected by alcohol. Alcohol releases serotonin, decreasing the long-term storage of this chemical in the body. A lack of serotonin may contribute to anxiety and depression. Researchers are now studying whether alcohol also intensifies a serotonin receptor, thereby increasing the reward response in the brain that reinforces the tendency to drink. It is also interesting to note that while most antidepressant drugs enhance serotonin function, they are not consistently helpful in the depression associated with alcoholism.

Diagnosis and Treatment

Alcohol affects a person’s life by gradually eroding normal relationships and functions. A typical alcoholic may cope with the impairment produced by alcohol for years before finally succumbing to its behavioral toxicity. As a result, an alcoholic may not come to medical attention until the disease is far advanced. However, early treatment is much more effective than later treatment, after so much social and medical damage has been done.

Typically, a person’s alcoholism comes to the attention of a physician because of some precipitating event, such as a car accident, a violent episode, a suicide attempt, divorce, or loss of a job. In other cases, the first evidence of the disease is a medical problem, such as gastrointestinal bleeding, liver failure, memory loss, heart disease, or high blood pressure. Alcoholism may also be noted incidentally when a person has a routine physical or is being evaluated for another problem. Usually, even an early alcoholic will have some abnormal blood test involving blood cells or liver enzymes.

Unfortunately, there are no definitive biological tests for alcoholism since abnormalities in blood tests could be due to other causes. Some medical professionals use the CAGE test, which is a series of questions developed by Dr. John Ewing:

  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing 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 (Eye opener)?

One “yes” answer suggests a possible alcohol problem. More than one “yes” answer means it is highly likely that a problem exists.

Determining whether a person is intoxicated is somewhat more straightforward than determining if he or she is an alcoholic. Since alcohol is distributed throughout the body, the level in blood is a good measure of the level in the brain. The amount of alcohol in expired air (measured in a Breathalyzer test) can also give a reliable measure of blood alcohol. In most states, the legal definition of intoxication is 100 mg of alcohol per 100 ml of blood. It is important to note, however, that alcohol begins to produce measurable impairment in brain function at about a third of that level. Thus, even lower alcohol levels greatly increase the risk of car accidents. Most European countries set the limit much lower than the United States. In France the legal limit is 50 mg per 100 ml of blood—about the level achieved after two glasses of wine drunk within an hour.

Impairment of judgment is a critical factor in measuring the effects of alcohol. People who show great tolerance, usually by inheriting some and acquiring more through experience with high doses of alcohol, may be able to show fairly normal motor function at alcohol levels that could kill an average person (200–400 mg per 100 ml of blood). However, these individuals’ judgment is still likely to be severely impaired, which can lead them to take dangerous risks.

For many years the medical profession neglected to treat alcoholism. Then, in the 1930s, a physician and a salesman started a self-help movement that became known as Alcoholics Anonymous (AA). This movement has grown into one of the greatest American inventions of all time. AA has spread to virtually every country in the world and has been a great solace to many, many alcoholics.

Today the medical community has come to see the AA movement and other self-help programs as partners in helping alcoholics and other addicts. AA does not consider itself to be a treatment program, however; it defines itself simply as a “worldwide fellowship of men and women who help each other to stay sober.” Not everyone responds to AA’s style and message, and many alcoholics either refuse to go to meetings or drop out after one or two. Even those who are helped by AA usually find that it works best in combination with other treatment, including counseling and medical care.

The standard medical treatment program for alcoholism consists of an abstinence-oriented residential or inpatient stay of 28 days, followed by aftercare that may consist simply of encouraging a person to attend AA meetings. Throughout the United States the standard goal of treatment is complete abstinence from alcohol, since long term follow-up studies show that total abstinence is the most stable state and that those who try to take alcohol in moderation more often relapse to uncontrolled drinking. However, some research oriented physicians have advocated a more flexible approach. Alcoholics are not all alike, and requiring everyone to accept the same treatment and goal does not seem reasonable. In European countries, there is more acceptance of the goal of controlled, nonexcessive drinking. Many alcoholics refuse to join a treatment program that requires total abstinence until their condition has progressed and both social and medical damage have occurred. If, on the other hand, they work to control their drinking, they are limiting the damage. If they continue to relapse, they can switch to total abstinence. Often individuals must make several tries before they stop drinking to excess.

Medical treatment can be important in the acute phase of detoxification, when the sudden abstinence from alcohol may cause seizures and cardiovascular collapse. In severe cases, medication can be essential for preventing death, although in mild cases it may not be necessary. Benzodiazepines have been used for the past 30 years to help people through alcohol withdrawal. The most commonly used of these is oxazepam, which does not require liver metabolism; that is important because alcoholics’ livers are often impaired. Oxazepam also has a low abuse potential. Anticonvulsant medications, such as carbamazepine, can also be useful during detoxification.

Even after a person has achieved detoxification and stopped drinking to excess, he or she is still considered an alcoholic. Alcoholism is a chronic disorder that is rarely cured. Those who try to return to controlled drinking after successful treatment usually relapse. The most stable condition is total abstinence, and even then people can slip, sometimes after years of total abstinence.

Recently it has been found that the incidence of relapse can be reduced if doctors prescribe a medication that blocks the reward from alcohol. Naltrexone is one such drug. After being detoxified, approximately 50 percent of alcoholics show some degree of relapse within three to six months. With naltrexone, that relapse rate has been reduced by about half. The major weakness of naltrexone is that it is necessary to take it regularly; researchers are working at developing a monthly injection. Furthermore, there is no indication that naltrexone permanently changes behavior, so people still have a tendency to relapse when their medication is stopped. This is why behavioral rehabilitation is essential, and naltrexone is often used very effectively in combination with AA meetings. 

Another medication, called acamprosate, has been approved for use in Europe and is currently in clinical trials in the United States, on its own and combined with naltrexone. Acamprosate works on a different brain mechanism from naltrexone, so the combination may have an added benefit. It appears that acamprosate acts on the GABA system to reduce the hyperarousal often seen during alcohol withdrawal and for months afterward.

The long-term prognosis for alcoholism depends on the stage at which it is treated, the long-term treatments and supports that are available, and the characteristics of each person. For example, alcoholics with more education, better job prospects, better family supports, fewer medical problems, and fewer psychiatric problems have a better prognosis than those with severe problems in these areas.

Research continues into the relationship between alcohol and the brain, with the hope that with better understanding we will find more effective treatments. Perhaps once we know why some people become alcoholics, we will be able to eliminate the disease and its destructive effects on alcoholics and those close to them.  

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