Alcoholism

I

Introduction

Alcoholism, chronic and usually progressive illness involving ingesting inappropriately high levels of ethyl alcohol, whether in the form of familiar alcoholic beverages or as a constituent of other substances. Alcoholics will drink to such an extent that that they exhibit an emotional and often physical dependence on alcohol classified by the World Health Organization (WHO) in 1977 as “alcohol dependence syndrome”. This term continues to be included in the International Classification of Diseases (10th revision). The transition between continued excessive alcohol consumption and alcoholism is an individual behaviour and the condition of degrees rather than absolutes: low risk or sensible; increasing risk or hazardous; high risk or harmful. It is thought to arise from a combination of a wide range of physiological, psychological, social, and genetic factors. Alcoholism frequently leads to brain damage or early death.

More men than women are directly affected by alcoholism. The heaviest drinkers have traditionally been men in their late teens or early twenties, but drinking among the young generally and among women is increasing. Peer pressure is likely to play an important role in encouraging the young to start drinking. In the developed world, male and female drinking patterns are converging. “Binge drinking” (heavy episodic drinking) among young women is a particular cause for concern. For various physiological reasons, besides smaller body-size, women are less able to tolerate alcohol. Consumption of alcohol is apparently on the rise in the United Kingdom and the United States, as is the total alcohol consumption and prevalence of alcohol-related problems in the former communist countries of Eastern Europe and the former Soviet Union (where alcohol is often produced at home). It is estimated that alcohol-use disorders reached 10 per cent of the adult male population in North America and Eastern Europe in 2000. This increase is paralleled in other countries, including developing nations, where home production is also common and therefore consumption is much more difficult to control through legislation.

The WHO calculates that alcohol-related problems account for about 4 per cent of the global disease and injury burden. For comparison, tobacco use accounts for 4.1 per cent and high blood pressure 4.4 per cent. In the developed world, 9.2 per cent of disability-adjusted life years (DALYs) lost are due to alcohol. In the developing world, the figure is 6.2 per cent, but as a contribution to disease, injury, disability, and premature death, it is the single greatest risk factor.

An excessive alcohol intake is frequently associated with other high-risk behaviours, for example, unsafe sex and the use of other psychoactive drugs. This pattern leads to co-morbidity with the ill health caused by other forms of drug dependence, sexually transmitted diseases, and, for women, unplanned pregnancy.

In addition to the self-inflicted harm caused by alcoholism, an alcoholic presents a danger to those living in close contact. Rates of domestic violence are higher where there is an alcoholic in the family, and the general standard of living is frequently compromised. The social costs of heavy drinking also include death and injury caused by drink driving and the added burden on healthcare providers of dealing with accidents and intentional harm.

The WHO estimated that in 2000, 1.8 million deaths (3.2 per cent) were due to the use of alcohol. In studies in the United Kingdom, United States, and Sweden it is estimated that the mortality rate among excessive drinkers is twice that otherwise expected. Among women aged between 15 and 39 years it may be as high as 17 times greater.

II

Development

Until the 1960s, when a medical model of alcohol was strongly advocated and entered the mainstream, a moral view of excessive alcohol use predominated. This sought to punish rather than help the victim. While attitudes have changed considerably, “blaming the victim” is still part of society’s purview of alcoholics and can affect legislation to control alcohol availability, for instance those who drink and drive, and cause harm, are frequently demonized in the media for their alcohol intake.

Among medical personnel, alcoholism, as opposed to merely excessive or irresponsible drinking, has been thought of as a symptom of psychological or social stress, or as a learned, maladaptive, coping behaviour. More recently, and probably more accurately, it has come to be viewed as a complex disease in its own right with a neurological model for alcohol reward, tolerance, and dependence. While the medicalization of alcoholism undoubtedly offers a more humane and effective treatment policy than the moral view, it does mean that only certain people are perceived to constitute the “at risk” group. In fact, anyone who drinks excessively over a long period of time has the potential to cross the boundary between this stage of drinking and alcoholism, where removing access to alcohol would result in alcohol dependence syndrome.

A family history of alcoholism is one of the strongest predictors of risk. Heritability is estimated at between 45 and 65 per cent. It is thought that the genetic basis for alcoholism may include congenital abnormalities in the brain’s neurotransmitter systems involving dopamine, opioid, and serotonin.

Alcoholism usually develops over a period of years. Early and subtle symptoms include placing excessive importance on the availability of alcohol. Ensuring this availability strongly influences the person's choice of associates or activities. Alcohol comes to be used more as a mood-changing drug than as a foodstuff or beverage served as a part of social custom or religious ritual.

Initially, the alcoholic may demonstrate a high tolerance to alcohol, consuming more and showing fewer adverse effects than others. Subsequently, however, the person begins to drink against his or her own best interests, as alcohol comes to assume more importance than personal relationships, work, reputation, or even physical health. The person commonly loses control over drinking and is increasingly unable to predict how much alcohol will be consumed on a given occasion or, if the person is currently abstaining, when the drinking will resume again. Physical addiction to the drug may occur, sometimes eventually leading to drinking around the clock to avoid withdrawal symptoms.

III

Effects

Alcohol has direct toxic as well as sedative effects on the body, and failure to take care of nutritional and other physical needs during prolonged periods of excessive drinking may further complicate matters. Alcoholics frequently suffer from protein deficiency and lack of B vitamins. Advanced cases often require hospitalization for alcohol-related disabilities, and specialist psychiatric units may be necessary to deal with the withdrawal symptoms associated with the most severe aspects of alcohol dependence syndrome.

Excessive alcohol consumption compromises virtually all the major organ systems of the body and the effects are cumulative. Among the primary causes of excess mortality resulting from alcohol abuse are liver disease, severe respiratory infections, cancer (most commonly of the digestive system and upper respiratory system), cardiovascular disease, suicide, and the effects of violence and accidents.

A

Liver

The liver is the body’s primary site of alcohol metabolism and is supplied directly with blood from the intestines via the portal vein, which in heavy drinkers will contain large amounts of alcohol. The liver tissue is subject to two main types of damage resulting from this overexposure: inflammation (hepatitis) and scarring (cirrhosis). Women are more adversely affected than men, probably because of a harmful interaction of female sex hormones and the enzymes involved in alcohol metabolism. Genetic differences in enzyme metabolism may account for other individual differences in the severity of liver disease, but overall the risk of death from cirrhosis of the liver is ten times higher among alcoholics than the normal population.