Alcoholism is the popular term for alcohol abuse and alcohol dependence. The hallmarks of both of these disorders involve repeated life problems that can be directly tied to a person's abuse of alcohol. Alcoholism has serious consequences, affecting an individual's health and personal life, as well as having a negative impact on society at large. Alcoholism is the use of alcohol in any harmful way.
The effects of alcoholism are quite far reaching. Alcohol affects every body system, causing a wide range of health problems. Such problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, weakness of muscles (including the heart), disturbances of heart rhythm, anemia, clotting disorders, weak immunity to infections, inflammation and irritation along the entire gastrointestinal system, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, and weak bones.
On a personal level, alcohol can be responsible for marital and other relationship difficulties, depression, unemployment, child abuse, and general family dysfunction.
Alcoholism causes or contributes to a variety of severe social problems: homelessness, murder, suicide, injury, and violent crime. Alcohol is a contributing factor in 50% of all deaths due to motor vehicle accidents. In fact, more than 100,000 deaths occur each year due to the effects of alcohol, of which 50% are due to injuries of some sort. In the United States, the annual economic cost of alcoholism and alcohol abuse is estimated at more than $160 billion.
Causes and symptoms
There are probably a number of factors that work together to cause a person to become an alcoholic. Genetic studies have demonstrated that close relatives of an alcoholic are more likely to become alcoholics themselves. This risk appears to hold true even for the child adopted away from his or her biological family at birth and raised in a non-alcoholic adoptive familyith no knowledge of the biological family's difficulties with alcohol. More research is being conducted to determine whether genetic factors can account for differences in alcohol metabolism, thereby increasing the risk of an individual becoming an alcoholicr whether the involvement of genetics is less direct, perhaps producing personality traits that render people susceptible to alcoholism. Many investigators believe that environmental factors, such as availability and acceptance of alcohol, peer pressure, or stressful lifestyle are at least as important as genetic factors. At the time of this writing in early 2001, researchers were seeking the location of specific genes that affect susceptibility to alcoholism.
The symptoms of alcoholism can be broken down into two major categories, symptoms of acute alcohol abuse and symptoms of long-term alcohol abuse.
Immediate (acute) effects of alcohol abuse
Alcohol exerts a depressive effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain-alcohol level will quickly become equivalent to the blood-alcohol level. Alcohol's depressive effects result in difficulty walking, poor balance, slurred speech, and generally poor coordination(i.e., accounting, in part, for the increased likelihood of injury). At higher alcohol levels, a person's breathing and heart rates will be slowed, and vomiting may occur, with a high risk of the vomit being inspired (breathed) into the lungs; this can result pneumonia, or in choking and death (especially if the person is unconscious). Extremely high blood alcohol levels may result in coma and death.
Effects of long-term (chronic) alcoholism
Long-term abuse of alcohol affects virtually every organ system of the body:
- Nervous system. An estimated 30-40% of all men in their teens and twenties have experienced alcoholic blackouts, which occur when drinking a large quantity of alcohol. This can also result in loss of memory of the time surrounding the episode of drinking. Alcohol is well known to cause sleep disturbances, so that overall sleep quality is affected. Numbness and tingling may occur in the arms and legs. Two syndromes, which can occur together or separately, are known as Wernicke's and Korsakoff's syndromes. Both are due to the low thiamin levels found in the blood of alcoholics. Wernicke's syndrome results in disordered eye movements, very poor balance and difficulty walking; Korsakoff's syndrome severely affects memory, preventing new learning from taking place.
- Gastrointestinal system. Alcohol causes loosening of the muscular ring that prevents the stomach's contents from re-entering the esophagus. Therefore, the acid from the stomach can flow backwards into the esophagus, thereby burning those tissues and causing pain and bleeding. Inflammation of the stomach can also result in bleeding and pain, and decrease the appetite. A major cause of severe, uncontrollable bleeding (hemorrhage) in an alcoholic is the development of enlarged (dilated) blood vessels within the esophagus, called esophageal varices. These varices are actually developed in response to liver disease, and are extremely prone to bursting and hemorrhaging. Diarrhea is also a common affect of alcohol abuse due to alcohol's effect on the pancreas. Another condition, inflammation of the pancreas (pancreatitis) can be a serious and painful consequence of alcoholism. Throughout the intestinal tract, alcohol interferes with the absorption of nutrients, creating a malnourished state. Alcohol is broken down (metabolized) in the liver, which is profoundly affected by consistently high alcohol levels. Alcohol interferes with a number of important chemical processes that also occur in the liver. As a result, the liver begins to enlarge and fill with fat (i.e., fatty liver), fibrous scar tissue interferes with the liver's normal structure and function (cirrhosis), and the liver may become inflamed (hepatitis).
- Blood alcohol can cause changes to all types of blood cells. Red blood cells become abnormally large. The number of white blood cells (WBCs) (important for fighting infections) decreases, resulting in a weakened immune system. This places alcoholics at increased risk for infections; it is thought to account, in part, for the increased risk of cancer in alcoholics (i.e., ten times the normal risk). Platelets and blood clotting factors are negatively affected, causing an increased risk of hemorrhage.
- Heart. Small amounts of alcohol can cause a drop in blood pressure. With increased use, however, alcohol begins to move blood pressure into a dangerously high range. High levels of fats circulating in the bloodstream increase the risk of heart disease. Heavy drinking results in an increase in heart size, weakening of the heart muscle, abnormal heart rhythms, and risk of the formation of blood clots within the chambers of the heart. These factors greatly increase the risk of stroke, which can occur if a blood clot from the heart enters the circulatory system, goes to the brain, and blocks one of its blood vessels.
- Reproductive system. Heavy drinking has a negative effect on fertility in both men and women. It decreases testicle and ovary size, thereby interfering with both sperm and egg production. When an alcoholic woman becomes pregnant, she assumes the great risk of giving birth to a baby who has fetal alcohol syndrome. This causes distinctive facial defects, lowered IQ, and behavioral problems.
Two different types of trouble with alcohol are identified. The first is called alcohol dependence, and refers to a person who is physiologically dependent on the use of alcohol. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), an individual must have three of the following traits to be diagnosed with alcohol dependence:
- Tolerance, meaning that a person becomes accustomed to a particular dose of alcohol and must increase the dose in order to obtain the desired effect.
- Withdrawal, meaning that a person experiences unpleasant physical and psychological symptoms when he or she does not drink alcohol.
- The tendency to drink more alcohol than one intends(i.e., once an alcoholic starts to drink, he or she finds it difficult to stop).
- Being unable to avoid drinking or stop drinking once started.
- Having large blocks of time taken up by alcohol abuse.
- Choosing to drink at the expense of other important tasks or activities.
- Drinking despite evidence of negative effects on one's health, relationships, education, or job.
Under DSM-IV, a diagnosis of alcohol abuse requires that one of the following four criteria is met within a 12-month period. Because of drinking, a person repeatedly:
- Fails to live up to his or her most important responsibilities.
- Physically endangers himself, herself, or others (e.g., by drinking when driving).
- Gets into trouble with the law.
- Experiences difficulties in relationships or jobs.
Diagnosis is often brought about when family members relate the alcoholic's difficulties to a physician. A physician may become suspicious when a patient suffers repeated injuries or begins to experience medical problems that seem related to alcohol abuse. Alcohol abuse is so widespread that some estimates suggest that about 20% of a physician's patients will be alcoholics.
Diagnosis is aided by the answers to questionnaires that try to determine what aspects of a person's life may be affected by his or her abuse of alcohol. Determining the exact quantity of alcohol that a person drinks is much less important than learning how drinking affects his or her relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body
breaks down and processes alcohol) is so unique, the quantity of alcohol consumed is not a criterion for diagnosing either alcohol dependence or alcohol abuse.
One very simple tool for beginning to diagnose alcoholism is the CAGE questionnaire. It consists of four questions, with the first letters of each key word spelling the word CAGE:
- Have you ever tried to Cut down on your drinking?
- Have you ever been Annoyed by anyone's comments about your drinking?
- Have you ever felt Guilty about your drinking?
- Do you ever need an Eye-opener (a morning drink of alcohol) to start the day?
There are other, longer lists of questions that help to determine the severity and effects of a person's alcohol abuse. Given the evidence of genetic involvement in alcoholism, it is important to ascertain whether any relative of the person has ever suffered from alcoholism.
Physical examination may reveal signs suggestive of alcoholism: evidence of old injuries; a visible network of enlarged veins just under the skin around the navel (called caput medusae); fluid in the abdomen (ascites); yellowish tone to the skin; decreased testicular size; and poor nutritional status. Lab work may reveal an increase in the size of red blood cells; abnormalities in WBCs (responsible for fighting infection) and platelets (particles responsible for clotting); and an increase in certain liver enzymes.
Treatment of alcoholism has two parts. The first step in the treatment of alcoholism, called detoxification, involves helping the person stop drinking and ridding his or her body of the harmful (toxic) effects of alcohol. Because the person's body has become accustomed to alcohol, he or she will need to be supported through withdrawal. Withdrawal will be different for different patients, depending on the severity of the alcoholism (as measured by the quantity of alcohol ingested daily and the length of time the patient has been an alcoholic). Withdrawal symptoms can range from mild to life-threatening. Mild withdrawal symptoms include nausea, aches, diarrhea, difficulty sleeping, sweats, anxiety, and trembling. This phase is usually over in about three to five days. More severe effects of withdrawal can include hallucinations, seizures, an unbearable craving for more alcohol, confusion, fever, fast heart rate, high blood pressure, and delirium (a fluctuating level of consciousness). Patients at highest risk for the most severe symptoms of withdrawal (referred to as delirium tremens) are those with other medical problems, including malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begins approximately three to five days after the patient's last drink, progressing from the more mild symptoms to the more severe, and may last a number of days.
Patients going through only mild withdrawal are simply monitored carefully to ensure that more severe symptoms do not develop. However, no medications are necessary. Treatment of a patient suffering the more severe effects of withdrawal may require sedating medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Benzodiazepines are helpful in those patients suffering from hallucinations. If the patient is nauseated, fluids may need to be given through a vein (intravenously), along with some necessary sugars and salts. It is crucial that thiamin be included in the fluids, because of it is usually quite low in alcoholic patients. Further, thiamin deficiency can lead to Wernicke-Korsakoff syndrome.
After cessation of drinking has been accomplished, the next steps involve helping the patient avoid ever taking another drink. This phase of treatment is referred to as rehabilitation. The best programs incorporate the family into the therapy; it has no doubt been severely affected by the patient's drinking. Some therapists believe that family members, in an effort to deal with their loved one's drinking problem, sometimes develop patterns of behavior that unintentionally support or "enable" the patient's drinking. This situation is referred to as "codependence," and must be addressed in order to successfully treat a person's alcoholism.
Sessions led by peers, where recovering alcoholics meet regularly and provide support for each other's recoveries, are considered to be among the best methods of preventing a return to drinking (relapse). Perhaps the most well-known group of this kind is called Alcoholics Anonymous, which uses a "12-step" model to help people avoid drinking. These steps involve recognizing the destructive power that alcohol has held over the alcoholic's life, looking to a higher power for help in overcoming the problem, and reflecting on the ways in which the abuse of alcohol has hurt others and, if possible, making amends to those people.
There are also medications that may help an alcoholic avoid returning to drinking. These have been used with varying degrees of success. Disulfiram (Antabuse) is a drug that, when mixed with alcohol, causes a very unpleasant reaction that includes nausea and vomiting, diarrhea, and trembling. Naltrexone (Revia) and acamprosate (calcium acetylhomotaurinate) seem to be helpful in limiting the effects of a relapse. None of these medications would be helpful unless the patient is also willing to work very hard to change his or her behavior.
Alternative treatments can be a helpful adjunct for the alcoholic patient once the medical danger of withdrawal has passed. Because many alcoholics have very stressful lives (whether because of or leading to the alcoholism is sometimes a matter of debate), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. The malnutrition of long-term alcohol abuse is addressed by nutrition-oriented practitioners, with careful attention being given to a healthy diet and the use of nutritional supplements, such as vitamins A, B complex, and Cs well as certain fatty acids, amino acids, zinc, magnesium, and selenium. Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs believed to be helpful for the patient suffering through withdrawal include lavender (Lavandula officinalis), skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), peppermint (Mentha piperita), yarrow (Achillea millefolium), and valerian (Valeriana officinalis). Acupuncture is believed to both decrease withdrawal symptoms and to help improve a patient's chances for continued recovery from alcoholism.
Recovery from alcoholism is a lifelong process. In fact, the person who has suffered from alcoholism is encouraged to refer to himself or herself ever after as "a recovering alcoholic," never a recovered alcoholic. This is because most researchers in the field believe that one can never fully recover from alcohol because the vulnerability to alcoholism is still part of the individual's biological and psychological makeup. The potential for relapse (returning to illness) is always there, and must be acknowledged and respected. Statistics suggest that, among middle-class alcoholics in stable financial and family situations who have undergone treatment, 60% or more can be successful at an attempt to stop drinking for at least a year, and many for a lifetime.
Health care team roles
The International Nurses Society on Addictions (IntNSA) says that it is appropriate for nurses to assess patients for alcohol-related problems in any setting, and to initiate discussion of such problems with not only the patient, but also the family, significant others, and appropriate members of an interdisciplinary health team. Nurses have a responsibility to educate and counsel alcoholic patients, their families, and significant others. Nurses with special knowledge or experience in the subject can play an important role in educating both the community and fellow health-care professionals. General-care nurses might wish to seek help or advice from a clinical specialist in alcoholism. According to IntNSA, the nurse's role in treating alcoholism is not restricted to psychiatric and mental health nursing, as it involves every other clinical nursing specialty. It is important that nurses be aware of community resources so that they can make appropriate treatment referrals. IntNSA offers Certified Addiction Registered Nurse certification to nurses who pass rigorous testing.
Prevention must occur at a relatively young age, since the first experience with alcohol intoxication usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholismhose with a family history of alcoholism, early or frequent abuse of alcohol, a tendency to drink to drunkenness, alcohol abuse that interferes with school work, a poor family environment, or a history of domestic violencere educated about alcohol and its longterm effects. How this is best achieved, without irritating the youngsters and losing their attention, is a matter of debate and study.
Blood-brain barrier membrane that separates the circulating blood from reaching the brain and the fluid that surrounds it and the spinal cord. It prevents many damaging substances from reaching the brain, but alcohol is able to cross the barrier.
Dependence state in which a person requires a steady amount of a particular drug in order to avoid experiencing symptoms of withdrawal.
Detoxificationhe phase of treatment during which a patient stops drinking and is monitored and cared for while he or she experiences withdrawal from alcohol.
Relapse return to a disease state, after recovery appeared to be occurring; in alcoholism, relapse refers to a patient beginning to drink alcohol again after a period of avoiding alcohol.
Tolerance phenomenon whereby a drug abuser becomes physically accustomed to a particular quantity of alcohol (or dosage of a drug), and requires ever-increasing quantities in order to obtain the same effects.
Withdrawalhose signs and symptoms experienced by a person who has become physically dependent on a drug, experienced upon decreasing the drug's dosage or discontinuing its use.
"Alcoholism and Alcohol Abuse." In Cecil Textbook of Medicine, edited by J. Claude Bennett and Fred Plum. Philadelphia: W.B. Saunders, 2000.
Schuckit, Marc A. "Alcohol and Alcoholism." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
Ianelli, Joseph, "When Alcoholism Hits Home." American Journal of Nursing. (July 1997): 68+.
O'Brien, Charles P. and A. Thomas McLellan, "Addiction Medicine." Journal of the American Medical Association. (June 18, 1997): 1840+.
Al-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown Station, New York, NY 10018-0862. (800)356-9996. <<a href="http://www.recovery.org/aa">http://www.recovery.org/aa>.
International Nurses Society on Addictions. 1500 Sunday Drive, Suite 102, Raleigh, NC 27607. (919)783-5871. <<a href="http://www.nnsa.org">http://www.nnsa.org>.
National Clearinghouse for Alcohol and Drug Information. <<a href="http://www.health.org">http://www.health.org>.
David L. Helwig
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