Alcoholism

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Definition

The essential feature of alcohol abuse is the maladaptive use of alcohol with recurrent and significant adverse consequences related to its repeated use. Alcoholism is the popular term for two disorders, alcohol abuse and alcohol dependence. The hallmarks of both these disorders involve repeated life problems that can be directly attributed to the use of alcohol. Both these disorders can have serious consequences, affecting an individual's health and personal life, as well as having an impact on society at large.

Description

The effects of alcoholism are quite far-reaching. Alcohol affects every body system, causing a wide range of health problems. Some such problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, muscle weakness (including the heart), heart rhythm disturbances, anemia, clotting disorders, decreased immunity to infections, gastrointestinal inflammation and irritation, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, and weakened bones.

On a personal level, alcoholism results in marital and other relationship difficulties, depression, unemployment, child abuse, and general family dysfunction.

Alcoholism causes or contributes to a variety of severe social problems including homelessness, murder, suicide, injury, and violent crime. Alcohol is a contributing factor in at least 50% of all deaths from motor vehicle accidents. In fact, about 100, 000 deaths occur each year due to the effects of alcohol, of which 50% are due to injuries of some sort. According to a recent special report prepared for the U.S. Congress by the National Institute on Alcohol Abuse and Alcoholism, the impact of alcohol on society, including violence, traffic accidents, lost work productivity, and premature death, costs our nation an estimated $185 billion annually. In addition, it is estimated that approximately one in four children (19 million children or 29 percent of children up to 17 years of age) is exposed at some time to familial alcohol abuse, alcohol dependence, or both. Furthermore, it has been estimated that approximately 18 percent of adults experience an episode of alcohol abuse or dependence a some time during their lives.

— Bill Asenjo, MS, CRC

Dictionary: al·co·hol·ism  (ăl'kə-hô-lĭz'əm, -hŏ-)

A disorder characterized by the excessive consumption of and dependence on alcoholic beverages, leading to physical and psychological harm and impaired social and vocational functioning. Also called alcohol abuse, alcohol dependence.

The continuous or excessive use of alcohol (ethanol) with associated pathologic results. Alcoholism is characterized by constant or periodic intoxication, although the pattern of consumption varies markedly. Individuals admitted for the first time to an alcoholism treatment center typically have been consuming approximately 3–4 oz (80–100 g) of pure alcohol per day, corresponding to about seven to nine drinks or bottles of beer or glasses of wine. Studies have shown that problem drinking in these populations starts at about 2 oz/day (60 g/day), that is, four to five drinks per day, and that these are consumed in rapid succession, leading to intoxication on three or more days per week. Individuals who consume these levels of alcohol have also a greater than average risk of developing alcoholic liver cirrhosis. However, the levels should not be taken as absolute, since they can vary greatly in different individuals, according to body weight and other factors.

The symptoms and consequences associated with severe alcohol consumption also vary greatly; that is, in some individuals only a few may be present. These may consist of the development of physical dependence manifested as a state of physical discomfort or hyperexcitability (tremors or shakes) that are reduced by continued consumption; the development of tolerance to the effects of alcohol, which leads individuals to increase their consumption; accidents while intoxicated; blackouts, characterized by loss of memory of events while intoxicated; work problems, including dismissal; loss of friends and family association; marital problems, including divorce; financial losses, including bankruptcy or continual unemployment. Medical problems can include gastric ulcers, pancreatitis, liver disease, and brain atrophy. The last is often associated with cognitive deficiencies, as shown by the inability to comprehend relatively simple instructions or to memorize a series of numbers. See also Cognition.

Almost without exception, individuals seeking an early treatment for their alcohol problems have very good probabilities of recovery. The lesser the number of presenting problems described above, the better the chances of favorable outcome, and so an early identification of problem drinking by family, friends, employers, or physicians becomes very important. The types of intervention vary greatly, progressing from self-monitoring techniques to intensive outpatient and inpatient programs to Alcoholics Anonymous groups.

The exact mechanisms of the pharmacological actions of alcohol are not known. Alcohol can act as a stimulant at lower doses and as a depressant at higher doses. Even at very low doses alcohol can impair the sensitivity to odors and taste. Also, low doses are known to alter motor coordination and time and space perception, important aspects of car driving. Some effects are already seen at levels of 0.05%. Pain sensitivity is diminished with moderate doses. In some individuals, alcohol is known to diminish feelings of self-criticism and to inhibit fear and anxiety, effects which are probably related to an alcohol-induced sociability. These effects act, no doubt, as psychological reinforcers for the use of alcoholic beverages.

It is generally accepted that alcohol affects the nerve cell by preventing the production and propagation of electric impulses along a network consisting of axons and synapses. A major finding in the mid-1980s was that some of the neurologic effects of alcohol can be quickly reversed by new experimental drugs. Studies have shown that alcohol enhances the actions of an inhibitory brain neurotransmitter referred to as gamma-aminobutyric acid (GABA). Benzodiazepines, such as diazepam, are anxiety-reducing and sedative drugs which also enhance the effects of GABA. These effects can be reduced by experimental antagonist molecules, which interact in the brain in the same regions where GABA is found. See also Synaptic transmission.

The liver is responsible for about 80% of the metabolism of alcohol. In the liver, alcohol is first oxidized to acetaldehyde and then to acetate, which is metabolized in many tissues, including the brain, heart, and muscles. A 150-lb (68-kg) person metabolizes approximately 0.4 oz (10 g) of pure alcohol per hour (about 1 oz of a distilled beverage per hour) or, if alcohol is continuously present in the bloodstream, about 8–10 oz (190–240 g) of pure alcohol per day, equivalent to 1300–1600 calories per day. Since alcoholic beverages contain negligible levels of essential nutrients, these calories are called “empty calories.” Many alcoholics show malnutrition due to the fact that an important part of their caloric intake is alcohol. Alcohol also impairs the absorption and the metabolism of some essential nutrients. In the presence of alcohol, about 80% of oxygen consumed by the liver is devoted to the metabolism of alcohol; as a consequence, other substances such as fats, normally oxidized by the liver, are not metabolized, leading to fat accumulation in the liver. See also Liver; Malnutrition.

Alcoholic liver disease is characterized by two conditions: failure of the liver to detoxify noxious substances and to produce essential products; and increased resistance to blood flow through the liver. Alcoholic liver disease and liver cirrhosis rank among the 10 leading causes of mortality in the United States and Canada. See also Cirrhosis.

There is abundant evidence that tendency to alcoholism can be of familial origin, due to environmental, cultural, and genetic factors. A Swedish study demonstrated that identical twins are twice as likely to have a common alcoholic problem as fraternal twins. In an American-Danish study, it was shown that children of alcoholic parents are more likely to develop alcoholism (18%) than children of nonalcoholic parents (4%) when both groups of children were adopted by nonrelatives within 6 weeks of birth. See also Behavior genetics; Behavioral toxicology.

Pharmacotherapy for alcohol rehabilitation has been gaining wider acceptance. Specific pharmacotherapies which have received the most research attention utilize naltrexone and disulfiram. Other promising pharmacological interventions are acamprosate and buspirone. Naltrexone is an opiate receptor antagonist which blocks the effects of endogenous opioids in the brain. Research from animal studies suggests that alcohol activates endogenous opioid systems and, thereby, may contribute to the pleasurable effects produced by alcohol consumption. Consequently, naltrexone might reduce the reinforcing effects of alcohol consumed by people and decrease their incentive to drink. Disulfiram is a drug which causes an inhibition of the enzyme aldehyde dehydrogenase, leading to an increase in acetaldehyde blood levels. This rise will produce nausea, vomiting, tachycardia, difficulty in breathing, and changes in blood pressure leading to hypotension. Acamprosate may function to reduce alcohol-induced euphoria related to the effects of excitatory neurotransmitters such as N-methyl-D-aspartate and have some blocking effects on opiate receptors. Buspirone, a nonbenzodiazepine antianxiety agent, may decrease anxiety symptoms associated with a protracted alcohol withdrawal syndrome, thus reducing alcohol relapse potential. Both of these medications require further investigation to determine their effectiveness as a pharmacotherapeutic agent in the treatment of alcoholism.

The term ‘alcoholism’ was first used by a Swedish professor of medicine, Magnus Huss (1807-90), to mean poisoning by alcohol. Huss distinguished between two types of alcoholism. Acute alcoholism was a result of the temporary effects of alcohol taken within a short period of time — drunkenness and intoxication; chronic alcoholism was a pathological condition caused by the habitual use of alcoholic beverages in poisonous amounts over a long period of time. Using case studies to illustrate the condition of chronic alcoholism, Huss provided the first systematic description of the physical damage caused by excessive drinking. This first use of the term ‘alcoholism’ in 1852 emerged from a combination of specific historical circumstances within which changes in perceptions of excessive alcohol consumption were taking place.

Prior to the nineteenth century, symptoms and problems related to ‘habitual drunkenness’, or excessive alcohol use, were known and recorded, but habitual drunkards were seen as morally weak or criminal, rather than suffering from an illness or a disease. Public concern revolved around drunkards' moral attitudes and social behaviours, which were regarded as licentious, sinful, or criminal, punishable by a period in the stocks, whipping, or fines — or by the eternal damnation preached in fiery sermons. On the whole, however, the dominant social response

to drunkenness was tolerance and social disapproval; heavy drinking was not, in itself, regarded as a problem. The emergence of a new understanding of habitual drunkenness (or inebriety) as a disease was led by medical and psychiatric practitioners at the beginning of the nineteenth century, most notably by Benjamin Rush (1745-1813) in America and Thomas Trotter (1760-1832) in Scotland. According to some historians, it was Rush who provided the first clearly developed modern conception of alcohol addiction. This included the idea of gradual and progressive addiction; bouts of drunkenness characterized by an inability to refrain from alcohol; the description of the condition as a ‘disease’; and total abstinence as the cure. For the first time, ‘treatment’ became a possible option in responding to the harm associated with habitual drunkenness. Throughout the nineteenth century efforts were made to provide more scientific descriptions of the disease and its cure, leading, in 1901, to the use of the term ‘alcohol addiction’ to describe the inability to give up harmful drinking.

Twentieth century developments

During the first half of the twentieth century interest in alcoholism and the alcoholic waned. Prohibition in America and changing social conditions and consumption patterns in Britain drew attention towards control of the substance and away from the disease and its treatment. But with the repeal of prohibition in America, any attempt to address problems associated with drinking had to be concerned with the behaviour of individuals rather than with the consumption patterns of the nation or the nature of the substance itself. In post-prohibition America and, later, in post war Britain, the freedom of the majority to drink as they pleased was paramount. The nineteenth century temperance approach, which had inveighed against the dangers of alcohol itself, was now rejected as moralistic and unscientific and the focus of attention was, once again, on the disease of alcoholism.

The ‘new’ disease approach to alcoholism started in America and was led by three linked groups, often referred to as the ‘alcoholism movement’: a research group established at the Yale Centre for Alcohol Studies; Alcoholics Anonymous (AA) (a self-help group which was set up in 1935), and the National Committee for Education on Alcoholism (later the National Council on Alcoholism), which became the leading voluntary organization offering alcoholism treatment. The ‘alcoholism movement’ quickly spread to Britain and subsequently throughout the world.

In essence there was little difference between descriptions of the disease in Rush's work and later use of the term. The main objectives in labelling it as the ‘new’ approach to alcoholism were practical and political rather than based on any ‘scientific’ discovery. On the practical side was the desire to gain a better deal for people suffering from alcoholism. Promoting the disease concept was part of a strategy to combat the stigma and prejudice that hindered alcoholics and their families from seeking help and that was a barrier to securing the interest and involvement of the helping professions. On the political side, the concept served as a device to unite diverse interests, including the alcohol industry, because the focus was on a few unfortunate individuals rather than on the drinking habits of the majority.

The strategy was successful. The disease theory was accepted by the American Medical Association in 1956 and by a number of influential doctors and voluntary groups in Britain over the course of the 1950s and 60s. In the early 1950s, the World Health Organization formally declared its support and provided a definition of ‘alcoholism’ which noted that alcoholics were excessive drinkers, dependent on alcohol to the extent that they suffered noticeable mental disturbance or interference with bodily or mental health, interpersonal relations, and economic functioning. They were people who required treatment.

As in the previous century, there was continuing interest in refining the disease concept and in producing classifications or ‘typologies of drinkers’. The most famous typology was derived from the research of E. M. Jellinek, a member of the Yale Centre for Alcohol Studies and a consultant to the WHO during the 1950s. Influenced strongly by AA philosophy, Jellinek distinguished between five different types of alcoholism. Only two types (Gamma and Delta) were diseases because, in his view, they were addictions in the pharmacological sense that physical dependence on alcohol was present and too sudden cessation of alcohol use would result in withdrawal symptoms. The defining characteristics of Gamma and Delta alcoholism were: acquired increased tissue tolerance; adaptive cell metabolism; withdrawal and craving; and loss of control (Gamma alcoholism) or an inability to abstain (Delta alcoholism). Typically, Gamma alcoholics drank mainly in bouts and were often drunk; Delta alcoholics drank regularly to achieve a blood alcohol level at which they felt comfortable, usually without getting drunk. According to Jellinek, ‘alcoholics’ were those who suffered from Gamma or Delta forms of alcoholism. Other forms of alcoholism were considered to be symptomatic, the dependence on alcohol being psychological without the presence of physiological addiction; individuals in those groups were not, therefore, alcoholics.

Alcohol dependence and related disabilities

Jellinek's classification has continued to have a significant influence over beliefs about alcoholism and about appropriate treatment approaches for alcoholics. But the ambiguities in the terms led to repeated efforts to clarify the concepts, resulting eventually in the substitution of ‘alcoholism’ with the term ‘alcohol-dependence syndrome’, approved by the World Health Assembly in 1976 and incorporated, three years later, into the International Classification of Diseases as a new medical diagnosis. One important feature of the syndrome is that it includes both psychological and physiological dependence. It has seven elements: subjective awareness of the compulsion to drink; narrowing of the drinking repertoire (drinking becomes predominantly a response to the need to avoid withdrawal so that daily intake becomes ‘scheduled’) ; primacy of drinking (drinking becomes more important than any other activity) ; altered tolerance to alcohol; repeated withdrawal symptoms; relief or avoidance of withdrawal symptoms by further drinking; reinstatement after abstinence (return to the drinking pattern established before abstinence, which can happen very quickly after starting to drink again).

At the same time as the alcohol dependence syndrome emerged as a new concept, a WHO group were formulating criteria for the identification and classification of alcohol-related disabilities. The report, published in 1977, described the range of mental, physical, and social disabilities related to alcohol use and emphasized that there were degrees of disabilities. It was not only the ‘alcoholic’ or alcohol-dependent person who was adversely affected by alcohol; damage might be incurred even if the individual was neither dependent nor an excessive drinker.

The emphasis on degrees of disability related to alcohol use rather than dependence is significant since it signalled changes in perceptions of the nature of the alcohol problem. The notion that ‘alcoholics’ suffering from a ‘disease’ were different from the remainder of the population was no longer generally accepted (although some groups still base their therapeutic approaches on disease theories). By the 1980s, many people preferred the term ‘problem drinking’, which covered a continuum of drinking harms, from relatively minor harm, such as behaving in socially embarrassing ways when drunk, missing work because of a hangover, or suffering a fall when drinking, to the severe harms associated with excessive and dependent drinking. Problem drinking was not a disease; it was a ‘learned behaviour’, and anyone who drank was at risk of becoming alcohol dependent. Concern now focused on the much greater number of people drinking above recommended levels, or in ways likely to incur harm to themselves, to other people, or to the wider community.

Today, the term ‘alcoholism’ and ‘alcoholic’ are regarded by many people as stigmatizing labels which are unhelpful in developing appropriate responses to alcohol-related harms. But their continuing use by some groups indicates the co-existence of alternative beliefs about the nature of harmful alcohol use and of different approaches to helping those who become ‘problem drinkers’ or ‘alcoholics’.

— Betsy Thom

Bibliography

• Heather, N. and Robertson, I. (1997). Problem drinking: the new approach, (3rd edn). Oxford University Press

See also addiction; disease; drug abuse.

Physiological addiction to alcohol, associated with persistent heavy consumption of alcoholic beverages. In addition to the addiction, there may be damage to the liver (cirrhosis), stomach (gastritis), and pancreas (pancreatitis), as well as behavioural changes and peripheral nerve damage.

The continued extreme dependence on excessive amounts of alcohol, accompanied by a cumulative pattern of deviant behaviors. The most frequent medical consequences of alcoholism are chronic gastritis, central nervous system depression, and cirrhosis of the liver, each of which can compromise the delivery of dental care.

Definition

Alcoholism is the layman's term for alcohol dependence and alcohol abuse. According to the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association and commonly called the DSM-IV, the essential feature of substance abuse (in this instance, alcohol abuse) is maladaptive use of the substance with recurrent and significant adverse consequences related to its repeated use. Dependence is a physical addiction with psychological, social and genetic components. Despite damage to health, finances, reputations, and relationships, the alcohol dependent person will continue to drink unless an intervention occurs. Abuse, distinguished from dependence by retaining some control over the use of alcohol, nevertheless carries many of the same consequences over time, and certainly increases risk of dependence.

Today, alcohol abuse and alcohol dependence are often associated with abuse of, or dependence on, other substances including nicotine, marijuana, cocaine, heroin, amphetamines, sedatives, and anxiolytics (antianxiety drugs). Alcoholism is more common in males than in females, with an estimated male-to-female ratio as high as five-to-one. A United States study conducted between 1990 and 1991, using DSM standards, found that 14% of the adult population (ages 15–54) had, at some time, met the criteria for alcohol dependence; and 7% had been alcohol-dependent in the past year. An earlier, similar study showed that about 5% of Americans qualified for a diagnosis of alcohol abuse at some point during their life. According to a 2002 report by the National Council on Alcoholism and Drug Dependence, 14 million Americans abuse alcohol, and 100,000 die annually of alcohol related preventable causes. Though it is difficult to develop accurate statistics worldwide, it is known that the incidence of what we call alcoholism has been steadily rising around the globe for several years.

Description

The effects of alcoholism are quite far-reaching. Alcoholism affects every body system, causing a wide range of drinking related health problems, including lower testosterone, shrinking gonads, erectile dysfunction, interference with reproductive fertility, weak bones, 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 of the entire gastrointestinal system, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, and poor nutrition.

Its mental health implications include marital and other relationship difficulties, depression, unemployment, poor performance at school or work, spouse and 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 from motor vehicle accidents. In fact, 50% of the 100,000 deaths that occur each year due to the effects of alcohol are due to injuries of some sort. Alcohol costs the United States over $150 billion yearly in lost productivity and alcohol related medical expense.

Causes & Symptoms

A physical dependence on alcohol develops insidiously, over time. The body is a magnificent adaptor; therefore, with persistent use, many adaptations occur physically and psychologically, resulting in both a higher tolerance to and increased need for alcohol—craving it—The physical adaptation to alcohol involves changing levels and altered balances of neurotransmitters, chemicals in the brain which not only affect physical abilities like muscle coordination, but also mood. The abuse of alcohol is associated with a desire to feel better and to avoid feeling poorly. Initially a stimulant, it eventually acts as a central nervous system (CNS) depressant and is used in a majority of societies or cultures in the world as an accepted part of dealing with life events, except where religious opposition bans, discourages or prohibits its use, as in most Muslim communities. It is included in celebrations and, ironically, its use is perceived as an appropriate response to sadness and loss, such as at wakes.

There is, at this point, no single known factor that causes some people to be alcohol-dependent and others not. Recent genetic studies have demonstrated that close biological relatives of an alcoholic are four times more likely to become alcoholics themselves. Furthermore, this risk holds true even for children who were adopted away from their biological families at birth and raised in non-alcoholic homes, without knowledge of their biological family's difficulties with alcohol. Male gender,

being the child of an alcoholic parent or parents, extended family history and being of Irish (Celtic), Scandinavian, German, Polish, Russian or Native American ancestry, beginning drinking as a teenager, and being depressed or highly anxious all increase the risk of experiencing problems with alcohol. Further research may determine if genetic factors are accountable, in part, for differences in alcohol metabolism and increase the risk of an individual becoming an alcoholic. Other cause related factors in alcoholism include high levels of stress and turmoil or pain, having drinking friends, drinking partners, and "enablers"—people who facilitate a drinkers habits and denial mechanisms. Heavy advertising that makes drinking appear to be "sexy" or the basis of a good time also contributes. Consider, for example, the number of televised sporting events that are sponsored heavily by alcohol related enterprises.

One of the classic symptoms of alcoholism is denial of a problem with alcohol. An addicted person, under the influence of the addictive substance, is physically and psychologically motivated to perpetuate the addiction. Therefore, intervention often starts when loved ones, recognizing the signs and symptoms, bring attention to the problem and call for help. Occasionally, an intervention requires a whole family unit and outside assistance. Signs and symptoms of alcohol dependence and abuse may include the following:

• not remembering conversations or commitments
• losing interest in activities that were once pleasurable
• ritualized drinking, before, with, and after dinner and being upset if the pattern is interrupted
• becoming irritable as "happy hour" approaches, especially if alcohol is not available
• drinking alone or secretly
• hiding alcohol in unusual places
• ordering doubles, drinking quickly, and drinking to become drunk, intentionally
• focusing attention on the source of one's next drink
• unstable relationships, financial, legal, and employment difficulties

Physical symptoms of alcoholism can be broken into two major categories: symptoms of acute alcohol use and symptoms of long-term alcohol use.

Immediate (Acute) Effects of Alcohol Use

Though the initial reaction to alcohol may be stimulatory, ultimately alcohol exerts a depressive, uninhibiting effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain alcohol level quickly becomes equivalent to the blood alcohol level. Alcohol's depressive effects result in impaired thinking, feeling and judgment, short term memory loss, muscle weakness difficulty walking, poor balance, slurring of speech, and generally poor coordination (accounting for the increased likelihood of injury and alcohol related injury statistics). At higher alcohol levels, a person's breathing and heart rate slows. Vomiting may occur, with a high risk of vomitus "aspiration" (inhaling vomit into the lungs), and may result in further complications includingpneumonia. Still higher alcohol levels may result in coma and death.

Effects of Long-Term (Chronic) Alcoholism

Alcohol is considered a lethal poison, requiring continuous detoxification by the liver. As drinking continues and overwhelms the liver's ability to detoxify, long term consequences to health occur, affecting virtually every organ system of the body.

NERVOUS SYSTEM. It is estimated that 30–40% of all men in their teens and twenties have experienced alcoholic blackout (loss of consciousness) as a result of drinking a large quantity of alcohol. In an alcoholic blackout, all memory of time and behavior surrounding the episode of drinking is lost. Alcohol causes sleep disturbances, thus affecting overall sleep quality. Numbness and tingling may occur in the arms and legs. Two conditions that may occur either together or separately are Wernicke's and Korsakoff's syndromes. Both are due to the depleted thiamin levels found in alcoholics. Wernicke's syndrome results in disordered eye movements, very poor balance, and difficulty walking, while Korsakoff's syndrome severely affects one's memory, preventing new learning from taking place.

GASTROINTESTINAL SYSTEM. Alcohol causes a loosening of the muscular ring (the cardiac sphincter) that prevents the stomach's contents from reentering the esophagus. As a result, acid from the stomach flows upward into the esophagus, burning those tissues and causing pain and bleeding, or gastro-esophageal reflux disease (GERD). Inflammation of the stomach can also result in bleeding (ulcers) and pain as well as a decreased desire to eat. A major cause of severe, uncontrollable bleeding (hemorrhage) in an alcoholic is the development in the esophagus of enlarged (dilated) blood vessels, which are called esophageal varices (varicose veins of the esophagus). These varices actually develop in response to the toxic effect of alcohol on the liver, and are extremely prone to bursting and hemorrhage.

A malnourished state arises from the loss of appetite for food—due to caloric substitution of alcohol and its effects on blood sugar levels—and interference with the absorption of nutrients throughout the intestinal tract. Inflammation of the pancreas (pancreatitis) is a serious and painful problem in alcoholics that disrupts carbohydrate and fat digestion, and increases the risk of insulin resistance, weight gain, hyperlipidemia, diabetes, and pancreatic cancer. Diarrhea is also a common symptom of chronic alcohol use, due to alcohol's effect on the pancreas.

LIVER. Because alcohol is broken down (metabolized) within the liver, that organ is severely affected by constant levels of alcohol. Alcohol interferes with the large number of important chemical processes that occur in the liver. As alcohol converts to blood sugar, which in turn converts to blood fat, the liver begins to enlarge, filling with fat, a condition called fatty liver. Cirrhosis, a potentially deadly complication, develops when fibrous tissue, while trying to support the extra burden placed on the liver by the accumulation of fat and liver cell weakness, interferes with the liver's normal structure and function. The liver may also become inflamed, a condition called hepatitis, producing jaundice, fatigue, and elevated liver enzymes indicative of liver cell death and destruction. Because of the liver's enormous role in digestion, metabolism and immunity, damage to the liver takes a serious toll throughout the body.

BLOOD. Alcohol can cause changes to any of the types of blood cells. Red blood cells become abnormally large. White blood cells (important for fighting infections) decrease in number, resulting in a weakened immune system. This places alcoholics at increased risk for infections and is thought to account in part for an alcoholic's increased risk of cancer (ten times greater than normal). Platelets and blood clotting factors are affected, causing an increased risk of bleeding and hemorrhage, especially when coupled with vascular weaknesses, varices, or aneurism.

HEART AND CIRCULATORY SYSTEM. Small amounts of alcohol cause a drop in blood pressure, but increased use begins to raise blood pressure dangerously. Increased blood pressure negatively affects the kidneys. While some studies demonstrate that one to two alcoholic drinks per night improves heart disease risk values, higher amounts and chronic intake produce high levels of circulating fats, which increases the risk of heart disease. Heavy drinking results in an enlarged heart, coronary arterial disease (CAD), peripheral vascular disease, weakening of the heart muscle, abnormal heart rhythms, a risk of blood clots forming within the chambers of the heart, and a greatly increased risk of stroke. Strokes result when a blood clot from the heart enters the circulatory system, goes to the brain, and blocks a blood vessel. Stroke may also result from a hemorrhage within the brain, as weakened vessel walls give way and platelet deficient blood pours through.

REPRODUCTIVE SYSTEM. Heavy drinking has a negative effect on fertility in both men and women, decreasing testicular and ovarian size, interfering with sperm and egg production and viability, disrupting menstrual cycles, and reducing libido. When pregnancy is achieved reduced quality of sperm and egg may significantly and permanently affect the quality of life, pre-, peri- and postnatally, of the child. A child born to an alcohol using woman has a great risk of being born with fetal alcohol syndrome, which causes distinctive cranial and facial defects, including a smaller head size, shortening of the eyelids, and a lowered IQ. Developmental disabilities, heart defects, and behavioral problems are also more likely.

Diagnosis

The DSM-IV breaks substance abuse into specific criteria that can be of aid in diagnosing a substance abuse problem. These criteria are paraphrased here to relate to alcoholism. At least one of the following must have manifested itself within a 12-month period to qualify for a diagnosis of alcohol abuse:

• Recurrent alcohol use that results in failure to fulfill major role obligations at work, school, or home. Specific examples are repeated absences from work or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; and neglect of children or household.
• Recurrent alcohol use in situations in which it is physically hazardous. Specific examples are driving an automobile and operating a machine while impaired by alcohol use.
• Recurrent alcohol-related legal problems, such as arrests for alcohol-related disorderly conduct.
• Continued alcohol use despite having persistent and recurring social or interpersonal problems caused or exacerbated by the effects of the alcohol. Examples include arguments with a spouse about the consequences of intoxication, and alcohol-related physical fights.

A diagnosis of alcohol dependence requires habitual, long-term tolerance for and heavy consumption of alcohol as well as the development of symptoms of withdrawal when the amount of alcohol in the system is substantially lowered or completely stopped. Once a pattern of compulsive alcohol use has developed, alcohol-dependent people may devote large portions of their time to the procurement and drinking of alcohol.

A significant number of illnesses categorized in DSM-IV as alcohol-induced disorders has come into being as a result of alcohol abuse and dependence, illustrating the negative impacts of alcoholism on physical and mental health. Among the psychiatric diagnoses that are included in alcohol-induced disorders are:

• dementia
• amnestic disorder
• psychotic disorder
• mood disorder
• anxiety disorder
• sexual dysfunction
• sleep disorder

As previously mentioned, due to the strong element of denial and a need, usually, for an intervention, diagnosis is often brought about because family members call an alcoholic's difficulties to the attention of a physician. A physician may become suspicious when a patient suffers repeated injuries or begins to experience medical problems that are related to the use of alcohol. In fact, some estimates suggest that about 20% of a physician's patients are alcoholics, a percentage which is higher than the general population and lower than the increased risk to health posed by alcoholism. In other words, alcohol related illness may prompt an alcoholic to see medical counsel, but their illness may not be recognized as alcohol related until the disease toll is quite advanced.

Questionnaires that try to determine what aspects of a person's life may be affected by use of alcohol can be an effective diagnostic aid. Determining the exact quantity of alcohol that a person drinks is much less important than determining how his or her drinking affects health, relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body breaks down and processes alcohol) is so individual, the quantity of alcohol consumed is not part of the criteria list for diagnosing either alcohol dependence or alcohol abuse.

One very simple tool for beginning the diagnosis of alcoholism is called the CAGE questionnaire. It consists of four questions, with the first letter of each key word spelling out 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?

Other, longer lists of questions may help determine the severity and effects of a person's alcohol use. A thorough physical examination may reveal the physical signs suggestive of alcoholism, such as an enlarged liver, a visible network of enlarged veins just under the skin around the navel (called caput medusae) (or herniated umbilicus), fluid in the abdomen (ascites), yellowish tone to the skin (jaundice), decreased testicular size or gynecomastia (breast enlargement in men), osteoporosis, physical deterioration, loss of teeth, evidence of old injuries, and poor nutritional status. Diagnostic testing may include cardiovascular, CNS, GI, general chemistry and liver function tests (LFTs) and reveal poor stress test performance, arterial disease, congestive heart failure, palsy, loss of coordination, reflux disease or history of stomach ulcer, irritable bowel syndrome, an increased red blood cell size and anemia, abnormal white blood cells (cells responsible for fighting infection) counts or characteristics, abnormal platelets (particles responsible for clotting), and increased liver enzymes. Given the genetic risk factors for alcoholism, determinations of familiar alcoholism related illness and death may be additive.

Treatment

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 (because of, or leading to, the alcoholism), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. A list from the Mayo Clinic also includes acupuncture (may reduce craving, anxiety, depression, tremor, fatigue, and the symptoms of withdrawal), biofeedback (monitoring of internal systems for stress reduction), behavioral therapy motivational enhancement therapy (problem acknowledgment), and aversion therapy (may involve simultaneous use of medications the cause nausea or vomiting with relapse.)

Nutritionally oriented practitioners may be consulted to address the malnutrition associated with long-term alcohol use. Careful and remedial attention toward a healthier diet and lifestyle, including use of nutritional supplements, such as vitamins A, B complex, and C; certain fatty acids; amino acids; zinc; magnesium; and selenium—supplements that support antioxidant, detoxifying, restorative and corrective deficiencies—may further enhance recovery and lessen the likelihood of relapse.

Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs are thought to be helpful for the patient suffering through withdrawal. Some of these include the antidepressive attributes of lavender (Lavandula officinalis), the calming and restorative nerve tonifying effects of skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), and valerian (Valeriana officinalis), the stimulating and GI helpful effects of peppermint (Mentha piperita), and the bladder aid, yarrow (Achillea millefolium).

Allopathic Treatment

Allopathic treatment of alcoholism has two parts. The first phase is the treatment of acute effects of alcoholism, called detoxification. The second phase involves learning how to live with the disease of alcoholism.

Withdrawal

Detoxification, or withdrawal, involves helping the person to rid his or her body of alcohol as well as the harmful physical effects of the alcohol. Because the person's body has become accustomed to alcohol, he or she needs care and monitoring during withdrawal. Withdrawal is an individual experience, 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 drinking (the adaptation factor). Withdrawal symptoms can range from mild to life threatening. Mild withdrawal symptoms include nausea, ache, diarrhea, difficulty sleeping, excessive sweating, anxiety, and trembling. This phase may last from three to seven days. More severe effects of withdrawal may include hallucinations (in which a patient sees, hears, or feels something that is not real), 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 or DTs) are those with other medical problems, such as malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begins about three to five days after the patient's last drink and may last a number of days. Withdrawal usually progresses from the more mild symptoms to the more severe ones.

Patients going through only mild withdrawal, monitored carefully to make sure that more severe symptoms do not develop, may not require medication, however, fluids are encouraged to facilitate detoxifying the person's system. Patients suffering more severe effects of withdrawal may need to be given sedative medications, benzodiazepines like Valium or Librium, to relieve discomfort and to avoid the potentially life threatening complications of high blood pressure, fast heart rate, and seizures. Because of the patient's nausea, fluids may need to be given intravenously (through a vein), along with some necessary sugars and salts (electrolyte pushes). It is crucial that thiamin be included in the fluids, because thiamin is usually quite low in alcoholic patients, and deficiency of thiamin is responsible for the Wernicke-Korsakoff syndrome. In-patient treatment is usually short-term (three to seven days), though longer rehabilitation programs lasting weeks or even months are sometimes needed. Any treatment is usually followed by longer-term outpatient treatment.

Recovery

After the physical problems associated with alcohol withdrawal have been treated, the more difficult task begins: helping the person to clearly recognize the nature and severity of his or her illness. This is done on both an in-patient and outpatient basis. Alcoholism is a disease of denial; as members of Alcoholics Anonymous put it, it is "the only disease that keeps telling you that you do not have a disease." Recall that often the alcoholic is made aware of his or her condition through what is called an intervention, a meeting with family and/or significant people who describe for the alcoholic the symptoms of alcoholism that they have witnessed and how these symptoms have affected them. This is important because alcoholics who are actively drinking are often not aware of what they do, nor do they remember later what they have done. (Interventions are sometimes done before the problem becomes serious enough to require detoxification from alcohol). Essential to recovery is the awareness of powerlessness over the disease, acceptance of having the disease, and abstinence from the substance that perpetuates the disease.

There is no cure for alcoholism. Sessions led by peers, such as Alcoholics Anonymous (AA) meetings, are often part of in-patient hospital treatment. AA meetings, where recovering alcoholics meet regularly and provide support for each other's recovery, are considered among the best methods of preventing a return to drinking (relapse). The AA program is a twelve-step program. Its 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, reflecting on the ways in which the use of alcohol has hurt others, and if possible, making amends to those people. The final step involves carrying the message of hope and recovery to other sick and suffering alcoholics. The Serenity Prayer becomes an ally: "God grant me the strength to accept the things I cannot change, the courage to change the things I can change, and the wisdom to know the difference."

The best programs incorporate the alcoholic's family or loved ones into the therapy, because loved ones have undoubtedly been severely affected by the drinking. Many therapists believe that families, in an effort to deal with the alcoholic's drinking problem, develop patterns of behavior that unwittingly support or "enable" the patient's drinking. This situation is referred to as co-dependency. The twelve-step programs of Al Anon and Adult Children of Alcoholics are often very successful in helping the families or loved ones of alcoholics.

There are also medications that may help an alcoholic avoid returning to drinking. These have been used with variable success. Disulfiram (Antabuse) is a drug which, when mixed with alcohol, causes a very unpleasant reaction that includes nausea and vomiting, diarrhea, and trembling. Naltrexone (a drug that blocks a narcotic high and may reduce the urge to drink) and acamprosate seem to be helpful in limiting the effects of a relapse. Naltrexone, found to produce liver damaging side effects, may be a difficultly exercised option. None of these medications has been found to be helpful unless the patient is also willing to work very hard to change his or her behavior.

Expected Results

As noted earlier, there is no cure for alcoholism. Recovery from alcoholism is a lifelong process. In fact, people who have suffered from alcoholism are encouraged to refer to themselves ever after as a recovering alcoholic, never a recovered alcoholic. Alcoholism can only be arrested—by abstaining from the drug, alcohol. The potential for relapse (returning to illness) is always there, and it 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 successfully stop drinking for at least a year, and many for a lifetime.

Prevention

Prevention is primarily related to education and early intervention. In a culture where alcohol is so ingrained, education about the dangers of this drug is vitally important, even as early as early childhood. Since alcohol is the easiest and cheapest drug to obtain and the one most commonly used by teens, the first instance of intoxication (drunkenness) with alcohol usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholism be made aware of this danger. Those at high risk include those with a family history of alcoholism, an early or frequent use of alcohol, a tendency to drink to drunkenness, alcohol use that interferes with schoolwork, a poor family environment, or a history of domestic violence. Peers are often the best people to provide this education, and groups such as SADD (Students Against Drunk Driving, a Marlborough, Massachusetts-based organization), appear very effective. Courts and schools sometimes provide education through local substance abuse programs, as well. Setting a good example, developing and practicing communication skills with your children, and frank discussions about the consequences of drinking, are all encouraged to prevent alcoholism related problems. Developing alternative coping skills to life's problems is also essential, as is encouraging a more distant perspective on the pervasive advertising that deceptively promotes alcohol's health reducing glamour.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

Diamond, Ivan. "Alcoholism and Alcohol Abuse." Cecil Textbook of Medicine, edited by J. Claude Bennett and Fred Plum. Philadelphia: W.B. Saunders, 1996.

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.

Periodicals

Aesoph, Lauri M. "Kick the Habit—Naturally: Quit Drinking or Smoking With Herbs, Acupuncture, and the Right Diet." Vegetarian Times (March 1996): 100+.

Bullock, M. L., P. D. Culliton, and R. T. Oleander. "Controlled Trial of Acupuncture for Severe Recidivist Alcoholism." Lancet (June 1989): 1435–1439.

Dorsman, Jerry. "Improving Alcoholism Treatment: an Overview." Behavioral Health Management (January-February 1996): 26+.

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+.

"Spotting a Drinking Problem." Consumer Reports on Health (September 1997): 106+.

Organizations

Al-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown Station, New York, NY 10018-0862. (800) 356-9996. http://www.recovery.org/aa.

National Alliance on Alcoholism and Drug Dependence, Inc. 12 West 21st St., New York, NY 10010. (212) 206-6770.

National Clearinghouse for Alcohol and Drug Information. .

Other

Alcohol Abuse and Alcoholism. MedicineNet, Inc. 1996-2004. [cited May 28, 2004]. .

Alcoholism. Mayo Foundation for Medical Education and Research. 1998-2004. Updated, July 3, 2002. [cited May 28, 2004]. .

FAQs on Alcohol Abuse and Alcoholism. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Updated, March 2003. [cited May 28, 2004]. .

[Article by: Katherine E. Nelson, N.D.]

Definition

Alcoholism, or alcohol dependence, is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress."

That maladaptive pattern is manifested, according to the DSM-IV, by the following behaviors occurring any time within one 12-month period:

• tolerance for alcohol
• withdrawal from alcohol
• alcohol taken in larger amounts and over a longer period of time than was intended
• persistent desire or unsuccessful efforts to cut down or control alcohol use
• much time spent in activities necessary to obtaining alcohol
• various important activities, for example, in socializing or at work, are given up or reduced because of alcohol use
• alcohol use continued regardless of the pattern of physical or psychological problems that it causes or worsens

Alcohol abuse has the same definition but is manifested by one (or more) of the following behaviors occurring within the same 12-month period:

• repeated alcohol use leading to failure to fulfill major role obligations at work, school, or home
• repeated alcohol use in situations in which it is physically hazardous
• repeated alcohol-related legal problems
• persistent alcohol use despite its causing social and interpersonal problems or exacerbating them

This definition and the criteria established by DSMIV apply to both adults and children. The American Academy of Pediatrics (AAP) states that the pattern of use and abuse of alcohol in children and adolescents is not observably different from what is manifested in young people using marijuana or cocaine.

Description

The AAP divides the progression into childhood alcoholism into three stages:

• Stage 1: Experimentation with alcohol. Normally there is no change noted in physical status or behavior, and the drinking usually occurs only on weekends during social occasions with peers, making it the least detectable of the three. Peer pressure to use alcohol "just for fun."
• Stage 2: Actively trying to obtain alcohol. Alcohol use happens during the week to provide relief when stress is felt or to "feel good" when depressed.
• Stage 3: Preoccupation with alcohol. The child or adolescent has nearly lost the capacity for controlling alcohol use. Setting limits results in withdrawal symptoms, including depression, moodiness, or irritability. Severe withdrawal can result in serious medical problems, including delirium tremens.

Demographics

Prevalence and Severity of the Problem

Based on findings mostly coming from the 1990s, the National Council on Alcohol and Drug Dependence (NCAAD) cites the following in its fact sheet Youth, Alcohol and Other Drugs:

• Approximately 10.4 million Americans ages 12 to 20 have at least one drink per month. One fifth of these (2.1 million) are heavy drinkers who have five or more drinks on a minimum of five different occasions. More than half of these (6.8 million) are considered binge drinkers who have five or more drinks on a single occasion.
• Eighty percent of all high school seniors have tried alcohol.
• Eight percent of eighth graders, 24 percent of tenth graders, and 32 percent of high school seniors have been intoxicated from alcohol in the past month.
• Children who begin smoking tobacco before the age of 13 are significantly more at risk for alcohol problems.
• Among high school seniors, alcohol use is more prevalent among Caucasian and Hispanic students than among African American students.
• Junior, middle, and senior high school students consume 35 percent of all wine coolers sold in the United States as well as 1.1 billion cans of beer.
• A Southern Illinois University study showed that students with overall grades of D or F drank on average three times as much alcohol as students with overall grades of A.
• A United States Department of Justice survey showed that nearly one third of children below the age of 18 incarcerated in juvenile institutions are under the influence of alcohol at the time of their arrest.
• More than half (56%) of children and teens in grades five through 12 report that alcohol advertising encourages them to drink.
• Thirty percent of children in grades four through six state that they have received pressure from peers to drink beer.
• Two thirds of teenagers who drink report that they are able to make their own alcohol purchases.
• The total cost of alcohol use by young people, including automobile crashes, violent crime, alcohol poisoning, burns, drowning, suicide attempts, and fetal alcohol syndrome is more than 58 billion dollars each year.
• Eighty percent of teenagers do not know that a 12-ounce can of beer has the same amount of alcohol as a shot of whiskey or a five-ounce glass of wine.

Causes and Symptoms

In their article "Early Identification and Intervention for Adolescent Alcohol Use," Mark Werner and Hoover Adjer Jr., both fellows at the American Academy of Pediatrics (AAP), state that attitudes regarding alcohol use are developed quite early in life, usually by the age of eight. Parental attitudes regarding alcohol and behaviors related to alcohol use have a major impact on how children and young adults view drinking alcohol. Not every child or teen who experiments with alcohol becomes an alcoholic, but NCADD studies have shown that children who drink before the age of 15 are four times more likely to become alcoholic than those who begin drinking after the age of 21. Some evidence supports a genetic component to this disease. Parents who are themselves alcoholic or problem drinkers are more likely to have children who develop alcohol dependence. Statistically, one in five children who have an alcoholic parent becomes an alcoholic, too.

Physical symptoms seen in adult alcoholics, such as gastritis, pancreatitis, hepatitis, or even cirrhosis, usually are absent in childhood alcoholics. Such physical damage normally takes longer to develop and is more typical of long-term adult alcoholics. More often in potential childhood alcoholics, behavioral symptoms provide the most significant clues.

These behavioral warning signs, according to the AAP, typically include the following:

• decline in school functioning, decreased attendance, poorer grades, and/or general deterioration in social functioning in school
• increased isolation outside school; rejection of usual long-term friendships in favor of new or different friends
• frequent arguments or less communication with family members; being more secretive
• marked changes in grooming and clothing styles
• noticeable increase in unexplained injuries and fights
• running away from home
• depressive symptoms such as weight loss, sleep problems, lethargy, feelings of hopelessness, mood swings, suicidal feelings, or suicide attempts
• evidence of the presence of risk-taking behaviors such as either driving while under the influence of alcohol or driving with others who are intoxicated, engaging in violent behaviors such as fights, or participating in unsafe sex

When to Call the Doctor

It is worth noting that these behavioral warning flags can appear in non-alcoholic children or teens and also are usually not observed before the second or third stage of childhood alcoholism. Parents observing some or all of these warning signs need professional help to both clarify diagnosis and plan treatment. Individual and family denial is considered a large portion of any alcohol problem. Parents need objectivity and open and honest communication with their children in order to deal effectively with childhood alcoholism and to know when to seek help.

Diagnosis

As noted, behavioral symptoms help to determine the diagnosis, but not usually until the second and third stage of the disease. There are assessments available that can provide both earlier identification and intervention for childhood alcoholism.

Diagnostic assessments for alcoholism, according to the APA, include:

• CAGE, a mnemonic that points to four key questions by highlighting key words: "Cut down," "Annoyed," "Guilty," and "Early" (see below)
• Alcohol Use Disorders Inventory Test (AUDIT)
• Personal Experience Screening Questionnaire (PESQ)
• Problem Oriented Screening Instrument for Teenagers (POSIT)

CAGE is an assessment guide containing the following four questions:

• C: Have you ever felt the need to cut down on your drinking?
• A: Do you get annoyed at criticism by others about your drinking?
• G: Have you ever felt guilty about your drinking or something you have done while drinking?
• E: Have you ever felt the need for a drink early in the morning?

Treatment

Once assessment has led to a diagnosed problem with alcohol, its severity determines the treatment needed. In "Early Identification and Intervention for Adolescent Alcohol Use," Werner and Adjer divide problem teen drinkers into three groups:

• The first category includes those teens who are using alcohol occasionally but still doing well emotionally and developmentally and who are not drinking and driving. The treatment objectives for this group are to encourage abstinence and re-enforce safety by fostering the continuation of not driving while drinking and not driving with others who are drinking.
• The second category includes those teens who are more at-risk because while they are maintaining stability in physical, developmental, and emotional status, they are also drinking and driving. Professionals dealing with members of this group may not be able to maintain confidentiality, and people in this group may benefit from an introduction to organizations such as Students Against Drunk Driving (SADD).
• The third category includes those showing serious signs of impairment, including inability to follow through on obligations at school or on a job, alcohol-related encounters with police or the justice system, and mental health problems such as anxiety, depression, or oppositional-defiant behavior. These children may experience frequent acute intoxication or withdrawal symptoms, medical complications, or an inability to stop or reduce their alcohol intake. Werner and Adjer suggest that professionals dealing with members of this group probably need to set aside confidentiality in order to involve parents in the treatment process. Treatment may include detoxification in an in-patient facility and/or rehabilitation in a youth-centered substance abuse program.

Treatment Options

The following key issues should be considered in determining which treatment option is appropriate:

• severity of the problem and evidence to suggest other mental health problems (e.g. depression, suicide attempts)
• staff credentials of those treating the child or teen, and what forms of therapy (e.g., family, group, medications) are to be used
• nature of family involvement
• how education is to be continued during treatment
• if an in-patient program is necessary, what length it should be
• what aftercare is to be provided following discharge
• what portion of treatment is to be covered by health insurance and what needs to be paid out of pocket

Alcoholics Anonymous

Since its inception in the 1930s, Alcoholics Anonymous (AA) has been an important non-medical means of treating alcoholism with millions of members worldwide, many of whom are teenagers. It is a spiritual but non-religious program that fosters abstinence from alcohol based upon a belief that the person suffering from alcoholism is "powerless" over their addiction. AA suggests that people can stay free of alcohol by using an attitude that focuses on "one day at a time" and that consciously seeks spiritual support from "a power greater than themselves." AA is generally a part of most in-patient treatment and rehabilitation programs.

Prognosis

Prevention provides the best possible prognosis for alcohol abuse and dependence. The National Council on Alcoholism and Drug Dependence estimates that parents who talk with their children regularly about the danger from drugs (including alcohol) have children who are 42 percent less likely to use these substances. Once alcoholism is present, abstinence is the only known completely successful treatment. Children suffering from alcohol dependence continue for the rest of their lives to be at risk for problems with alcohol if they again drink. The prognosis is excellent for young alcoholics who remain alcohol-free and who do not substitute other drugs for alcohol, sometimes called "chewing their booze" in AA.

Prevention

Alcohol use and abuse has been a feature of Western culture for centuries, a facet of American life since Europeans arrived in North America, literally arriving with the pilgrims on the Mayflower. It is typically part of U.S. celebrations and even some American-observed religious rites. Because alcohol overuse and abuse has been so much a part of Western experience, there is clearly a tremendous need–among children and adults—for better education about both alcohol consumption and alcoholism. The statistics indicate that parents, teachers, and healthcare professionals need to begin educating children as early as possible regarding the risks involved in alcohol use. Parents who provide the example of limiting their own alcohol and other drug use can help their children inestimably. It should never be inferred that difficult situations can be better coped with by having a drink or that getting drunk is either helpful or amusing. Moreover, parents and other adults need to set the example by not driving a car or operating machinery while they are drinking or under the influence of alcohol.

The APA suggests the following as the most effective ways that parents can aid their children in resisting drinking:

• Provide children with self-confidence by building self-esteem and not engaging in constant criticism. Good self-esteem is the best defense against peer pressure to drink.
• Listen to children. Parents who listen attentively and provide support during difficult times give their children invaluable aid in coping with pressures.
• Get to know the children's friends.
• Provide supervision and discourage teens from attending parties where alcohol is served or parents are absent, and band together with other parents to arrange alcohol-free social events for children.
• Be available and encourage children and teens to call home for a ride rather than drive with someone who has been drinking; assure children there will be no recrimination, as SADD recommends.
• Teach therapeutic coping mechanisms by modeling how to handle stress, pain, or tension in healthy ways, by exercising, using yoga and meditation, and talking about feelings.
• Understand the tremendous importance of child and adolescent issues, including alcohol and other drug use and acceptance by peers; be ready and able to discuss these subjects with children.
• Encourage and participate in enjoyable, worthwhile activities with children; be reassuring that there is time enough for both work and fun.
• Be willing to learn about alcohol abuse; attend, along with their children, programs offered by schools, churches, and other groups providing information about the prevention of alcohol abuse.
• Maintain healthy lines of communication with children; remember the saying, "You are only as sick as the secrets you keep."

Nutritional Concerns

Most childhood alcoholics do not reach the serious state of malnutrition that chronic adult alcoholics can reach. However, severe cases of alcohol abuse and dependence may result in a child or teen not eating normally, resulting in weight loss and vitamin deficiencies (B-vitamins particularly). Resumption of normal eating habits and possible addition of vitamin supplements can help in regaining normal nutrition.

Parental Concerns

Parents of alcoholic children often encounter persistent and highly traumatic worries regarding serious physical, emotional, social, and legal problems for the affected child as well as the terrifying possibility of that child's death or serious injury. Clearly, these concerns can take a huge toll in a family. The denial mentioned earlier is often a complicating factor. The notion of "Not my son or daughter!" can actually hinder treatment and recovery for a child. Parents are also often embarrassed by their child's alcohol abuse and may believe that it is somehow their fault. It is not uncommon for parents to feel isolated and to feel as if they are the only ones with this problem. High school programs such as the earlier-described SADD can address some of the fear regarding drunk driving. Parental support groups such as Tough Love programs and twelve-step groups such as Al Anon can help parents to better understand the problem they facing and can help make them aware that they not alone and that they have options.

Al Anon is a twelve-step program (that is, a program based on the twelve steps employed by Alcoholics Anonymous) that provides support and spiritual recovery for the families and loved ones of alcoholics. This program was begun in the early 1940s by the wives of some of AA's earliest members and founders, including Lois Wilson, wife of AA founder Bill Wilson. Twelve-step programs have spun off over the years to meet the needs of specific populations, including adult children of alcoholics and teens who are alcoholics.

Because parents of alcoholic children often believe they are responsible for their child's drinking, the Three C's that Al Anon offers its participants may be particularly helpful. These Three C's state:

• "I didn't cause anyone else's alcoholism."
• "I can't control anyone else's alcoholism."
• "I can't cure anyone else's alcoholism."

Tough Love, a program begun by Phyllis and David York, co-authors of a book by the same title, is designed to help families and especially parents cope with a variety of problems, including alcoholism and drug abuse, that often affect children and ultimately the whole family. Tough Love's approach is different from that of Al Anon. The ten beliefs listed below form the basis for this program and show clearly the difference in philosophy:

• Parents are people too.
• Parents' material and emotional resources are limited.
• Parents and kids are not equal.
• Blaming keeps people helpless.
• Kids' behavior affects parents. Parents' behavior affects kids.
• Taking a stand precipitates a crisis.
• From a controlled crisis comes the possibility of positive change.
• Families need to give and get support in their own community in order to change.
• The essence of family life is cooperation, not togetherness.

Al Anon and Tough Love are offered in a variety of formats to the families of alcoholic children through treatment centers, churches, and other community services. It is clear that there are dramatic differences between these two philosophies. But perhaps the best way for parents to decide which approach makes sense to them is to take the advice Al Anon offers all newcomers: "Take what you like and leave the rest."

Resources

Books

Egendorf, Laura K. Teen Alcoholism. Farmington Hills, MI: Gale, 2001.

Greenleaf, Victoria C. G. Fighting the Good Fight: One Family's Struggle against Adolescent Alcoholism. Fort Bragg, CA: Cypress House, 2002.

Shannon, Joyce Brennflech. Alcohol Information for Teens: Health Tips about Alcohol and Alcoholics. Detroit, MI: Omnigraphics, 2004.

Organizations

Alcoholics Anonymous. (See white pages of local telephone book for area groups.) Web site: www.alcoholicsanonymous.org.

National Council on Alcoholism and Drug Dependence. 20 Exchange Place, Suite 2902, New York, NY 10005. Web site: www.ncadd.org.

National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Health, Willco Building, 6000 Executive Blvd., Bethesda, MD 20892–7003. Web site: www.niaaa.nih.gov.

Students Against Drunk Driving (SADD). Marlborough, MA. 01752. Web site: www.saddonline.com.

Web Sites

Al-Anon and Alateen. Available online at www.al-anon.alateen.org (accessed October 16, 2004).

Alcoholics Anonymous. Available online at www.alcoholicsanonymous.org (accessed October 16, 2004).

"Alcohol Use and Abuse: A Pediatric Concern." American Academy of Pediatrics, Committee on Substance Abuse. Available online at (accessed October 16, 2004).

Werner, Mark J., and Hoover Adjer. "Early Identification and Intervention for Adolescent Alcohol Use." American Academy of Pediatrics. Available online at www.aap.org/advocacy/chm98ado.htm (accessed October 16, 2004).

"Youth, Alcohol, and Other Drugs: An Overview." National Council on Alcoholism and Drug Dependence. Available online at www.ncadd.org/facts/youthalc.html (accessed October 16, 2004).

[Article by: Joan Schonbeck, R.N.]

For more information on alcoholism, visit Britannica.com.

The term "alcoholism" is a noun and concept suggesting both a destructively and chronically excessive beverage alcohol consumption and a medical-style conception of the source, character, explanation, and social and medical handling of the purported condition. The word's introduction is often attributed to Swedish physician Magnus Huss in 1849. The sam