Alcoholism

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The term “alcoholism” was first used in 1849 by the physician Magnus Huss to describe the systematic adverse effects of alcohol. ^[1]

In the United States, use of the word “alcoholism” was largely popularized by the inception and growth of Alcoholics Anonymous in 1939. Although lacking a specific definition for alcoholism, AA’s “Big Book” compares alcoholism to an allergy and an illness.^[2]

A 1960 study by E. Morton Jellinek is considered the foundation of the modern disease theory of alcoholism.^[3] 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 within the medical field, notably Herbert Fingarette and Stanton Peele, argue against the existence of this disease. However, critics of the disease model acknowledge that the word “alcoholism” refers to a disease, and use the term “heavy drinking” when discussing the negative effects of alcohol consumption.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Alcoholism must be differentiated from other diseases such antisocial personality disorder, conduct disorder in childhood, and nonpathological use of alcohol.^[1]

Alcoholism must be differentiated from other diseases that cause personality changes, altered level of consciousness and hand tremors (asterixis). The differentials include the following:^{[2][3][4][5][6][7][8][9][10][11][12]}

• Other medical conditions

• Cerebellar ataxia
• Diabetic acidosis
• Multiple sclerosis

• Sedative, hypnotic, or anxiolytic intoxication

• Antihistamines
• Anticholinergic drugs^[1]

• Adult antisocial personality disorder
• Conduct disorder in childhood
• Nonpathological use of alcohol
• Sedative, hypnotic, or anxiolytic use disorder^[1]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Delband Yekta Moazami, M.D.[2]

The consumption of alcohol is a significant determinant of public health outcomes. According to global statistics from 2016, alcohol is the seventh leading cause of disability-adjusted life years, a rise of more than 25% from 1990 to 2016. The epidemiology of the alcoholic liver disease, as well as geographic differences in intake and public policy, is a hot topic of research. There tends to be a reduction in disease burden in countries where per capita alcohol intake decreases. Given the negative health effects of alcohol, more emphasis on alcohol control policies is needed.

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.”^[1] In the United Kingdom, the number of ‘dependent drinkers’ was calculated as over 2.8 million in 2001.^[2] The World Health Organization estimates that about 140 million people throughout the world suffer from alcohol dependence.^[3][4]According to global statistics from 2016, alcohol is the seventh leading cause of disability-adjusted life years, a rise of more than 25% from 1990 to 2016. The epidemiology of the alcoholic liver disease, as well as geographic differences in intake and public policy, is a hot topic of research. There tends to be a reduction in disease burden in countries where per capita alcohol intake decreases. Alcohol consumption is usually measured per capita, or the amount of alcohol consumed in liters per person, for epidemiologic purposes.^[5]

Within the medical community, there is a broad consensus regarding alcoholism as a disease state. Outside the medical community, there is considerable debate regarding the Disease Theory of Alcoholism. Proponents argue that any structural or functional disorder having a predictable course, or progression, should be classified as a disease. Opponents cite the inability to pin down the behavioral issues to a physical cause as a reason for avoiding classification.

The 12-month prevalence of alcohol use disorder is:

• 4,600 per 100,000 (4.6%) in ages 12-17 years
• 8,500 per 100,000 (8.5%) in age group of 18
• 12,400 per 100,000 (12.4%) in adult men
• 4,900 per 100,000 (4.9%) in adult women^[6]

About 18% of American adults have had an alcohol abuse problem at some time in their life, in addition to about 12% who have also had an alcohol dependence problem. Significant correlations exist between alcohol abuse and other substance abuse disorders. A 2002 study by the National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adult alcoholics and found the^[7] following after one year:

• 25% still dependent
• 27.3% in partial remission (some symptoms persist)
• 11.8% asymptomatic drinkers (consumption increases chances of relapse)
• 35.9% fully recovered — made up of 17.7% low-risk drinkers plus 18.2% abstainers.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Risk factors for alcohol use disorder include cultural attitudes, genetic predisposition, and peer substance use.^[1]

• Heavy drinking environment
• Impulsivity
• Personality characteristics^[1]
• Availability of alcohol
• Cultural attitudes
• Genetic predisposition
• Personal experiences with alcohol
• Peer substance use
• Positive expectations of the effect of alcohol^[1]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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

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

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

• The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor’s office.

Two “yes” responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. 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?^[1][2]

The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.

• The Alcohol Dependence Data Questionnaire is a more sensitive diagnostic test than the CAGE test.^[3] It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.

• The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses,^[4] driving under the influence being the most common.

• The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally.^[5] Like the CAGE questionnaire, it uses a simple set of questions – a high score earning a deeper investigation.

• The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.^[6]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging. The secondary damage caused by an inability to control one’s drinking manifests in many ways.

It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption may include cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources.

The social problems arising from alcoholism can be significant. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic’s behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic’s children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

Alcohol withdrawal differs significantly from most other drugs because it can be directly fatal. While it is possible for heroin addicts, for instance, to die from other health problems made worse by the strain of withdrawal, an otherwise healthy alcoholic can die from the direct effects of withdrawal if it is not properly managed. Heavy consumption of alcohol reduces the production of GABA, which is a neuroinhibitor. An abrupt stop of alcohol consumption can induce a condition where neither alcohol nor GABA exists in the system in adequate quantities, causing uncontrolled firing of the synapses. This manifests as hallucinations, shakes, convulsions, seizures, and possible heart failure, all of which are collectively referred to as delirium tremens. All of these withdrawal issues can be safely controlled with a medically supervised detoxification program.

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