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Alcoholism

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Related Terms
  • Acetaldehyde, acetic acid, addiction, ADHD, alanine aminotranferease, Alcohol Dependence Data Questionnaire, alcoholic beverage, ALT, anxiety, aspartate aminotransferase, AST, attention-deficit/hyperactivity disorder, BAC, binge drinking, blackout, blood alcohol content, CAGE questionnaire, cancer, carbon dioxide, cardiomyopathy, CDT, chronic, cirrhosis, depression, Diagnostic Criteria of Mental Disorders, dopamine D2 receptor, dopamine, DRD2, DSM-IV-TR, FAS, fetal alcohol syndrome, gamma glutamyltransferase, GGT, hangover, high blood pressure, high carbohydrate deficient transferrin, hypertension, hypertriglyceridemia, liver, macrocytosis, mental retardation, metabolism, metabolized, Michigan Alcohol Screening Test, neurotransmitter, obesity, pancreatitis, porphyria, relapse, serotonin, smoking, social phobia, stroke, water, withdrawal.

Background
  • Alcoholism is a chronic (long-term), progressive disease that includes alcohol cravings and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law. Symptoms include cravings, impaired control, physical dependence, and increased tolerance. Left untreated, alcoholism can be fatal.
  • Alcohol is the most widely used psychoactive (affecting the mind or mental processes) drug.
  • According to the National Council on Alcoholism and Drug Dependence, almost 18 million Americans abuse alcohol. Almost three times as many men (9.8 million) as women (3.9 million) are problem drinkers and prevalence is highest for both sexes in the 18 to 29 years-old age group. Each year more than 100,000 Americans die of alcohol-related causes. Alcohol is a factor in nearly half of all U.S. traffic deaths.
  • About 43% of U.S. adults (76 million people) have been exposed to alcoholism in the family. They either grew up with or married an alcoholic or a problem drinker, or had a blood relative (cousin, aunt, uncle, etc) who was an alcoholic or problem drinker.
  • People who begin drinking before age 15 are four times more likely to develop alcoholism than those who begin at age 21.
  • Alcohol and drug abuse costs the American economy an estimated $276 billion per year in lost productivity, healthcare expenditures, crime, and motor vehicle crashes.
  • One-quarter of all emergency room admissions, one-third of all suicides, and more than half of all homicides and incidents of domestic violence are alcohol-related. Heavy drinking contributes to illness in each of the top three causes of death, including heart disease, cancer, and stroke. Almost half of all traffic fatalities are alcohol-related. Between 48-64% of people who die in fires have blood alcohol levels indicating intoxication.
  • Healthcare professionals recommend drinking alcoholic beverages in moderation. Experts suggest limiting intake to one drink per day for women or two per day for men taken with a meal to slow alcohol absorption. A drink of alcohol is considered 12 ounces beer, 5 ounces of wine (one glass) or 1.5 ounces of 80 proof distilled spirits (liquor). Avoid drinking before or when driving. Avoid drinking alcohol while taking prescription medications, unless otherwise recommended by a healthcare professional.
  • Binge drinking: Binge drinking is irresponsible heavy drinking that often comes under the disguise of fun and games. Binge drinking can be dangerous to the drinker and to people around him or her, possibly resulting in death. Binge drinkers drink "to get drunk." The goal is to drink large amounts of alcohol quickly resulting in loss of control of mental and physical faculties. Binge drinkers may engage in foolish, potentially deadly behaviors such as driving drunk, starting fights, and taking unnecessary risks such as having unprotected sex.
  • Studies that have been conducted in the past 10 years indicate that the highest proportion of drinkers, binge drinkers, and individuals with multiple substance dependencies tend to be within the age range that encompasses nearly 92% of all enrolled college students. College-aged individuals, from 18-22 years of age, are at very high risk for binge drinking and abusing alcohol. Binge drinking among college students has been consistently associated with higher incidences of physical injury, unplanned sexual activity, sexual and physical assaults, alcohol-related driving injuries and fatalities, date rape, criminal mischief, property damage, and trouble with campus and local police. Numerous college students die annually from alcohol poisoning. Alcohol poisoning is a serious and sometimes deadly result of consuming dangerous amounts of alcohol. When the body absorbs too much alcohol (depending on the weight, sex, heredity, and health of the individual), it can directly impact the central nervous system, slowing the breathing, heart rate, and gag reflex. This can lead to choking, coma, and death.
  • U.S. Government warning: The Alcoholic Beverage Labeling Act (or ABLA) is a U.S. Federal law enacted in 1988. The act requires that, among other provisions, the labels of alcoholic beverages must carry a "government warning," that reads: "Government Warning: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects; (2) Consumption of alcoholic beverages impairs the ability to drive a car or operate machinery, and may cause health problems."

Risk factors and causes
  • Alcohol has been used by man for thousands of years. However, drinking steadily and consistently over time can produce dependence and cause withdrawal symptoms during periods of abstinence. This physical dependence, however, is not the sole cause of alcoholism. To develop alcoholism, other factors usually come into play, including biology, genetics, culture, and psychology.
  • Age: People who begin drinking at an early age (by age 16 or earlier) are at a higher risk of alcohol dependence or abuse. Currently, 1.9 million young people between the ages of 12 and 20 are considered heavy (chronic or long-term) drinkers and 4.4 million are binge drinkers. Young people at highest risk for early drinking are those with a history of abuse, family violence, depression, and stressful life events.
  • Although alcoholism usually develops in early adulthood, the elderly are not exempt. A survey of 5,000 adults over 60 reported that 15% of men and 12% of women were hazardous drinkers and 9% of men and 3% of women were alcohol dependent. In another study, the prevalence of problem drinking was as high as 49% among nursing home patients. Individuals who maintain the same drinking patterns as they age can easily develop alcohol dependency without realizing it. Doctors may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process.
  • Family history/Genetics: People with a family history of alcoholism are also more likely to begin drinking before the age of 20 and to become alcoholics. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges or driving after drinking, than young drinkers without a family history of alcoholism. The risk for alcoholism in sons of alcoholic fathers is 25%. The familial link is weaker for women, but genetic factors contribute to this disease in both genders. In one study, women with alcoholism tended to have parents who drank. However, women who came from families with a history of emotional disorders, rejecting parents, or early family disruption had no higher risk for drinking than women without such backgrounds. A stable family and psychological health were not protective in people with a genetic risk. Unfortunately, there is no way to predict which members of alcoholic families are most at risk for alcoholism.
  • A proposed association between the dopamine receptor D2 (DRD2) gene and alcoholism has been made. The neurotransmitter (brain chemical) dopamine is critical to many of the vital functions of daily life, including emotional response, the regulation of movement, and the control of cognition, including attention. D2 receptor and dopamine imbalances in the brain have been linked with the tendency for compulsive activity such as addiction. Drugs of abuse, such as alcohol, have been shown to increase dopamine neurotransmitter levels in the reward pathway. Other neurotransmitters may also be involved with addiction and alcoholism, including serotonin (mood regulation).
  • Ethnicity: Overall, there is no difference in alcoholic prevalence among African Americans, Caucasians, and Hispanic people. Some population groups, however, such as Irish and Native Americans, have an increased incidence in alcoholism while others, such as Jewish and Asian Americans, have a lower risk. Although the biological or cultural causes of such different risks are not known, certain people in these population groups may have a genetic susceptibility or invulnerability to alcoholism because of the way they metabolize alcohol.
  • Gender: Most alcoholics are men, but the incidence of alcoholism in women has been increasing over the past 30 years. About 9.3% of men and 1.9% of women are heavy drinkers and 22.8% of men are binge drinkers compared to 8.7% of women. In general, young women problem drinkers follow the drinking patterns of their partners, although they tend to engage in heavier drinking during the premenstrual period. Women tend to become alcoholic later in life than men and it is estimated that 1.8 million older women suffer from alcohol addiction. Even though heavy drinking in women usually occurs later in life, the medical problems women develop because of the disorder occur at about the same age as men, suggesting that women are more susceptible to the physical toxicity of alcohol.
  • Psychosocial disorders: Being severely depressed or having anxiety places an individual at a greater risk of abusing alcohol. Adults with attention-deficit/hyperactivity disorder (ADHD) also may be more likely to become dependent on alcohol. The risk for heavy drinking in women who are depressed is 2.6 times greater than the risk in women who are not depressed. Depression and anxiety may play a major role in the development of alcoholism in the elderly, who are often subject to dramatic life changes, such as retirement, the loss of a spouse or friends, and medical problems. Problem drinking in these cases may be due to self-medication of the anxiety or depression. Major depression, in fact, accompanies about one-third of all cases of alcoholism.
  • Evidence suggests that 20% of people with a form of anxiety called social phobia abuse alcohol. Social phobia causes an intense fear of being publicly scrutinized and humiliated. Such individuals may use alcohol as a way to become less inhibited in public situations.
  • Long-term alcoholism itself causes chemical changes in the brain that produce anxiety and depression. In fact, a study on elderly people with depression reported that when even moderate drinkers reduced consumption, their mood improved. It is not always clear, then, whether people with emotional disorders are self-medicating with alcohol or whether alcohol itself is producing mood swings.

Signs and symptoms
  • Alcoholism includes four symptoms, craving (a strong need, or compulsion, to drink), loss of control (the inability to limit one's drinking on any given occasion), physical dependence (withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking), and tolerance (the need to drink greater amounts of alcohol in order to "get high"). Other indications of alcoholism and alcohol abuse include feelings of guilt toward drinking, drinking alone or in secret, being unable to limit the amount of alcohol one drinks, blacking out or not remembering conversations or commitments, making a ritual of having drinks at various times such as before, with, or after dinner, losing interest in activities and hobbies that used to bring pleasure, and feeling a need or compulsion to drink. Other symptoms include irritability when the usual drinking time nears, especially if alcohol is not available, keeping alcohol in "hiding" places with quick accessibility (at home, at work, or in the car), gulping drinks, ordering doubles, becoming intoxicated intentionally to feel good or drinking to feel "normal," the need to drink upon arising in the morning, having legal problems or problems with relationships, employment, or finances, building a tolerance to alcohol so that an increasing amount of alcohol is needed to feel the same effects, and experiencing physical withdrawal symptoms, including nausea, sweating, and shaking, when no drink is available.
  • The development of alcoholism or alcohol dependence can occur over a lengthy period of time ranging from five to 20 years. Initially, the alcoholic displays a tolerance for alcohol meaning it is necessary for the drinker to consume larger amounts of alcohol, as the usual amount ingested no longer produces the desired effect. With the increased dosages of alcohol, the likelihood is greater that complications will occur. Unfortunately, the alcoholic may not be aware of the effect that alcohol is having on the body.
  • Not all individuals suffering from alcoholism exhibit the same drinking patterns. Some drink every day while others engage in heavy drinking on the weekends. Stressful life experiences may be the causes for very heavy episodic drinking. Some alcoholics drink only late in the day and never in the mornings. Others engage in long periods of sobriety alternating with binge drinking episodes that can last weeks or months.
  • The alcoholic may engage in periods of abstinence from drinking. This "holiday" from drinking is often unsuccessful and the drinker may begin to drink again while attempting to exhibit some element of control over drinking behavior. Lack of control is paramount in the alcoholic who cannot control consumption. As time passes, some alcoholics develop a reverse tolerance to alcohol, which means that they require less alcohol before experiencing psychoactive effects. In this situation, even though a smaller amount of alcohol may produce feelings of intoxication, the alcoholic continues to drink in escalating amounts.
  • The abuse of alcohol may present the same symptoms as dependence upon alcohol. However, individuals who abuse alcohol are not preoccupied with drinking and usually do not experience physical withdrawal symptoms when they do not drink, except for the "hangover" effect. A dependence on alcohol also creates a tolerance to alcohol and the inability to control drinking.

Diagnosis
  • Identifying alcoholism usually involves psychoanalysis and an objective assessment regarding the damage that the consumption of alcohol has on the individual's life compared to the benefits the drinker perceives from consuming alcohol. Blood tests can also determine the level of intoxication and liver damage.
  • Psychological testing:
  • CAGE questionnaire: The CAGE questionnaire is named for its four questions and may be used to screen patients for alcoholism quickly in a healthcare provider's office. Two "yes" responses indicate that the respondent should be investigated further. Questions may include: Have you ever felt you needed to cut down on your drinking?; Have people annoyed you by criticizing your drinking?; Have you ever felt guilty about drinking?; and Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?.
  • Alcohol dependence data questionnaire: The Alcohol Dependence Data questionnaire helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use and is a more sensitive diagnostic test than the CAGE test.
  • Michigan Alcohol Screening Test (MAST): The Michigan Alcohol Screening Test is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses such as driving under the influence (DUI) or driving while impaired (DWI).
  • Alcohol Use Disorders Identification Test (AUDIT): The Alcohol Use Disorders Identification Test is a set of questions developed by the World Health Organization (WHO). This test has been validated in six countries and is used internationally.
  • DSM-IV-TR diagnosis: The DSM-IV-TR (Diagnostic Criteria of Mental Disorders - Text Revision) is a clinical reference for psychiatric illnesses that has a set of criteria to determine various psychological illnesses, including alcoholism. The diagnosis of alcoholism, including alcohol use with clinically significant impairment, is determined by at least three of the following criteria within any one-year period: tolerance, withdrawal, alcohol taken in greater amounts or over longer time course than intended, desire or unsuccessful attempts to cut down or control use, a great deal of time spent obtaining, using, or recovering from use, social, occupational, or recreational activities given up or reduced, and continued use despite knowledge of physical or psychological consequences.
  • Urine and blood tests:
  • Genetic predisposition testing: At least one genetic test exists for an allele (DNA coding) that correlates to alcoholism and opiate addiction. This test determines dopamine D2 receptor function, which is involved in the reward system.
  • Blood alcohol content (BAC): Law enforcement uses BAC commonly to determine if criminal levels of alcohol intoxication are involved in motor vehicle operation. Breathalyzer analysis (blowing into a machine to detect alcohol levels) or blood testing may be involved.
  • Liver enzymes: Gamma glutamyltransferase, or GGT, is an enzyme in the liver that is involved in the metabolism of alcohol. Chronic drinking of four or more drinks per day for four to eight weeks significantly raises GGT levels. Even small amounts of alcohol consumption can be detected with a GGT test. If a person stops drinking for four to five weeks, then the levels of GGT decrease to normal levels. Other liver enzymes that can be altered by chronic (long-term) alcohol consumption include elevation of alanine aminotranferease (ALT) and aspartate aminotransferase (AST).
  • Other blood tests: High carbohydrate deficient transferrin (CDT) is another test to determine if alcohol is used in excess. Macrocytosis (enlarged red blood cells) can also be common in alcoholism and may be tested.

Complications
  • Acute (short term) ingestion of alcohol may lower inhibitions and affect thoughts, emotions, and judgment. Too much alcohol can severely depress the vital centers of the brain that control body functions. Alcohol, in sufficient amounts, impairs speech and muscle coordination. An overdose of alcohol may even cause coma and death.
  • Social consequences: Social problems for the alcoholic and consequences with family, friends, and coworkers can be significant. They include domestic abuse and divorce, poor performance at work or school, damaged relationships with friends and family, increased likelihood of motor vehicle fatalities and arrest for drunken driving, greater susceptibility to accidental injuries from other causes, and a higher incidence of suicide and murder.
  • Health consequences: Alcoholic beverages supply calories but few nutrients. Excess alcohol alters judgment and can lead to dependency and a great many other serious health problems. Taking more than one drink per day for women or two drinks per day for men can raise the risk for motor vehicle crashes, other injuries, high blood pressure, stroke (neurological damage due to lack of oxygen to brain cells), and some cancers such as liver, mouth, throat, and pancreas. Consumption of alcoholic beverages is known to be a human carcinogen (cancer-causing agent) based on sufficient evidence from human studies that indicate a relationship between consumption of alcoholic beverages and cancer in humans. Studies indicate that the risk of cancer is most pronounced among alcoholics with the highest levels of alcohol consumption and those that smoked. Even one drink per day can slightly raise the risk of breast cancer. Alcohol abuse can cause erectile dysfunction in men. In women, it can interrupt menstruation.
  • Cirrhosis (replacement of normal tissue with scar tissue) of the liver, pancreatitis (inflammation of the pancreas), and damage to the brain and heart occur after years of heavy alcohol abuse. Heavy drinkers also are at risk of malnutrition because alcohol contains calories that may substitute for those in nutritious foods.
  • About 100,000 deaths a year can be wholly or partially attributed to drinking and alcoholism reduces life expectancy by 10 to 12 years. Next to smoking, it is the most common preventable cause of death in America. Although studies indicate that adults who drink moderately (about one drink a day) have a lower mortality rate than their non-drinking peers, their risk for untimely death increases with heavier drinking. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Once one becomes dependent on alcohol, it is very difficult to quit. In one study, after five years, two-thirds of people with alcoholism were still dependent.
  • Alcohol can also increase the chances of being addicted to other drugs, such as opiates (codeine, morphine, and heroin), cocaine, and methamphetamine.
  • Brain chemistry changes: The chronic (long-term) use of alcohol can cause imbalances in the brain. Alcohol can affect neurons (nerve cells), brain chemistry (including dopamine and serotonin), and blood flow within the front lobes of the brain.
  • Blackouts: Blackouts, sometimes referred to as alcohol-related memory loss or "alcoholic amnesia," occur when people have no memory of what happened while intoxicated. These periods may last from a few hours to several days. During a blackout, someone may appear fine to others; however, the next day the individual cannot remember parts of the night and what they did. The cause of blackouts is not well understood but may involve the interference of short-term memory storage, deep seizures, or in some cases, depression. Blackouts are different than "passing out," which happens when people lose consciousness from drinking excessive amounts of alcohol. Losing consciousness means that the person has reached a very dangerous level of intoxication and the individual could slip into a coma and die. If someone has passed out from drinking too much alcohol and is unresponsive, call EMS immediately (911), as immediate medical attention is necessary.
  • Hangover: Hangovers are the body's reaction to poisoning and withdrawal from alcohol. Hangovers begin eight to 12 hours after the last drink and symptoms include fatigue, depression, headache, thirst, nausea, and vomiting. The severity of symptoms varies according to the individual and the quantity of alcohol consumed. The only way to prevent a hangover is to drink in moderation.
  • Drug interactions: The interaction between alcohol and many medications can lead to a significant increase in one's risk of illness, injury, or even death. When certain medications and alcohol compete in the body for absorption, the potency of the medication and/or alcohol is often increased. There is no set formula for what will happen when an individual consumes both alcohol and a medication. Each person is different and the results of this type of potentially fatal mixture vary based on the type and quantity of medication and alcohol ingested, the time frame involved, and the individual's tolerance to both the medication and to alcohol. Alcohol should never be mixed with any type of medication, whether prescription or over-the-counter, before first checking with a licensed healthcare professional. Medications that have interactions with alcohol include sedative and anti-anxiety drugs (such as zoldipem, alprazolam, or diazepam), antidepressants (such as amitriptylline and fluoxetine), and antipsychotic medications (such as quetiapine or olanzapine). Alcohol also interacts with many drugs used by diabetics (such as insulin and oral medications). It interferes with drugs that prevent seizures (such as phenytoin) or blood clotting (such as warfarin). It increases the risk for gastrointestinal bleeding in people taking aspirin or other non-steroidal inflammatory drugs (including ibuprofen and naproxen). Chronic alcohol abusers have a particularly high risk for adverse side effects from consuming alcohol while taking antibiotics. These side effects include flushing, headache, nausea, and vomiting. There are many other examples of drug interactions with medications. A healthcare professional can help with advice regarding these interactions.
  • Fetal alcohol syndrome (FAS): Prenatal exposure to alcohol can cause a range of disorders, known as fetal alcohol spectrum disorders (FASDs). One of the most severe effects of drinking during pregnancy is fetal alcohol syndrome (FAS). FAS is one of the leading known preventable causes of mental retardation and birth defects. If a woman drinks alcohol during her pregnancy, her baby can be born with FAS, a lifelong condition that causes physical and mental disabilities. FAS is characterized by abnormal facial features, growth deficiencies, and central nervous system (CNS) problems. Individuals with FAS might have problems with learning, memory, attention span, communication, vision, hearing, or a combination of these. These problems often lead to difficulties in school and problems getting along with others. FAS is a permanent condition. It affects every aspect of an individual's life and the lives of his or her family.
  • Withdrawal: Alcoholics may experience physical withdrawal symptoms if alcohol is withheld. These symptoms may include elevated blood pressure, fine hand tremors (often called "the shakes"), increased rate of respiration or breathing, elevated heart rate, anxiety and restlessness, nausea sometimes accompanied by vomiting, decreased appetite, insomnia, sweating, and confusion. In severe withdrawal, symptoms include hallucinations, seizures, and delirium tremens (DT's). DTs are visual and auditory hallucinations accompanied by seizures and profound disorientation and confusion. Anyone experiencing DT's should be medically managed by a health professional.
  • Relapse: Alcohol relapse is the return to drinking alcohol after periods of sobriety. Between 80-90% of people treated for alcoholism relapse, even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. Factors placing an individual at high risk for relapse include frustration and anger, social pressure, internal temptation, impaired sleep, and poor dietary habits.

Treatment
  • Alcoholism is generally perceived as a disease. Like other diseases, alcohol addiction can be overcome with proper treatment and prevention. Research shows that successful prevention and treatment can lead to reductions in traffic fatalities, crime, unwanted pregnancy, child abuse, and diseases such as liver disease, cancer, and heart disease. Treatment can reduce alcohol and illegal drug use, improve general health, improve job performance, reduce involvement with the criminal justice system, reduce family dysfunction, and improve the overall quality of life.
  • Nonpharmacologic (conventional) treatment methods:
  • A number of treatment options now exist for alcoholism. Inpatient care, where the individual stays night and day for a defined period of time (generally 28 days), is performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. Most residential alcoholism treatment programs in the United States include detoxification (usually taking about four to seven days), total abstinence from mind altering drugs, individual and group therapy, participation in alcoholism support groups (such as Alcoholics Anonymous or AA), educational lectures, family involvement, reading and work assignments, activity therapy, and the use of counselors and professional staff experienced in treating alcoholism. Inpatient treatment is recommended for individuals with coexisting medical or psychiatric disorders, such as depression or bipolar disorder (manic-depressive), individuals who may harm themselves or others, those who have not responded to conservative treatments, and those who have a disruptive home environment. Outpatient therapy involves the individual coming to a general or psychiatric hospital or a center dedicated to the treatment of alcohol and other substance abuse during daytime hours. The individual participates in group therapy sessions and other counseling. Results have been mixed on whether inpatient treatment works better than outpatient. Given the ambiguity in results and high expense of inpatient treatment, most care providers do not choose inpatient treatment for alcoholics who are not a threat to others or themselves.
  • Drugs for detoxification:
  • The American Society of Addiction Medicine lists three goals for alcohol detoxification, including providing a safe withdrawal from the alcohol dependence and enable the individual to become drug-free. This may include minimizing the risks of withdrawal-related seizures and delirium. Also, providing a withdrawal that is humane and thus protects the patient's dignity and preparing the patient for ongoing treatment of his or her dependence to alcohol.
  • Benzodiazepines: Benzodiazepines decrease anxiety by stimulating gamma-aminobutyric acid (GABA) receptors in the brain, providing a pharmacological (drug) substitute for alcohol. Considered the drugs of choice for alcohol withdrawal, long-acting benzodiazepines, such as chlordiazepoxide (Librium®) and diazepam (Valium®), and short-acting agents, such as lorazepam (Ativan®) and oxazepam (Serax®), are the most effective drug therapies for the treatment of acute (immediate) alcohol withdrawal. Benzodiazepines have been shown to be more effective than placebo in reducing the signs and symptoms of alcohol withdrawal in several placebo-controlled trials. The results of a meta-analysis of treatments for alcohol withdrawal indicated a statistically significant decrease of 4.9 cases of delirium for every 100 patients treated with benzodiazepines. Likewise, a significant difference in the treatment of withdrawal-related seizures was demonstrated, with a reduction of 7.7 cases per 100 patients treated. In a Canadian meta-analysis, no difference in adverse effects was shown between benzodiazepines and alternative agents.Even in elderly cognitively impaired patients, benzodiazepines are recommended. These patients may be at an even greater risk for adverse events related to ethanol withdrawal. The most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat. They are usually not recommended by healthcare professionals for long-term use in alcoholism due to the potential for abuse and addiction.
  • Anticonvulsants: Anticonvulsant agents are also used in treating alcohol withdrawal. Anticonvulsants may actually help protect the nervous system from damage due to repeated alcohol detoxification. Additionally, anticonvulsants have low abuse potential and a minimal effect on cognition (memory and learning). Anticonvulsants used in alcohol withdrawal include carbamazepine (Tegretol®), valproic acid (Depakene®, Depakote®), phenytoin (Dilantin®), and gabapentin (Neurontin®). Anticonvulsants may cause drowsiness and drug interactions, as well as potentially severe dermatological problems.
  • Others: Several medications may be used along with benzodiazepines and anticonvulsants for the treatment of alcohol detoxification. Their selection should be based on treating specific symptoms associated with the syndrome. Beta-blockers, including Clonidine (Catapres®), may be used for moderate to severe hypertension (high blood pressure). Side effects of beta-blockers include fatigue (tiredness), hypotension (low blood pressure), impotence (lack of sexual arousal or desire), and insomnia. Antipsychotics such as haloperidol (Haldol®) can be used for managing hallucinations and severe agitation. However, care must be exercised, as the drug can reduce the seizure threshold. Side effects may include sedation and blurred vision. If tremors (nerve twitches or shakes) or involuntary movements of the face/tongue/or mouth (chewing movements, puckering, or twitching tongue) occur, seek medical attention.
  • Drugs for relapse prevention:
  • Antabuse®: Antabuse® (disulfiram) prevents the elimination of acetaldehyde, a toxic chemical the body produces when breaking down ethanol. Many hangover symptoms are caused by acetaldehyde itself. When Antabuse® is taken with alcohol in the body, severe discomfort will develop including cramping, nausea, vomiting, fatigue and other flu-like symptoms. This discourages the alcoholic from drinking even small amounts of alcohol. Heavy drinking while on Antabuse® can cause severe illness and death.
  • Naltrexone: Naltrexone binds to opioid receptors, effectively blocking our ability to use endorphins and opiates. It is commonly used in opiate addiction (such as heroin) but it also appears to decrease cravings for alcohol and encourage abstinence. A number of studies have confirmed its efficacy in reducing frequency and severity of relapse to drinking. Naltrexone comes in an oral form (Revia®) and in a time-release injection (Vivitrol®) and is used for up to 12 months in alcoholism treatment. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.
  • Campral®: Acamprosate (Campral®) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The U.S. Food and Drug Administration (FDA) approved this drug in 2004. Campral® may be given alone or with medications like naltrexone for up to 12 months. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use it cautiously.
  • Vitamin injections: Vitamin B12 (cyanocobalamin) and vitamin B1 (thiamine) are commonly administered by injection in alcohol withdrawal.
  • Others: Other drugs used off-label in the treatment of alcoholism include topiramate (Topamax®, commonly used in migraine treatment) and drugs to treat psychiatric problems associated with alcoholism (such as antidepressants and anti-anxiety agents). Ondansetron (Zofran®) is a drug that is ordinarily used to prevent nausea and vomiting due to chemotherapy. It also has actions that affect serotonin in the brain, a neurotransmitter (brain chemical) that helps regulate alcohol's effects on the body.

Integrative therapies
  • Good scientific evidence:
  • Vitamin B1 (Thiamine): Thiamine is a B-vitamin that may decrease the problems associated with acute alcohol withdrawal. Patients with chronic alcoholism or experiencing alcohol withdrawal are at risk of thiamine deficiency and its associated complications. Thiamin is generally considered safe and relatively nontoxic. Avoid if allergic or hypersensitive to thiamin. Rare hypersensitivity/allergic reactions have occurred with thiamin supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Use cautiously if pregnant or breastfeeding.
  • Yoga: Preliminary research suggests that yoga may be beneficial when added to standard therapies for the treatment of alcohol abuse. Additional studies are needed before a strong recommendation can be made. Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Unclear or conflicting scientific evidence:
  • 5-HTP: Early study suggests that 5-HTP may lessen alcohol withdrawal symptoms. Further research is needed to confirm these results. Avoid 5-HTP if allergic or hypersensitive to it. Signs of allergy to 5-HTP may include rash, itching, or shortness of breath. Avoid with eosinophilia syndromes, Down's syndrome, and mitochondrial encephalomyopathy. Use cautiously if taking antidepressant medications such as TCAs, MAOIs, SSRIs, nefazodone, trazodone, venlafaxine, mirtazapine, bupropion; 5-HTP receptor agonists such as sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, imotriptan, and frovatriptan; and carbidopa, phenobarbital, pindolol, reserpine, tramadol, or zolpidem. Use cautiously with renal (kidney) insufficiency, HIV/AIDS (particularly HIV-1 infection), epilepsy, and/or with a history of mental disorders. Avoid if pregnant or breastfeeding.
  • Acupuncture: Acupuncture is commonly used to treat alcoholism and addiction, although clinical studies have reported mixed results. One study compared the readmission rates of a six-month treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients). Acupuncture clients were less likely to be readmitted for detoxification within six months.
  • Aromatherapy: Aromatherapy may be as effective as some types of acupuncture in treating alcohol withdrawal symptoms. More study is needed in this area. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Borage seed oil: Borage oil may help treat or prevent alcohol-induced hangovers, although additional study is needed in this area. Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or in those taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or in those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as GLA, present in borage oil. Avoid if breastfeeding.
  • Globe artichoke: Globe artichoke (Cynara scolymus) may help the digestive system to function better. An extract of artichoke has been used and marketed as a remedy for alcohol-induced hangover. However, there is insufficient available evidence to form a clear conclusion in this area. Artichoke extract may be taken immediately before and following consumption of alcohol. Do not use artichoke with gall bladder or liver problems, unless under the supervision of a doctor. Use cautiously if allergic/hypersensitive to members of the Asteraceae or Compositae family (e.g., chrysanthemums, daisies, marigolds, ragweed, arnica), due to possible cross-reactivity. Use cautiously with cholelithiasis or biliary/bile duct obstruction or kidney disease. Avoid if pregnant or breastfeeding.
  • Hypnotherapy: Hypnosis is associated with a deep state of relaxation. Although used by psychotherapists, there is inconclusive evidence for the use of hypnotherapy in alcohol dependence. Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Kudzu: Kudzu (Pueraria lobata) is well known in the southern United States as an invasive weed. Research indicates that extracts of kudzu may be effective in treatment of alcoholism, such as with decreasing the cravings of alcohol. Clinical studies report positive benefits when using kudzu for alcohol craving. However, more research needs to be performed. Use caution with anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, and methotrexate. Well designed studies on the long-term effects of kudzu are currently unavailable. Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Avoid if pregnant or breastfeeding.
  • L-carnitine: L-carnitine (also known as acetyl-L-carnitine) is an antioxidant and may help blood flow, as well as neurological function. Early studies suggest that acetyl-L-carnitine may be of benefit in the treatment of alcoholism. Well-designed clinical trials are required before recommendations can be made in this field. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Massage: Massage shows promise as an adjunct to traditional medical detoxification for alcohol dependence. Further research is needed to confirm these results. Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: Meditation may offer general stress-reducing effects for treating or preventing alcohol abuse. However, more studies are needed before clinical recommendations can be made for or against meditation for alcoholism treatment or prevention. Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Nopal cactus: Limited available clinical study found that nopal cactus (Opuntia ficus-indica) may prevent alcohol-induced hangover, likely due to nopal's ability to inhibit the production of inflammatory mediators. More clinical studies are needed to confirm this finding. Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of its constituents, or to members of the Cactaceae family. Use cautiously if taking medications that alter blood sugar, cholesterol, or blood pressure. Use cautiously with thyroid dysfunction and rhinitis (runny or congested nose), or asthma. Avoid with immunosuppression or impaired liver function. Avoid if pregnant or breastfeeding. The nopal plant should be handled cautiously, as it is covered in long sharp spines and shorter soft-appearing barbs of glochids, which may be painful and difficult to remove once they are imbedded in the skin. It is recommended that oral doses of dried nopal be taken with at least eight ounces (250mL) of water.
  • Prayer: Traditional forms of prayer in the treatment of addiction and alcoholism are widely used. However, initial research reports no effects of intercessory prayer on alcohol dependency or drug dependency. Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or to receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. In limited available clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.
  • Psychotherapy: Psychotherapy, or a combination of psychotherapy and prescription medication, may help alcohol abuse patients prevent relapse, overcome withdrawal symptoms, and deal with underlying problems, depression, or anxiety. Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire about the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.
  • Traditional or theoretical uses lacking sufficient evidence:
  • Milk thistle: Although not supported for use in alcoholism by clinical studies, milk thistle (Silybum marianum) is widely known as an antioxidant and detoxifying herb for the liver. Studies do support the use of milk thistle in alcoholic liver disease and cirrhosis.
  • Omega-3 fatty acids: Omega-3 fatty acids have been suggested as a possible therapy for alcoholism. Alcoholics have been reported to have decreased amounts of the omega-3 essential fatty acids, particularly DHA or docosahexaenoic acid. Omega-3 fatty acids, such as found in fish oils, may be used as a supplement to the diet.

Prevention
  • Knowing and recognizing a family history of alcoholism is an important step toward seeking treatment before alcohol use or alcohol abuse progresses to alcoholism. Early intervention is particularly important to prevent alcohol dependence in teenagers. Alcohol use among teens increases dramatically during the high-school years and leads to serious consequences for many teens. The influence of parents, peers, and role models influences younger people. The susceptibility to advertising on television or the internet may play a role in how early in life individuals begin to use alcohol, especially if genetic factors are present to predispose them to addiction.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. Alcoholics Anonymous. . Accessed February 23, 2009.
  2. American Council on Alcoholism. . Accessed February 23, 2009.
  3. American Society of Addiction Medicine. . Accessed February 23, 2009.
  4. Boerth J, Strong KM. The clinical utility of milk thistle (Silybum marianum) in cirrhosis of the liver. J Herb Pharmacother. 2002;2(2):11-7. .
  5. Centers for Disease Control and Prevention. . Accessed February 23, 2009.
  6. Cravo ML, Gloria LM, Selhub J, et al. Hyperhomocysteinemia in chronic alcoholism: relations to folic acid and vitamins B(6) and B(12) status. Nutrition. 2000;16(4):296-302. .
  7. Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006;3:CD005032. .
  8. Ferenci P, Dragosics B, Dittrich H, et al. Randomized controlled trial of silymarin treatment in patients with cirrhosis of the liver. J Hepatol. 1989;9(1):105-13. .
  9. Hoyumpa AM Jr. Mechanisms of thiamin deficiency in chronic alcoholism. Am J Clin Nutr. 1980;33(12):2750-61. .
  10. Lieber CS. Relationships between nutrition, alcohol use, and liver disease. Alcohol Res Health. 2003;27(3):220-31. .
  11. National Institute of Alcohol Abuse and Alcoholism. . Accessed February 23, 2009.
  12. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed February 23, 2009.
  13. Trumpler F, Oez S, Stahli P, et al. Acupuncture for alcohol withdrawal: a randomized controlled trial. Alcohol Alcohol. 2003;38(4):369-75. .

Alcohol and the body
  • Alcohol, or ethanol, acts as a drug affecting the central nervous system (CNS). Its behavioral effects, such as slurred speech or stumbling, are a result of its influence on the response in the nervous tissue and not on the muscles or senses themselves. Alcohol is a depressant, and depending on the dose, can be a mild tranquilizer or a general anesthetic. At very low doses, alcohol can appear to be a stimulant by suppressing certain inhibitory brain functions. However, as concentration increases, further suppression of nervous tissue functions produce the classic symptoms of intoxication, including slurred speech, unsteady gate, disturbed sensory perceptions, and inability to react quickly. At high concentrations, ethanol produces general anesthesia. A highly intoxicated person will be in a coma-like state and very difficult to wake. In extreme cases, if the alcohol concentration is high enough, it will inhibit basic involuntary bodily functions such as breathing and can cause death.
  • Alcohol is metabolized (a body process of converting ingested substances to other compounds) by the liver. Metabolism involves a number of processes, one of which is referred to as oxidation. Through oxidation in the liver, alcohol is detoxified to the chemical acetaldehyde, then to acetic acid (vinegar), and finally to carbon dioxide and water. Alcohol and toxins are removed from the blood, preventing them from accumulating and destroying cells and organs. A small amount of alcohol escapes metabolism and is excreted unchanged in the breath, in the sweat, and in urine. Until all the alcohol consumed has been metabolized, it is distributed throughout the body, affecting the brain and other tissues.
  • The liver can metabolize only a certain amount of alcohol per hour, regardless of the amount that has been consumed. The rate of alcohol metabolism depends, in part, on the amount of metabolizing enzymes in the liver, which varies among individuals. In general, after the consumption of one standard drink, the amount of alcohol in the drinker's blood peaks within 30-45 minutes. A standard drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits, all of which contain the same amount of alcohol. Alcohol is metabolized more slowly than it is absorbed. Since the metabolism of alcohol is slow, consumption needs to be controlled to prevent accumulation in the body and further intoxication.
  • Moderation: Drinking in moderation may lower the risk for coronary heart disease, including high cholesterol levels, high blood pressure, and heart attack, mainly among men over age 45 and women over age 55. However, with increased consumption of alcohol, there are increased public health dangers, such as alcoholism, hypertension (high blood pressure), obesity, stroke (neurological damage resulting from lack of oxygen to brain tissue), cardiomyopathy (inflammation of the heart muscle), a number of cancers, liver disease, accidents, suicides, and fetal alcohol syndrome. In addition, individuals with an inherited predisposition to a variety of metabolic conditions, such as hypertriglyceridemia (genetic disorder where the levels of triglycerides in the blood are abnormally high), pancreatitis (inflammation of the pancreas), and porphyria (an inherited disease that results in low heme or iron carrying particle in the blood), should not consume alcohol at all. There are other factors that reduce the risk of heart disease, including a healthy diet, physical activity, avoidance of smoking, and maintenance of a healthy weight. Moderate consumption provides little, if any, health benefit for younger people.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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