Alcohol Information, Use, Testing and Treatment

Effects of long term alcohol misuse

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging to physical health. The secondary damage caused by an inability to control one's drinking manifests in many ways. Alcoholism also has significant social costs to both the alcoholic and their family and friends. Alcoholism can have adverse effects on mental health causing psychiatric disorders to develop. Approximately 18 percent of alcoholics commit suicide. Research has found that over fifty percent of all suicides are associated with alcohol or drug dependence. In adolescents the figure is higher with alcohol or drug misuse playing a role in up to 70 percent of suicides. Alcoholism also has a significant adverse impact on mental health. The risk of suicide among alcoholics has been determined to be 5,080 times that of the general public.

Physical health effects of alcohol abuse

It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption may include cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources. Severe cognitive problems are not uncommon in alcoholics. Approximately 10% of all dementia cases are alcohol related making alcohol the 2nd leading cause of dementia.

Mental health effects of alcohol abuse

Long term misuse of alcohol can cause a wide range of mental health effects. Alcohol misuse is not only toxic to the body but also to brain function and thus psychological well being can be adversely affected by the long-term effects of misuse. Psychiatric disorders are common in alcoholics, especially anxiety and depression disorders, with as many as 25% of alcoholics presenting with severe psychiatric disturbances. Typically these psychiatric symptoms caused by alcohol misuse initially worsen during alcohol withdrawal but with abstinence these psychiatric symptoms typically gradually improve or disappear altogether. Psychosis, confusion and organic brain syndrome may be induced by chronic alcohol abuse which can lead to a misdiagnosis of major mental health disorders such as schizophrenia. Panic disorder can develop as a direct result of long term alcohol misuse. Panic disorder can also worsen or occur as part of the alcohol withdrawal syndrome. Chronic alcohol misuse can cause panic disorder to develop or worsen an underlying panic disorder via distortion of the neurochemical system in the brain.

The co-occurrence of major depressive disorder and alcoholism is well documented. Among those with comorbid occurrences, a distinction is commonly made between depressive episodes that are secondary to the pharmacological or toxic effects of heavy alcohol use and remit with abstinence, and depressive episodes that are primary and do not remit with abstinence. Additional use of other drugs may increase the risk of depression in alcoholics. Depressive episodes with an onset prior to heavy drinking or those that continue in the absence of heavy drinking are typically referred to as "independent" episodes, whereas those that appear to be etiologically related to heavy drinking are termed "substance-induced". There is a high rate of suicide in chronic alcoholics with the risk of suicide increasing the longer a person drinks. The reasons believed to cause the increased risk of suicide in alcoholics include the long-term abuse of alcohol causing physiological distortion of brain chemistry as well as the social isolation which is common in alcoholics. Suicide is also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse.

Social effects of alcohol abuse

The social problems arising from alcoholism can be massive and are caused in part due to the serious pathological changes induced in the brain from prolonged alcohol misuse and partly because of the intoxicating effects of alcohol. Alcohol abuse is also associated with increased risks of committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic's behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

Alcohol withdrawal

Alcohol withdrawal differs significantly from most other drugs in that it can be directly fatal. For example it is extremely rare for heroin withdrawal to be fatal. When people die from heroin or cocaine withdrawal they typically have serious underlying health problems which are made worse by the strain of acute withdrawal. An alcoholic, however, who has no serious health issues, has a significant risk of dying from the direct effects of withdrawal if it is not properly managed. Sedative-hypnotic drugs such as barbiturates and benzodiazepines which have a similar mechanism of action to alcohol (which is also a sedative-hypnotic) also have a similar risk of causing death during withdrawal.

Alcohol's primary effect is the increase in stimulation of the GABA_A receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.

Acute withdrawal symptoms tend to subside after one to three weeks. Less severe symptoms (e.g. insomnia and anxiety, anhedonia) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more. Withdrawal symptoms begin to subside as the body and central nervous system makes adaptations to reverse tolerance and restore GABA function towards normal. Other neurotransmitter systems are involved, especially glutamate and NMDA.

Diagnosis

Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared with the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify.

Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.

Alcohol Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

• Macrocytosis (enlarged MCV)¹
• Elevated GGT²
• Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1.
• High carbohydrate deficient transferrin (CDT)

However, none of these blood tests for biological markers are as sensitive as screening questionaires.

Alcoholism Prevention

Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

To combat the health, social and educational underachievement which results from alcohol or drug dependence targeting adolescents and young adults is regarded as an important step to reduce the harm of alcohol abuse. The age at which licit drugs of abuse such as alcohol can be purchased as well as banning or restricting advertising of alcohol has been recommended. Credible and evidence based educational drives in the mass media about the consequences of alcohol and other drug abuse has also been recommended. Guidelines for parents on alcohol and drug use during adolescence and targeting young people with mental health problems has also been suggested to prevent the harm of alcohol and other drug abuse.

Management

Treatments for alcoholism (antidipsotropic) are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.

Effectiveness

When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own. A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.

Alcohol Detoxification

Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.

Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.

Group therapy and psychotherapy

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more members than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency. A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics".

Medications

A variety of medications may be prescribed as part of treatment for alcoholism.

• Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent 9-year study found that incorporation of supervised disulfiram and a related compound carbamide into a comprehensive treatment program resulted in an abstinence rate of over 50%.

• Temposil (calcium carbimide) works in the same way as Antabuse, but is weaker and safer^].

• Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. Alcohol causes the body to release endorphins, hence when naltrexone is in the body drinkers no longer get any pleasure from consuming alcohol. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction. This results in a reduced desire to drink that persists after naltrexone use is discontinued, as long as the patient always takes naltrexone before drinking.
  Naltrexone comes in two forms. Oral naltrexone (originally but no longer available as the brand ReVia) is a pill that must be taken one hour before drinking to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.

• Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse... Campral proved superior to placebo in maintaining abstinence for a short period of time..." The COMBINE study was unable to demonstrate efficacy for Acamprosate.

• Topiramate (brand name Topamax), a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. In one study heavy drinkers were six times more likely to remain abstinent for a month if they took the medication, even in small doses. In another study, those who received topiramate had fewer heavy drinking days, fewer drinks per day and more days of continuous abstinence than those who received the placebo. Evidence suggests that topiramate antagonizes excitatory glutamate receptors, inhibits dopamine release, and enhances inhibitory gamma-aminobutyric acid function. A 2008 review of the effectiness of topiramate concluded that the results of published trials are promising, however at this time, data are insufficient to support using topiramate in conjunction with brief weekly compliance counseling as a first-line agent for alcohol dependence.

Medications which may worsen outcome

• Benzodiazepines, whilst useful in the management of acute alcohol withdrawal, if used long-term cause a worse outcome in alcoholism. Alcoholics on chronic benzodiazepines have a lower rate of achieving abstinence from alcohol than those not taking benzodiazepines. This class of drugs are commonly prescribed to alcoholics for insomnia or anxiety management. Initiating prescriptions of prescription (or solid sedative-hypnotics) in individuals in recovery has a high rate of relapse with one author reporting more than a quarter of people relapse after being prescribed sedative-hypnotics. Patients often mistakenly think that they are sober despite continuing to take benzodiazepines. Those who are long-term users of benzodiazepines should not be withdrawn rapidly, taper regimes of 6–12 months have been found to be the most successful, with reduced intensity of withdrawal.

Dual addictions

The AMA definition of alcoholism refers to a disease entity involving the compulsive use of alcohol despite social, physical and mental harm. The DSM-IV definition of alcohol dependence refers to alcohol only, and DSM-IV uses sedative dependence to refer to the disease entity involving non-alcohol sedative agents.

Alcoholics may also require treatment for other psychotropic drug addictions. The most common dual addiction in alcohol dependence is a benzodiazepine dependence with studies showing 10 - 20% of alcohol dependent individuals having problems of dependence and/or misuse problems of benzodiazepines. Alcohol itself is a sedative-hypnotic and is cross-tolerant with other sedative-hypnotics such as barbiturates, benzodiazepines and the nonbenzodiazepines. Dependence on other sedative hypnotics such as zolpidem and zopiclone as well as opiates as well as illegal drugs is common in alcoholics. Dependence and withdrawal from sedative hypnotics, eg benzodiazepine withdrawal is similar to alcohol and can be medically severe and include the risk of psychosis and seizures if not managed properly. Benzodiazepine dependency requires careful reduction in dosage to avoid a serious benzodiazepine withdrawal syndrome and health consequences. Benzodiazepines have the problem of increasing cravings for alcohol in problem alcohol consumers. Benzodiazepines also increase the volume of alcohol consumed by problem drinkers.