Social Barriers

Social barriers

Attitudes and social stereotypes can create barriers to the detection and treatment of alcohol use disorder. This is more of a barrier for women than men.[why?] Fear of stigmatization may lead women to deny that they have a medical condition, to hide their drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to be less likely to suspect that a woman they know has alcohol use disorder.[45] In contrast, reduced fear of stigma may lead men to admit that they are having a medical condition, to display their drinking publicly, and to drink in groups. This pattern, in turn, leads family, physicians, and others to be more likely to suspect that a man they know is someone with an alcohol use disorder.[64]

Screening

Screening is recommended among those over the age of 18.[122] 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.[123]

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.

The CAGE questionnaire has demonstrated a high effectiveness in detecting alcohol-related problems; however, it has limitations in people with less severe alcohol-related problems, white women and college students.[126]

Other tests are sometimes used for the detection of alcohol dependence, such as the Alcohol Dependence Data Questionnaire, which is a more sensitive diagnostic test than the CAGE questionnaire. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.[127] 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,[128] driving under the influence being the most common. The Alcohol Use Disorders Identification Test (AUDIT), a screening questionnaire developed by the World Health Organization, is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions – a high score earning a deeper investigation.[129] 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.[130]

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC).[131] These tests do not differentiate people with alcohol use disorders from people without; however, long-term heavy drinking does have a few recognizable effects on the body, including:[132]

• Macrocytosis (enlarged MCV)

• Elevated GGT

• Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1

• High carbohydrate deficient transferrin (CDT)

With regard to alcoholism, BAC is useful to judge alcohol tolerance, which in turn is a sign of alcoholism.[4] Electrolyte and acid-base abnormalities including hypokalemia, hypomagnesemia, hyponatremia, hyperuricemia, metabolic acidosis, and respiratory alkalosis are common in people with alcohol use disorders.[5]

However, none of these blood tests for biological markers is as sensitive as screening questionnaires.

Prevention

Further information: Alcohol education

The World Health Organization, the European Union and other regional bodies, national governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism.[133][134]

Increasing the age at which alcohol can be purchased, and banning or restricting alcohol beverage advertising are common methods to reduce alcohol use among adolescents and young adults in particular. Another common method of alcoholism prevention is taxation of alcohol products – increasing price of alcohol by 10% is linked with reduction of consumption of up to 10%.[135]

Credible, evidence-based educational campaigns in the mass media about the consequences of alcohol misuse have been recommended. Guidelines for parents to prevent alcohol misuse amongst adolescents, and for helping young people with mental health problems have also been suggested.[136]

Because alcohol is often used for self-medication of conditions like anxiety temporarily, prevention of alcoholism may be attempted by reducing the severity or prevalence of stress and anxiety in individuals.[4][7]

Management

Treatments are varied because there are multiple perspectives of alcoholism. Those who approach alcoholism as a medical condition or disease recommend differing treatments from, for instance, those who approach the condition as one of social choice. Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support 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 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. Much of the treatment community for alcoholism supports an abstinence-based zero tolerance approach popularized by the 12 step program of Alcoholics Anonymous; however, some prefer a harm-reduction approach.[137]

Cessation of alcohol intake

Main article: Alcohol detoxification

Medical treatment for alcohol detoxification usually involves administration of a benzodiazepine, in order to ameliorate alcohol withdrawal syndrome's adverse impact.[138][139] The addition of phenobarbital improves outcomes if benzodiazepine administration lacks the usual efficacy, and phenobarbital alone might be an effective treatment.[140] Propofol also might enhance treatment for individuals showing limited therapeutic response to a benzodiazepine.[141][142] Individuals who are only at risk of mild to moderate withdrawal symptoms can be treated as outpatients. Individuals at risk of a severe withdrawal syndrome as well as those who have significant or acute comorbid conditions can be treated as inpatients. Direct treatment can be followed by a treatment program for alcohol dependence or alcohol use disorder to attempt to reduce the risk of relapse.[9] Experiences following alcohol withdrawal, such as depressed mood and anxiety, can take weeks or months to abate while other symptoms persist longer due to persisting neuroadaptations.[75]

Psychological

A regional service center for Alcoholics Anonymous

Various forms of group therapy or psychotherapy are sometimes used to encourage and support abstinence from alcohol, or to reduce alcohol consumption to levels that are not associated with adverse outcomes. Mutual-aid group-counseling is an approach used to facilitate relapse prevention.[8] Alcoholics Anonymous was one of the earliest organizations formed to provide mutual peer support and non-professional counseling, however the effectiveness of Alcoholics Anonymous is disputed.[143] A 2020 Cochrane review concluded that Twelve-Step Facilitation (TSF) probably achieves outcomes such as fewer drinks per drinking day, however evidence for such a conclusion comes from low to moderate certainty evidence "so should be regarded with caution".[144] Others include LifeRing Secular Recovery, SMART Recovery, Women for Sobriety, and Secular Organizations for Sobriety.[145]

Manualized[146] Twelve Step Facilitation (TSF) interventions (i.e. therapy which encourages active, long-term Alcoholics Anonymous participation) for Alcohol Use Disorder lead to higher abstinence rates, compared to other clinical interventions and to wait-list control groups.[147]

Moderate drinking

Moderate drinking amongst people with alcohol dependence—often termed 'controlled drinking'—has been subject to significant controversy.[148] Indeed, much of the skepticism toward the viability of moderate drinking goals stems from historical ideas about 'alcoholism', now replaced with 'alcohol use disorder' or alcohol dependence in most scientific contexts. A 2021 meta-analysis and systematic review of controlled drinking covering 22 studies concluded controlled drinking was a 'non-inferior' outcome to abstinence for many drinkers.[149]

Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most people with alcohol use disorders are unable to limit their drinking in this way, some return to moderate drinking. A 2002 US study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. This group, however, showed fewer initial symptoms of dependency.[150]

A follow-up study, using the same subjects that were judged to be in remission in 2001–2002, examined the rates of return to problem drinking in 2004–2005. The study found abstinence from alcohol was the most stable form of remission for recovering alcoholics.[151] There was also a 1973 study showing chronic alcoholics drinking moderately again,[152] but a 1982 follow-up showed that 95% of subjects were not able to maintain drinking in moderation over the long term.[153][154] Another study was a long-term (60 year) follow-up of two groups of alcoholic men which concluded that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."[155] Internet based measures appear to be useful at least in the short term.[156]

Medications

In the United States there are four approved medications for alcoholism: acamprosate, two methods of using naltrexone and disulfiram.[157]

• Acamprosate may stabilise the brain chemistry that is altered due to alcohol dependence via antagonising the actions of glutamate, a neurotransmitter which is hyperactive in the post-withdrawal phase.[158] By reducing excessive NMDA activity which occurs at the onset of alcohol withdrawal, acamprosate can reduce or prevent alcohol withdrawal related neurotoxicity.[159] Acamprosate reduces the risk of relapse amongst alcohol-dependent persons.[160][161]

• Naltrexone is a competitive antagonist for opioid receptors, effectively blocking the effects of endorphins and opioids. Naltrexone is used to decrease cravings for alcohol and encourage abstinence. Alcohol causes the body to release endorphins, which in turn release dopamine and activate the reward pathways; hence in the body Naltrexone reduces the pleasurable effects from consuming alcohol.[162] Evidence supports a reduced risk of relapse among alcohol-dependent persons and a decrease in excessive drinking.[161] Nalmefene also appears effective and works in a similar manner.[161]

• Disulfiram prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is discomfort when alcohol is ingested: an extremely rapid and long-lasting, uncomfortable hangover.

Several other drugs are also used and many are under investigation.

• Benzodiazepines, while useful in the management of acute alcohol withdrawal, if used long-term can cause a worse outcome in alcoholism. Alcoholics on chronic benzodiazepines have a lower rate of achieving abstinence from alcohol than those not taking benzodiazepines. This class of drugs is commonly prescribed to alcoholics for insomnia or anxiety management.[163] Initiating prescriptions of benzodiazepines or sedative-hypnotics in individuals in recovery has a high rate of relapse with one author reporting more than a quarter of people relapsed after being prescribed sedative-hypnotics. Those who are long-term users of benzodiazepines should not be withdrawn rapidly, as severe anxiety and panic may develop, which are known risk factors for alcohol use disorder relapse. Taper regimes of 6–12 months have been found to be the most successful, with reduced intensity of withdrawal.[164][165]

• Calcium carbimide works in the same way as disulfiram; it has an advantage in that the occasional adverse effects of disulfiram, hepatotoxicity and drowsiness, do not occur with calcium carbimide.[166]

• Ondansetron and topiramate are supported by tentative evidence in people with certain genetic patterns.[167][168] Evidence for ondansetron is stronger in people who have recently started to abuse alcohol.[167] Topiramate is a derivative of the naturally occurring sugar monosaccharide D-fructose. Review articles characterize topiramate as showing "encouraging",[167] "promising",[167] "efficacious",[169] and "insufficient"[170] results in the treatment of alcohol use disorders.

Evidence does not support the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), antipsychotics, or gabapentin.[161]

Research

Topiramate, a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. Evidence suggests that topiramate antagonizes excitatory glutamate receptors, inhibits dopamine release, and enhances inhibitory gamma-aminobutyric acid function. A 2008 review of the effectiveness of topiramate concluded that the results of published trials are promising, however as of 2008, data was insufficient to support using topiramate in conjunction with brief weekly compliance counseling as a first-line agent for alcohol dependence.[171] A 2010 review found that topiramate may be superior to existing alcohol pharmacotherapeutic options. Topiramate effectively reduces craving and alcohol withdrawal severity as well as improving quality-of-life-ratings.[172]

Baclofen, a GABAB receptor agonist, is under study for the treatment of alcoholism.[173] According to a 2017 Cochrane Systematic Review, there is insufficient evidence to determine the effectiveness or safety for the use of baclofen for withdrawal symptoms in alcoholism.[174] Psilocybin-assisted psychotherapy is under study for the treatment of patients with alcohol use disorder.[175][176]

Dual addictions and dependencies

Alcoholics may also require treatment for other psychotropic drug addictions and drug dependencies. The most common dual dependence syndrome with alcohol dependence is benzodiazepine dependence, with studies showing 10–20% of alcohol-dependent individuals had problems of dependence and/or misuse problems of benzodiazepine drugs such as diazepam or clonazepam. These drugs are, like alcohol, depressants. Benzodiazepines may be used legally, if they are prescribed by doctors for anxiety problems or other mood disorders, or they may be purchased as illegal drugs. Benzodiazepine use increases cravings for alcohol and the volume of alcohol consumed by problem drinkers.[177] Benzodiazepine dependency requires careful reduction in dosage to avoid benzodiazepine withdrawal syndrome and other health consequences. Dependence on other sedative-hypnotics such as zolpidem and zopiclone as well as opiates and illegal drugs is common in alcoholics. Alcohol itself is a sedative-hypnotic and is cross-tolerant with other sedative-hypnotics such as barbiturates, benzodiazepines and nonbenzodiazepines. Dependence upon and withdrawal from sedative-hypnotics can be medically severe and, as with alcohol withdrawal, there is a risk of psychosis or seizures if not properly managed.[178]

Epidemiology

Disability-adjusted life year for alcohol use disorders per million inhabitants in 2012

  234–806

  814–1,501

  1,551–2,585

  2,838

  2,898–3,935

  3,953–5,069

  5,168

  5,173–5,802

  5,861–8,838

  9,122–25,165

Alcohol consumption per person 2016[179]

The World Health Organization estimates that as of 2016 there are about 380 million people with alcoholism worldwide (5.1% of the population over 15 years of age),[12][13] with it being most common among males and young adults.[4] Geographically, it is least common in Africa (1.1% of the population) and has the highest rates in Eastern Europe (11%).[4]

As of 2015 in the United States, about 17 million (7%) of adults and 0.7 million (2.8%) of those age 12 to 17 years of age are affected.[14] About 12% of American adults have had an alcohol dependence problem at some time in their life.[180]

In the United States and Western Europe, 10–20% of men and 5–10% of women at some point in their lives will meet criteria for alcoholism.[181] In England, the number of "dependent drinkers" was calculated as over 600,000 in 2019.[182] Estonia had the highest death rate from alcohol in Europe in 2015 at 8.8 per 100,000 population.[183] In the United States, 30% of people admitted to hospital have a problem related to alcohol.[184]

Within the medical and scientific communities, there is a 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)."[185] Alcoholism has a higher prevalence among men, though, in recent decades, the proportion of female alcoholics has increased.[46] Current evidence indicates that in both men and women, alcoholism is 50–60% genetically determined, leaving 40–50% for environmental influences.[186] Most alcoholics develop alcoholism during adolescence or young adulthood.[79]

Prognosis

Alcohol use disorders deaths per million persons in 2012

  0–0

  1–3

  4–6

  7–13

  14–20

  21–37

  38–52

  53–255

Alcoholism often reduces a person's life expectancy by around ten years.[20] The most common cause of death in alcoholics is from cardiovascular complications.[187] There is a high rate of suicide in chronic alcoholics, which increases the longer a person drinks. Approximately 3–15% of alcoholics die by suicide,[188] and research has found that over 50% of all suicides are associated with alcohol or drug dependence. This is believed to be due to alcohol causing physiological distortion of brain chemistry, as well as social isolation. Suicide is also very common in adolescent alcohol abusers, with 25% of suicides in adolescents being related to alcohol abuse.[189] Among those with alcohol dependence after one year, some met the criteria for low-risk drinking, even though only 26% of the group received any treatment, with the breakdown as follows: 25% were found to be still dependent, 27% were in partial remission (some symptoms persist), 12% asymptomatic drinkers (consumption increases chances of relapse) and 36% were fully recovered – made up of 18% low-risk drinkers plus 18% abstainers.[190] In contrast, however, the results of a long-term (60-year) follow-up of two groups of alcoholic men indicated that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence....return-to-controlled drinking, as reported in short-term studies, is often a mirage."[155]

History

Adriaen Brouwer, Inn with Drunken Peasants, 1620s

1904 advertisement describing alcoholism as a disease

Historically the name dipsomania was coined by German physician C. W. Hufeland in 1819 before it was superseded by alcoholism.[191][192] That term now has a more specific meaning.[193] The term alcoholism was first used by Swedish physician Magnus Huss in an 1852 publication to describe the systemic adverse effects of alcohol.[16]

Alcohol has a long history of use and misuse throughout recorded history. Biblical, Egyptian and Babylonian sources record the history of abuse and dependence on alcohol. In some ancient cultures alcohol was worshiped and in others, its misuse was condemned. Excessive alcohol misuse and drunkenness were recognized as causing social problems even thousands of years ago. However, the defining of habitual drunkenness as it was then known as and its adverse consequences were not well established medically until the 18th century. In 1647 a Greek monk named Agapios was the first to document that chronic alcohol misuse was associated with toxicity to the nervous system and body which resulted in a range of medical disorders such as seizures, paralysis, and internal bleeding. In the 1910s and 1920s, the effects of alcohol misuse and chronic drunkenness boosted membership of the temperance movement and led to the prohibition of alcohol in many Western countries, nationwide bans on the production, importation, transportation, and sale of alcoholic beverages that generally remained in place until the late 1920s or early 1930s; these policies resulted in the decline of death rates from cirrhosis and alcoholism.[194] In 2005, alcohol dependence and misuse was estimated to cost the US economy approximately 220 billion dollars per year, more than cancer and obesity.[195]

Society and culture

See also: List of deaths through alcohol

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society; for example, money due to lost labor-hours, medical costs due to injuries due to drunkenness and organ damage from long-term use, and secondary treatment costs, such as the costs of rehabilitation facilities and detoxification centers. Alcohol use is a major contributing factor for head injuries, motor vehicle injuries (27%), interpersonal violence (18%), suicides (18%), and epilepsy (13%).[196] Beyond the financial costs that alcohol consumption imposes, there are also significant social costs to both the alcoholic and their family and friends.[65] For instance, alcohol consumption by a pregnant woman can lead to an incurable and damaging condition known as fetal alcohol syndrome, which often results in cognitive deficits, mental health problems, an inability to live independently and an increased risk of criminal behaviour, all of which can cause emotional stress for parents and caregivers.[197][198] Estimates of the economic costs of alcohol misuse, collected by the World Health Organization, vary from 1–6% of a country's GDP.[199] One Australian estimate pegged alcohol's social costs at 24% of all drug misuse costs; a similar Canadian study concluded alcohol's share was 41%.[200] One study quantified the cost to the UK of all forms of alcohol misuse in 2001 as £18.5–20 billion.[182][201] All economic costs in the United States in 2006 have been estimated at $223.5 billion.[202]

The idea of hitting rock bottom refers to an experience of stress that can be attributed to alcohol misuse.[203] There is no single definition for this idea, and people may identify their own lowest points in terms of lost jobs, lost relationships, health problems, legal problems, or other consequences of alcohol misuse.[204] The concept is promoted by 12-step recovery groups and researchers using the transtheoretical model of motivation for behavior change.[204] The first use of this slang phrase in the formal medical literature appeared in a 1965 review in the British Medical Journal,[204] which said that some men refused treatment until they "hit rock bottom", but that treatment was generally more successful for "the alcohol addict who has friends and family to support him" than for impoverished and homeless addicts.[205]

Stereotypes of alcoholics are often found in fiction and popular culture. The "town drunk" is a stock character in Western popular culture. Stereotypes of drunkenness may be based on racism or xenophobia, as in the fictional depiction of the Irish as heavy drinkers.[206] Studies by social psychologists Stivers and Greeley attempt to document the perceived prevalence of high alcohol consumption amongst the Irish in America.[207] Alcohol consumption is relatively similar between many European cultures, the United States, and Australia. In Asian countries that have a high gross domestic product, there is heightened drinking compared to other Asian countries, but it is nowhere near as high as it is in other countries like the United States. It is also inversely seen, with countries that have very low gross domestic product showing high alcohol consumption.[208] In a study done on Korean immigrants in Canada, they reported alcohol was typically an integral part of their meal but is the only time solo drinking should occur. They also generally believe alcohol is necessary at any social event, as it helps conversations start.[209]

Peyote, a psychoactive agent, has even shown promise in treating alcoholism. Alcohol had actually replaced peyote as Native Americans' psychoactive agent of choice in rituals when peyote was outlawed.[