The understanding of alcoholism, and hence its definition, continues to change. Many terms, often with hazy differences in meaning, have been used to describe different stages and manifestations of the disease. In 1992 the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published a definition reflecting the current understanding of the disease: "Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic." This definition recognizes alcoholism as a disease, i.e., as an involuntary disability. It accepts a genetic vulnerability in some people and identifies the phenomenon of denial as both a psychological defense mechanism and a physiological outcome of alcohol's effect on the memory.
Although anyone can become intoxicated while drinking, the alcoholic is less likely to recognize the signs and control his or her intake. Intoxication is produced by alcohol as it circulates in the blood and acts to depress the central nervous system (see depressant). Alcohol can pass directly into the bloodstream. The absorption rate depends principally on the concentration of the drug in the stomach and small intestine. This concentration is limited by the presence of alcohol dehydrogenase. Because women normally carry less alcohol dehydrogenase in their intestines, they usually consume less alcohol than men before showing its effects.
Alcohol is not stored in the body or excreted but is metabolized in the liver at a fixed rate of between 0.25 and 0.33 oz (7.1-9.4 grams) per hour, varying with the individual. Thus alcohol is found in the bloodstream and signs of intoxication appear when the rate of alcohol consumption is greater than the rate at which it is metabolized in the liver. At a blood level of about .05%, alcohol impairs concentration, visual function, psychomotor performance, and reaction time. For many years the legal standard for drunkenness in most states was a blood alcohol level of .10%, but in many states it now is .08%. The lethal level, often given as .60%, may be as low as .40% in some people. Blood alcohol concentrations are measured by breath (the Breathalyzer test), blood, or urine tests.Effects of Chronic Use
Alcohol abuse can result in broad range of medical problems. Alcohol can reduce production of the sex hormone testosterone in males, resulting in impotence and testicular atrophy. Alcohol has a high caloric value but a low nutritional value. Its "empty calories" may allow the alcoholic to feel satisfied while actually progressing toward a state of serious malnutrition. Ailments that can result from alcohol consumption include cirrhosis, a liver ailment; diseases of the digestive system; damage to the heart; lowered resistance to infection; and cancer (larynx, esophagus, liver). Women who consume alcohol during pregnancy are at risk of delivering children with fetal alcohol syndrome, a syndrome of physical, developmental, and psychological problems.
Although the medical effects of alcoholism have long been known, the study of how alcohol acts on the brain to produce intoxication, dependence, and tolerance is still new. Most studies focus on the effect of alcohol on cellular communication. These have found that different regions of the brain differ in their sensitivity to alcohol. In addition, alcohol affects many different kinds of receptors (see nervous system) and neurotransmitters, such as GABA, glutamate, and serotonin, creating different effects in each case. Whatever the exact mechanism, it is accepted that chronic consumption of alcohol results in disconnection of the fibers that connect brain cells, producing memory lapses, impaired learning ability, motor disturbances, and general disorientation. Two organic brain disorders, alcoholic dementia, characterized by general loss of intellectual abilities, and Wernicke-Korsakoff's syndrome, characterized by such symptoms as loss of physical coordination, incoherence, and mental confusion, are frequently seen in alcoholics.Withdrawal
Alcohol, like all addictive drugs, produces physical dependence in the habitual user. A hangover, a combination of headache, nausea, fatigue, and depression, may be a mild type of withdrawal from alcohol. Sudden abstinence by the chronic alcoholic produces a severe withdrawal syndrome—including tremors, vomiting, and convulsions resembling those of epilepsy—that is more likely to cause death than withdrawal from narcotic drugs. The final and most dangerous phase in this withdrawal pattern is delirium tremens, a toxic psychosis characterized by insomnia, hallucinations, seizures, and maniacal behavior.
The treatment of alcoholism depends on how far the disease has progressed. Treatment typically begins with professional advice or self-motivation to abstain, often coupled with medical efforts to achieve sobriety. In the presence of withdrawal symptoms, antianxiety drugs such as benzodiazepines may be prescribed. A next step is often enrollment in a treatment program suitable to the severity of the disease and patient's social stability. Residential programs offer a supportive atmosphere and a structured environment in which the patient can begin to learn how to restructure his or her life and develop new habits. Many programs educate the family as well, alerting them to patterns within the family that may have enabled the patient to keep drinking. Because alcoholism is a chronic recurring and relapsing disease, treatment programs are usually followed by membership in a support group such as Alcoholics Anonymous.
Medical treatment to help ensure continued sobriety includes self-administration of drugs such as Antabuse, which produces severe discomfort if present in the system when alcohol is consumed. Naltrexone, a drug formerly used in heroin abuse, and acamprosate are also now approved for use in the treatment of alcoholism. Naltrexone minimizes both the craving for alcohol and the "high" produced by its consumption. Acamprosate reduces the craving for alcohol in people who have stopped drinking. In addition to these standard treatments, many alcoholics are aided by alternative treatments such as acupuncture and hypnosis.
Because alcohol can profoundly alter motor control and behavior (by blocking inhibitions, for example, and releasing aggressive behavior), it is one of the most dangerous drugs. A large proportion of arrests in the United States are for driving while under the influence of alcohol, and a high proportion of crimes of violence (e.g., child abuse, homicide, and suicide) are committed by people who have been drinking. In the United States, members of minority groups (with the exception of Asian Americans) are affected disproportionately by alcohol-related problems. At different stages in the course of the disease, the alcoholic may experience problems with family and friends, absenteeism and reduced productivity, accidents, violent behavior, increased tolerance and consumption, or blackouts (periods of alcohol-induced memory loss). As the disease progresses, more and more serious physical and social problems may emerge.
See P. G. Bourne and R. Fox, ed., Alcoholism (1980); E. L. Gomberg et al., ed., Alcohol: Science and Society Revisited (1982); M. Grant and B. Ritson, ed., Alcohol: The Prevention Debate (1983); M. Elkin, Families under the Influence (1984); D. Gallant, Alcoholism: A Guide to Diagnosis, Intervention, and Treatment (1987).
While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, emotional health and genetic predisposition, have been identified.
The DSM-IV (the standard for diagnosis in psychiatry and psychology) defines alcohol abuse as repeated use despite recurrent adverse consequences. It further defines alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink. (See DSM diagnosis below.)
According to the APA Dictionary of Psychology, alcoholism is the popular term for alcohol dependence. Note that there is debate whether dependence in this use is physical (characterised by withdrawal), psychological (based on reinforcement), or both.
Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The introduction of politics and religion further muddles the issue.
Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol. Misuse, problem use, abuse, and heavy use do not have standard definitions, but suggest consumption of alcohol to the point where it causes physical, social, or moral harm to the drinker. The definitions of social and moral harm are highly subjective and therefore differ from individual to individual.
Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescription medications in excess of the prescribed dosage, sometimes refers to use of a prescription drug without a prescription, and sometimes refers to use that results in long-term health problems. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion with audiences that do not necessarily share a single definition.
Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. The American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full. The fellowship known as Alcoholics Anonymous does not use the term "remission" because AA's basic text, which was first published in 1939, uses the terms "recover" and "recovered" to describe those who have stopped consuming alcohol by addressing their underlying problem. On page 64, the AA text says "Our liquor was but a symptom. So we had to get down to causes and conditions."
In the United States, use of the word "alcoholism" was largely popularized by the founding and growth of Alcoholics Anonymous in 1935. AA's basic text, known as the "Big Book," describes alcoholism as an illness that involves a physical allergy and a mental obsession.
A 1960 study by E. Morton Jellinek is considered the foundation of the modern disease theory of alcoholism. Jellinek's definition restricted the use of the word "alcoholism" to those showing a particular natural history. The modern medical definition of alcoholism has been revised numerous times since then. The American Medical Association currently uses the word alcoholism to refer to a particular chronic primary disease.
A minority opinion within the field, notably advocated by Herbert Fingarette and Stanton Peele, argue against the existence of alcoholism as a disease. Critics of the disease model tend to use the term "heavy drinking" when discussing the negative effects of alcohol consumption.
Substance use disorders are a major public health problem facing many countries. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol." In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001. The World Health Organization estimates that about 140 million people throughout the world suffer from alcohol dependence.
Within the medical and scientific communities, there is broad consensus regarding alcoholism as a disease state. For example, the American Medical Association considers alcohol a drug and states that "drug addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite often devastating consequences. It results from a complex interplay of biological vulnerability, environmental exposure, and developmental factors (e.g., stage of brain maturity)."
Current evidence indicates that in both men and women, alcoholism is 50-60% genetically determined, leaving 40-50% for environmental influences.
A 2002 study by the National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adult alcoholics and found that after one year some were no longer alcoholics, even though only 25.5% of the group received any treatment, with the breakdown as follows:
In contrast, however, the results of a long-term (60 year) follow-up of two groups of alcoholic men by George Vaillant at Harvard Medical School indicated that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence." Vaillant also noted that "return-to-controlled drinking, as reported in short-term studies, is often a mirage."
Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.
At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.
However, none of these blood tests for biological markers are as sensitive as screening questionaires.
Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.
Acute withdrawal symptoms tend to subside after 1 - 3 weeks. Less severe symptoms (e.g. insomnia and anxiety) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more. Withdrawal symptoms begin to subside as the body and central nervous system makes adaptions to reverse tolerance and restore GABA function towards normal. Other neurotransmitter systems are involved, especially glutamate and NMDA.
Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.
Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.
The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more members than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.
Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six per cent of a country's GDP. One Australian estimate pegged alcohol's social costs at 24 per cent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 per cent.
A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).
Stereotypes of drunkenness may be based on racism, as in the depiction of the Irish as heavy drinkers. In Australia, Canada, and the United States, Aboriginal people have similarly been stereotyped as alcoholics.
On the other hand, studies by social psychologists Stivers and Greeley attempt to document the perceived prevalence of high alcohol consumption amongst the Irish in America.