Alcohol use is associated with a significant history in the United States, as alcohol is consumed in numerous social functions, business transactions, and personal activities. Because alcohol beverages are marketed aggressively in many different forms and legal for individuals over the age of 21, its use and availability will no doubt remain quite extensive despite numerous dangers associated with the use and abuse of alcohol.
AWhile the social use of alcohol is condoned by most segments of the country, the abuse of alcohol is condemned and highly stigmatized. Words such as alcoholic, alcoholism, alcohol abuse, etc., often elicit stigmatized images of individuals with moral failings or of individuals who live a skid row-type of existence and have very little willpower. These terms are often used as overall catchphrases for individuals who abuse alcohol; however, there is no particular presentation of an individual who has an alcohol abuse problem. Moreover, the current clinical description of a substance use disorder is a far more accurate description of issues with the use of any substance, including alcohol.
The term alcohol use disorder, as coined by the American Psychiatric Association (APA), is used to describe the entire spectrum of alcohol abuse. An individual with an alcohol use disorder is experiencing problems associated with their use of alcohol, and these problems can range from mild issues (previously referred to as alcohol abuse) to significant problems with addiction to alcohol (often referred to as alcoholism or being alcohol dependent). Only a trained mental health clinician can formally diagnose a substance use disorder, and only such a clinician is able to reliably ascertain the potential seriousness of one’s issues regarding their use of alcohol.
The Prevalence of Alcohol Use and Abuse in the US
There is significant data to surmise that alcohol use and alcohol use disorders are relatively common in the United States. According to information by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA):
- Well over 85 percent of individuals over the age of 18 report using alcohol at least once in their lifetime. In 2015, 133.8 million individuals admitted to using alcohol within the month prior to taking the survey from SAMHSA.
- Approximately 66.7 million individuals reported engaging in binge drinking within the month prior to the survey, whereas 17.3 million reported being heavy alcohol users.
- In 2015, there were approximately 15.7 million individuals who would qualify for diagnosis of an alcohol use disorder, according to SAMHSA.
- Adolescents between the ages of 12 and 20 are not immune to alcohol abuse issues. In 2015, approximately 7.7 million of these individuals admitted to drinking in the prior month, about 5.1 million admitted to binge drinking, approximately 1.3 million admitted to heavy alcohol use, and about 623,000 qualified for an alcohol use disorder.
- Nearly 100,000 people die every year from causes related to alcohol use and abuse.
Binge drinking is defined by SAMHSA as consuming five or more alcoholic drinks on a single occasion for men (four or more for women). This level of drinking will typically increase an individual’s blood alcohol level to 0.08 or higher within about a two-hour period. Heavy drinking is defined as binge drinking five or more times within a period of a month. Based on the current information, it is obvious that the use and abuse of alcohol is a major problem in the United States.
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Why Alcohol Use Disorders Develop
Alcohol is classified as a central nervous system depressant, meaning that its primary mechanism of action is to slow down and even inhibit the firing of the neurons in the brain and spinal cord; this does not mean that drinking alcohol makes one emotionally depressed, although in certain instances that can certainly occur. Drinking alcohol affects numerous neurotransmitters in the brain and spinal cord, increasing levels of the major inhibitory neurotransmitter in the brain, GABA (gamma-aminobutyric acid); affecting levels of dopamine in the brain, which can lead to feelings of reinforcement and a tendency to repeat behavior; and inhibiting excitatory neurotransmitters, including NDMA (a form of glutamate-N-methyl-D-aspirate).
The initial effects of drinking alcohol will result in feelings of wellbeing, euphoria, enhanced mood, relaxation, loss of inhibitions, and decreased reflex actions and motor coordination. The effects of alcohol are dose-dependent. Many individuals experience mild stimulation with very small doses of alcohol, whereas the central nervous system depressant effects begin to occur at moderate to high doses.
There is no singular path that individuals transverse from social alcohol use to the development of a formal alcohol use disorder. Typically, individuals begin drinking alcohol socially and may increase their use in order to deal with stress, socialize, or even as a substitution for companionship. Because repeated use of alcohol is reinforcing for many individuals, a significant number of people are at risk to develop alcohol use disorders.
APA and the National Institute on Drug Abuse (NIDA) have listed numerous risk factors that can increase the potential that an individual will develop an alcohol use disorder. Risk factors represent conditions that can contribute to an increased probability that one will develop a specific disorder or disease; however, the presence of any of these risk factors does not guarantee that an individual will develop any specific condition. Some risk factors are associated with a more salient probability of developing a specific type of disorder, and having more than one risk factor can increase the risk of developing a specific disorder substantially. Risk factors associated with the development of an alcohol use disorder include:
- Having a family history of alcohol abuse or some other substance abuse issue: Having a first-degree relative with a history of a substance use disorder substantially increases the risk that one will develop a substance use disorder, and having any family member with a substance use disorder can also increase this risk. Most often, this risk factor is linked to the notion that certain genetic factors can increase the risk of developing an alcohol use disorder; however, having a first-degree relative with a history of a substance use disorder can also be associated with learning these types of behaviors. Certainly, it is well accepted that there are genetic factors that significantly increase the risk for developing any form of substance abuse issue, but specific genetic factors that could aid in the diagnosis of a substance use disorder have not been identified.
- Being male: Males are at greater risk to develop alcohol abuse issues than females, although the gap between the prevalence of alcohol use disorders in males and females has narrowed in recent years.
- Having some other mental health diagnosis: A very significant risk factor for the development of any substance use disorder is being diagnosed with a formal mental health disorder, such as depression, a personality disorder, a trauma- or stressor-related disorder, an anxiety disorder, etc. The co-occurrence of substance use disorders and other psychological disorders is so prevalent that when individuals are assessed for a substance abuse issue, they should automatically also be assessed for the presence of any other formal psychiatric diagnosis. While the exact reason for this relationship has not been determined, it is most often believed that the biological and environmental factors that make one susceptible to any type of mental health disorder also result in the individual being more susceptible to developing a substance abuse issue.
- A person’s peer group: Individuals with friends who drink heavily are more likely to drink heavily themselves, and this increases the risk for the development of a formal alcohol use disorder. This risk factor is influential over all ages, but particularly salient in younger individuals.
- A lack of perceived social support: People who do not believe they have strong family ties or productive peer relations often become isolated, and this makes them more vulnerable to the development of substance use disorders.
- Experiencing stress or trauma: Individuals who perceive they are under extreme stress or have experienced traumatic events are more vulnerable to the development of substance use disorders. While this risk factor is salient across all age groups, it is particularly influential in younger individuals and children.
- Numerous other personal variables: There are numerous personal factors that can increase the risk that an individual might develop issues with alcohol abuse. These can include having a history of delinquent behavior, beginning to use alcohol at an early age, having a natural higher tolerance to the effects of alcohol, living in areas where there are high rates of drug abuse or high rates of crime, etc.
Signs of an Alcohol Use Disorder
According to APA, any individual who develops a substance use disorder must demonstrate significant distress or functional impairment as a result of their substance use. In addition, APA lists specific diagnostic criteria for different substance use disorders in its Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition (DSM-5). In general, individuals diagnosed with a substance use disorder must present with two or more of the diagnostic criteria within a time period of one year. Only a professional mental health clinician can diagnose alcohol use disorder. The diagnostic criteria are not formally presented here but briefly summarized.
- Major issues with control over alcohol use are covered under numerous diagnostic criteria. These issues can include issues with:
- Being unable to control the amount of alcohol one frequently drinks
- Being unable to control the amount of time one spends drinking alcohol
- Formally stating or attempting to cut down or stop using alcohol but not being able to do so
- Continuing to drink alcohol in spite of experiencing negative issues at work, in personal relationships, at school, or in other important areas of life
- Continuing to drink alcohol even though one recognizes that it is causing physical and/or psychological distress
- Frequently drinking alcohol in situations where it is hazardous to do so
- Individuals frequently display cravings or strong urges to drink alcohol.
- Individuals give up important activities as a result of their alcohol use.
- Individuals may fail to meet major role obligations as a result of their alcohol use.
- Individuals develop significant tolerance to alcohol.
- Individuals display withdrawal symptoms when they stop drinking alcohol or significantly cut down on the amount they drink.
The severity of the individual’s alcohol use disorder is determined by the number of symptoms they qualify for:
- Individuals who meet the criteria for 2-3 symptoms would be diagnosed with a mild alcohol use disorder.
- Individuals who display 4-5 symptoms would be diagnosed with a moderate alcohol use disorder.
- Individuals who display six or more symptoms would be diagnosed with a severe alcohol use disorder.
Numerous descriptions of the effects of chronic alcohol abuse have been documented in books, research studies, and journal articles. Some of these effects include:
- Significant and often irreparable damage to professional and/or personal relationships
- Significant losses of productivity or failures to meet goals
- Increased financial burdens to the individual, the individual’s family, and society as a result of lost productivity and increased need for medical and psychological services
- Increased risk of having accidents that can lead to serious and even permanent physical injuries
- Increased risk of developing serious diseases or disorders of numerous organ systems that can include increased risk for cardiovascular disease, cancer, fetal alcohol syndrome in the children of pregnant mothers, liver damage, etc.
- Increased potential to be a victim of crime, to be a perpetrator of the crime, or to engage in acts of self-harm
- Increased potential to develop serious neurological issues, such as dementia
- Increased potential to develop other mental health disorders, including depression, anxiety disorders, trauma- and stressor-related disorders, bipolar disorder, etc.
- The development of physical dependence on alcohol
Alcohol and Physical Dependence
Chronic use of alcohol is associated with the development of physical dependence. Physical dependence is comprised of the syndromes of tolerance and withdrawal. As individuals continue to drink alcohol on a regular basis, they will often find that they need to drink more alcohol to achieve the effects that they once achieved with lower amounts (tolerance). After the development of tolerance, some individuals will begin to experience negative effects that can consist of physical and psychological/emotional issues once they have not consumed alcohol. This is the beginning of the withdrawal syndrome. When an individual expresses both tolerance and withdrawal symptoms, they have developed physical dependence on alcohol.
The overall body of research suggests that the actual withdrawal syndrome an individual experiences is dependent on numerous factors, including an individual’s genetic makeup, how much alcohol they typically drink, metabolic differences in individuals, whether or not they used alcohol in conjunction with other drugs, and numerous other variables. Overall, there are two identified withdrawal syndromes associated with alcohol:
- A minor alcohol withdrawal syndrome where individuals experience discomfort and stress but do not experience potentially severe consequences: This syndrome is far more common in individuals with alcohol use disorders than the more severe presentation.
- A severe alcohol withdrawal syndrome that is associated with a far more chronic and severe level of an alcohol use disorder: This syndrome has potentially serious complications associated with it.
A minor withdrawal alcohol syndrome would typically consist of the following features:
- Symptoms begin appearing within roughly six hours after the person has stopped using alcohol.
- The withdrawal syndrome will typically last 24-72 hours, with most individuals experiencing withdrawal symptoms for 24-48 hours.
- Withdrawal symptoms peak for most individuals 12-24 hours after discontinuation of alcohol.
- Major symptoms associated with minor alcohol withdrawal include nausea, stomach cramps, vomiting, sweating, increased heart rate, loss of appetite, shakiness, mild tremors, sleep difficulties, headache, dehydration, anxiety, and mild depression.
Most individuals who experience withdrawal at this level are moderate users of alcohol.
Some individuals who have chronic and more severe alcohol abuse histories will experience more severe withdrawal syndromes. The symptoms of these more severe syndromes are outlined below.
- Though symptoms may appear only a few hours after discontinuation of alcohol, it may take up to 48 hours for them to appear for some people. Some individuals may experience withdrawal symptoms while they are still intoxicated as these individuals have extremely high tolerance and normally have high levels of alcohol in their blood. When the individual’s blood alcohol level begins to fall, the withdrawal syndrome is elicited.
- Withdrawal symptoms can last a week or longer. The symptoms that occur in individuals with minor withdrawal alcohol syndrome may be present.
- Individuals with severe alcohol withdrawal are at risk to develop seizures. Seizures can develop rapidly after discontinuation (within six hours), and the potential to develop seizures typically peaks within 12-18 hours after the individual has discontinued alcohol use. Nonetheless, individuals with severe alcohol use disorders may be at risk to develop seizures for several days to weeks following discontinuation. Seizures occurring as a result of alcohol withdrawal can be potentially fatal, and individuals who experience them require medical treatment immediately.
- Some individuals will develop hallucinations (most often, visual hallucinations or auditory hallucinations) within 18 hours after discontinuation. Hallucinations may continue to occur for a week or more.
- Individuals may have severe issues with depression, hopelessness, and anxiety, and may be at risk for self-harm.
- These individuals are also at risk to develop delirium tremens (DTs). This occurs when there is a sudden drop in an individual’s blood alcohol level. The syndrome consists of severe disorientation, severe confusion, psychosis (hallucinations, delusions, and a loss of reality), potential seizures, and other typical withdrawal symptoms, such as chills, sweating, nausea, vomiting, etc. Individuals with severe alcohol use disorders are at risk for the development of delirium tremens within 48-72 hours after discontinuation, and the risk may continue for days or even weeks, depending on the individual and the serious nature of their alcohol abuse. Because individuals can become extremely dehydrated, develop seizures, and become psychotic, delirium tremens is potentially fatal.
Treatment for Alcohol Abuse
The majority of individuals with alcohol use disorders will not experience severe complications, such as seizures or delirium tremens. However, the American Society of Addiction Medicine (ASAM), which is the largest organization of physicians specializing in addiction medicine in the country, recommends that anyone with alcohol use disorder undergo a physician-assisted withdrawal management program (medical detox) when they discontinue alcohol for a variety of reasons.
- There is no standard protocol that can predict what symptoms an individual undergoing withdrawal from alcohol will experience.
- Other issues besides seizures and delirium tremens can be potentially serious, such as dementia, dehydration, etc.
- Significant relief of withdrawal symptoms is associated with greater success and lower instances of relapse in the early days of recovery.
- The use of medications in a physician-assisted withdrawal management program results in the easiest and safest approach to manage alcohol withdrawal.
There are various medications that can be used to assist individuals withdrawing from alcohol in a physician-assisted withdrawal management treatment program.
- Benzodiazepines, such as Librium, Valium, Xanax, etc., are often the primary treatment for alcohol withdrawal. They reduce the symptoms of withdrawal, protect against seizures, guard against delirium tremens, and alleviate other issues. Benzodiazepines should only be used under the supervision of a physician.
- Beta blockers are drugs that are typically used in the treatment of hypertension, and they can be used to address issues with high blood pressure, irregular heartbeat, etc., during withdrawal from alcohol.
- Certain anticonvulsant medications may reduce the withdrawal symptoms associated with alcohol.
- The muscle relaxant baclofen has been shown to reduce cravings in individuals undergoing withdrawal from alcohol.
- Antabuse is a medication that may be given to individuals who have had relapses. It does not address the symptoms of withdrawal, but if an individual drinks alcohol while taking the medication, they become violently ill. This increases the individual’s motivation to stay abstinent from alcohol.
- Physicians have access to numerous other medications for specific symptoms that can also be useful during the early and middle stages of withdrawal.
Simply going through a physician-assisted withdrawal management program is not sufficient for an individual to recover from alcohol use disorder. Individuals must become involved in some form of comprehensive care once they have gotten through the withdrawal period. For most individuals, 90 days of treatment is the typical time period that will place them on the road to abstinence; however, years of participation in treatment-related activities are required for individuals to undergo a successful program of recovery. Treatment should consist of:
- Therapy: Getting involved in substance use disorder therapy in either a group format or in individual sessions; some individuals may be able to participate in both. This therapy is designed to give the individual the insight and tools needed to ensure that recovery will be successful on a long-term basis.
- Peer support: Becoming involved in social support groups that can include 12-Step groups (e.g., Alcoholics Anonymous) is important. These groups represent potential long-term aftercare programs that the person can continue to participate in for years, even after they have completed their formal program of therapy. These groups offer a formal program of recovery, peer support, the chance to meet individuals in recovery and develop new relationships, and long-term participation in treatment-related activities.
- Comprehensive care: There should be continued medical management of issues that are relevant to the individual’s personal situation. This can include treatment of co-occurring disorders, physical problems, etc. In addition, there should be continued treatment of co-occurring psychological/psychiatric conditions.
- Complementary therapies: Involvement in complementary activities, including alternative forms of therapy like animal-assisted therapy, psychodrama, music therapy, etc., can be beneficial. These activities are not mandatory and should only be used if the individual enjoys them. They can add variation to an individual’s recovery program, but should only be used in conjunction with formal treatment and should not be considered as standalone treatments.
Long-term success in recovery from alcohol use disorders is an ongoing process. Many individuals in 12-Step groups continue to participate on a regular basis for years following discontinuation of alcohol. For most individuals, some form of involvement in treatment-related activities should continue for 5-7 years following the completion of a withdrawal management program in order to be successful in long-term recovery. This involvement can include social support group participation, participation in community groups, periodic checkups with therapists, long-term psychoanalysis for individuals interested in this type of treatment, etc.
This spring, take a close look at your life, and the priorities you have established. If you rely on alcohol to calm down, or feel better, seriously consider the steps below. If you can successfully carry these steps out, great! Keep it up! But if these are a struggle, consider seeking help.
The following is a partial list is taken from Moderation Management, a group that helps people with alcohol abuse problems learn to modify their drinking so that it isn’t a problem. These are not suggestions for alcoholics, who need more intense treatment.
Steps Toward Moderation:
1. Attend meetings or on-line groups and learn about the program of Moderation Management.
2. Abstain from alcoholic beverages for 30 days and complete steps three through six during this time.
3. Examine how drinking has affected your life.
4. Write down your life priorities.
5. Take a look at how much, how often, and under what circumstances you had been drinking.
6. Learn the MM guidelines and limits for moderate drinking.
Strictly obey local laws regarding drinking and driving.
Do not drink in situations that would endanger yourself or others.
Do not drink every day. MM suggests that you abstain from drinking alcohol at least 3 or 4 days per week.
Women who drink more than 3 drinks on any day, and more than 9 drinks per week, may be drinking at harmful levels.
Men who drink more than 4 drinks on any day, and more than 14 drinks per week, may be drinking at harmful levels.
America’s Drinking Problem
A report released by SAMHSA last week says that most people with an alcohol abuse disorder don’t know they have a drinking problem. The statistical analysis shows that Americans are in denial about alcohol abuse and that we need to do a better job of educating the public about this problem.
Statistics of Alcohol Abuse and Addiction
The report, released April 7th, concludes that 98.8% of the people in our country with an alcohol abuse disorder do not think they have a problem. It goes on to say that only 7.8% of the 6 million Americans with alcohol dependence recognize their need for help.
These numbers almost seem unbelievable. How could that many people not know they have a drinking problem? Could it be that the administration’s definition of alcohol abuse or dependence is so much more stringent than the public’s definition? SAMHSA classifies alcohol abuse as when someone puts themselves or others in physical danger, has trouble with the law, or has problems at work or in relationships because of their drinking. Alcoholism is a more serious disorder that involves alcohol addiction, an inability to stop drinking, and problems with work and relationships because of drinking. (1)
Justifying Alcohol Abuse
If what SAMHSA says is true, we must be a society flooded with alcoholics and alcohol abusers. Actually, if we look around, we might have to admit that we do see people abusing alcohol frequently. Almost any young person going out with friends is going to drink, and they see nothing wrong with it because that’s just what they do. Someone coming home from work may not think twice about having a number of drinks at night, because they worked hard all day and they deserve it. It is possible that people today just don’t see their drinking as a problem because we have become so numb to the alcohol abuse around us.
Perhaps some of the people taking the survey for this study were just not being honest, or maybe they didn’t want to admit to anyone that they have a drinking problem. Most people, however, were probably too busy justifying the reasons they abuse alcohol to see the problem it is really causing in their lives.
Some people really don’t know that they have a drinking problem, and it is very clear that not enough people are getting the treatment they need for an alcohol problem. That’s why this report is important. Education is imperative, from telling people of the dangers of binge drinking, to helping people see the need for treatment for alcoholism.
SAMHSA administrators are hoping their report helps Americans see the seriousness of alcohol abuse. The report was released on National Alcohol Screening Day, a time when people are encouraged to talk about the alcohol problems that they or a loved one face.
“SAMHSA’s spotlight provides striking evidence that millions of Americans are in serious denial regarding problem drinking,” said SAMHSA Administrator Pamela S. Hyde, J.D. “Individuals, friends and family members clearly need help and support in confronting and doing something about the problem. Without help alcoholism can be fatal. As a nation we need to ask ourselves why we stand by and allow so many people to self destruct before intervening. National Alcohol Screening Day provides one day to have the conversation we should be willing to have every day until screening for alcohol problems becomes the norm — just like heart disease, cancer, and diabetes.” (1)
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