Alcohol Use Disorders (AUDs) — sometimes collectively termed alcoholism — represent a costly and prevalent problem in the United States. The annual cost of alcohol dependence in the United States is over $150 billion dollars, and about 100,000 people die annually due to alcohol-related causes.
People with alcohol-related medical illnesses have more frequent hospitalizations and longer hospital stays compared with individuals without alcoholism. In fact, the price of healthcare resulting from AUDs in the United States is estimated at more than $26 billion per year.
Unfortunately, alcohol abuse and dependence are frequently under-diagnosed in the clinical setting, typically due to inadequate screening and the unreliability of self-reported alcohol use. In one study, retrospective analysis demonstrated that less than 25% of patients admitted to hospital who screened positively for AUD received either inpatient alcohol intervention or a referral for outpatient alcohol treatment.
Alcoholism occurs when a person has developed dependence on alcohol and continues to use it, despite the problems it causes with that person’s job performance, academic performance, or relationships. The National Institute on Drug Abuse states that alcoholism is defined as a “chronic, relapsing brain disease” when the chronic use of a substance causes changes in the structure of the brain and how it works.
An Alcohol Use Disorder starts with drinking to excess on multiple occasions. This may include drinking alcohol to the point of feeling intoxicated or out of control in behavior. A person can still develop a drinking problem when he or she drinks more than what is recommended for health and safety.
According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the following are the recommended Maximum Drinking Limits. People, with exceptions noted below, are advised to stay within these limits:
For healthy men up to age 65
- No more than 4 drinks a day AND
- No more than 14 drinks in a week
For healthy women (and healthy men over age 65)
- No more than 3 drinks in a day AND
- No more than 7 drinks in a week
Abstinence is advised to individuals who:
- Take prescriptions or over-the-counter medications that may interact with alcohol
- Have a health condition that may be exacerbated by alcohol
- Are pregnant
- Are considering becoming pregnant
- Are younger than age 21
Signs of Alcoholism
The Diagnostic and Statistical Manual (DSM) is the classification system published by the American Psychiatric Association. In 2013, the 5th edition was released. It eliminated the terms Alcohol Abuse and Alcohol Dependence, and it created the broad category of Alcohol Use Disorders (AUD). In order to meet the criteria for an AUD, a person must have at least two of the following symptoms:
- Alcohol is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
- A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
- Craving, or a strong desire or urge to use alcohol.
- Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
- Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
- Recurrent alcohol use in situations in which it is physically hazardous.
- Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
- Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.
- Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
The presence of at least 2 of these symptoms indicates an alcohol use disorder (AUD). The severity of an AUD is either mild, moderate, or severe, depending on the number of symptoms.
Mild: The presence of 2 to 3 symptoms.
Moderate: The presence of 4 to 5 symptoms.
Severe: The presence of 6 or more symptoms.
Effects of Alcohol
Alcohol acts rapidly because it is very lipid soluble. Cell membranes, with their lipid bilayers, offer almost no impediment to it. Alcohol’s small size and lipid solubility make it pass the blood-brain barrier very quickly. Once in the brain, it stimulates some neurotransmitters and inhibits others. Alcohol’s effects on the gamma-aminobutyric acid (GABA) receptor are what leads to its psychoactive effects.
Though our knowledge of the neurobiology of alcohol is limited, we know plenty about its psychological effects. At low to moderate doses, alcohol creates relaxation and disinhibition. It is remarkably effective at reducing social anxiety, making it a staple at parties and earning it the nickname “the social lubricant.”
However, with greater consumption, alcohol’s effects penetrate to progressively deeper parts of the brain. The effects start on the surface, at the frontal lobes, where it relaxes the executive functions. As the blood alcohol level rises, it quiets the reticular activating system, which is what keeps us awake and alert to our surroundings, so sedation ensues. Next, the cerebellum is affected, which impacts coordination and causes staggering.
Ultimately, the brainstem is affected, which reduces the respiratory drive—at this point, we’ve reached the level of alcohol poisoning.
Thankfully, alcohol poisoning (overdose) is fairly rare: Since alcohol is a liquid, a person must consume a large amount to produce the alcohol level necessary to overdose, and the body will generally expel the alcohol through vomiting before reaching that level.
Depending on how much is taken and the physical condition of the individual, alcohol can cause:
- Slurred speech
- Upset stomach
- Breathing difficulties
- Distorted vision and hearing
- Impaired judgment
- Decreased perception and coordination
- Anemia (loss of red blood cells)
- Blackouts (memory lapses, where the drinker cannot remember events that occurred while under the influence)
Each patient will experience differing severity of alcohol withdrawal, ranging from nonexistent to life-threatening. Predicting the likelihood of withdrawal is more art than science. In general, patients who have consumed larger amounts for longer periods of time on a consistent basis will have more severe withdrawal. Binge drinkers will rarely have withdrawal symptoms other than a bad hangover.
Early symptoms occur within a few hours after the last drink—although it may take 24–48 hours for symptoms to manifest—and usually last 48–72 hours. They include insomnia, nervousness, tremor, and sweating. Early withdrawal symptoms may subside on their own, although repeated episodes of alcohol withdrawal increase the likelihood of progression to worse withdrawal, also known as late withdrawal or delirium tremens.
Heavier drinkers and those who have experienced repeated early withdrawal may experience delirium tremens, which starts after development of early withdrawal has continued to progress, usually 48–72 hours after the last drink. Also known as “the DTs,” “the shakes,” and “rum fits,” symptoms of delirium tremens include worsening of the signs of early withdrawal, with serious altered mental status (hallucinations such as the famous “pink elephants”) and severe autonomic dysregulation manifested by rapid fluctuations in vital signs.
Development of delirium tremens carries a mortality of 5%, even when adequately treated. Because alcohol withdrawal can progress quickly and result in mortality, it is important to recognize and treat it early. Seizures are an early sign of alcohol withdrawal syndrome and can complicate management. Patients who present with an alcohol withdrawal– related seizure or with delirium tremens should be treated as a medical emergency and referred to the nearest emergency department for adequate medical monitoring and aggressive pharmacologic management to prevent significant morbidity and mortality.
Alcoholic hallucinosis is a condition that can resemble alcohol withdrawal syndrome. It presents with auditory and/or visual hallucinations, but not the autonomic dysregulation of alcohol withdrawal syndrome. Alcoholic hallucinosis is not life-threatening and is a consequence of intoxication, but not withdrawal. It often resolves with resolution of intoxication over time, or with pharmacologic treatment to prevent alcohol withdrawal syndrome.
Therapy for Alcoholism
Cognitive Behavioral Therapy (CBT): A type of therapy most commonly used to treat depression and anxiety, but it has also been shown to be valuable in treating alcoholism and drug addiction, especially as part of an overall program of recovery. Cognitive-behavioral coping skills treatment is a short-term, focused therapeutic approach to helping drug-dependent people become abstinent by using the same learning processes the person used to develop alcohol and drug dependence initially.
Alternatives to AA
SMART Recovery: Alternative to AA with local and online meetings. It uses cognitive-behavioral approaches that help members recognize environmental and emotional factors for alcohol and other drug use (as well as other “addictive” behaviors) and then to respond to them in new, more productive ways. It also incorporates motivational interviewing concepts. Unlike some support groups whose principles remain static, SMART Recovery maintains a philosophy of evolving as scientific knowledge evolves. Although it is an abstinence-based program, SMART Recovery welcomes those who are ambivalent about quitting substance use.