What is alcoholism?                                                                            To Home Page

Alcoholism, also known as "alcohol dependence," is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law. It includes four symptoms:

Craving -- A strong need, or compulsion, to drink.

Impaired control -- The inability to limit one's drinking on any given occasion.

Physical dependence -- Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking.

Tolerance -- The need for increasing amounts of alcohol in order to feel its effects.

For clinical and research purposes, formal diagnostic criteria for alcoholism also have been developed. Such criteria are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association, as well as in the International Classification Diseases, published by the World Health Organization.

 

 

How Is Alcoholism Diagnosed?

 

Even when people with alcoholism experience withdrawal symptoms, they nearly always deny the problem, leaving it up to coworkers, friends, or relatives to recognize the symptoms and take the first steps toward treatment.

Family members cannot always rely on a physician to make an initial diagnosis. Although 15% to 30% of people who are hospitalized suffer from alcoholism or alcohol dependence, physicians often fail to screen for the problem. In addition, doctors themselves often cannot recognize the symptoms. In one study, alcohol problems were detected by the physician in less than half of patients who had them. It is particularly difficult to diagnose alcoholism in the elderly, where symptoms of confusion, memory loss, or falling may be attributed to the aging process alone. Heavy drinkers may be more likely to complain to their doctors about so-called somatization symptoms, which are vague ailments such as joint pain, intestinal problems, or general weakness, that have no identifiable physical cause. Such complaints should signal the physician to follow-up with screening tests for alcoholism. Alcoholism is particularly less likely to be recognized in elderly women. In fact, only 1% of older women who need treatment for alcoholism are diagnosed accurately and treated appropriately. Instead, they are often diagnosed with depression and may even be prescribed anti-anxiety drugs or antidepressants that can have dangerous interactions with alcohol. Even when physicians identify an alcohol problem, however, they are frequently reluctant to confront the patient with a diagnosis that might lead to treatment for addiction.

Screening for Alcoholism

A physician who suspects alcohol abuse should ask the patient questions about current and past drinking habits to distinguish moderate from heavy drinking. If alcohol abuse or dependency is indicated, the physician will usually perform a screening test. Many are available for diagnosing alcoholism, usually either standardized questionnaires that the patient can take on their own or that are conducted by the physician. Because people with alcoholism often deny their problem or otherwise attempt to hide it, the tests are designed to elicit answers related to problems associated with drinking rather than the amount of liquor consumed or other specific drinking habits. The quickest test takes only one minute; it is called the CAGE test, an acronym for the following questions: (C) attempts to Cut down on drinking; (A) Annoyance with criticisms about drinking; (G) Guilt about drinking; and (E) use of alcohol as an Eye-opener in the morning. This test and another called the Self-Administered Alcoholism Screening Test (SAAST), however, appear to be most useful in detecting alcoholism in white middle-aged males. They are not very accurate for identifying alcohol abuse in older people, white women, and African- and Mexican-Americans. A more effective test for such individuals may be the Alcohol Use Disorders Identification Test (AUDIT), which asks three questions about amount and frequency of drinking, three questions about alcohol dependence, and four questions about problems related to alcohol consumption. Other short screening tests are the Michigan Alcoholism Screening Test (MAST) and The Alcohol Dependence Scale (ADS).

Laboratory and Other Tests

Tests for alcohol levels in the blood are not useful for diagnosing alcoholism because they reflect consumption at only one point in time and not long-term usage. A mean corpuscular volume (MCV) blood test is sometimes used to measure the size of red blood cells, which increase with alcohol use over time. A test for a factor known as carbohydrate-deficient transferrin may prove to be fairly accurate indicator of heavy drinking. A physical examination and other tests should be performed to uncover any related medical problems. Sometimes the results of tests that detect other problems, such as blood tests reporting liver damage or low testosterone levels in men, can persuade alcoholics to seek help.

Getting the Patient to Seek Treatment

Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. One study reported that the main reasons alcoholics do not seek treatment are lack of confidence in successful therapies, denial of their own alcoholism, and the social stigma attached to the condition and its treatment. Studies have found that even a brief intervention (e.g., several fifteen-minute counseling sessions with a physician and a follow-up by a nurse) can be very effective in reducing drinking in heavy drinkers who are not yet dependent. However, the best approaches are group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this interventional approach, each person affected offers a compassionate but direct and honest report describing specifically how he or she has been specifically hurt by their loved one's or friend's alcoholism. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation. The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and consistently demand that the patient seek treatment. Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if he or she does not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers.

The alcoholic patient and everyone involved should fully understand that alcoholism is a disease and that the responses to this disease -- need, craving, fear of withdrawal -- are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as treatments for other life-threatening diseases, such as cancer, are, but that it is the only hope for a cure.

What Is the Treatment for Alcohol Withdrawal?

Symptoms of Withdrawal

When a person with alcoholism stops drinking, withdrawal symptoms begin within six to 48 hours and peak about 24 to 35 hours after the last drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are over-produced and the central nervous system becomes over-excited. About 5% of alcoholic patients experience delirium tremens, which usually develops two to four days after the last drink. Symptoms include fever, rapid heart beat, either high or low blood pressure, extremely aggressive behavior, hallucinations, and other mental disturbances.

Treatment of Withdrawal Symptoms

Upon entering a hospital, patients should be given a physical examination for any injuries or medical conditions and should be treated for any potentially serious problems, such as high blood pressure or irregular heartbeat. The immediate goal of treatment is to calm the patient as quickly as possible. Patients are usually given one of the anti-anxiety drugs known as benzodiazepines, which relieve withdrawal symptoms and help prevent progression to delirium tremens. An injection of the B vitamin thiamine may be given to prevent Wernicke-Korsakoff syndrome. Patients should be observed for at least two hours to determine the severity of withdrawal symptoms. Physicians may use assessment tests, such as the Clinical Institute Withdrawal Assessment Scale (CIWA), to help determine treatment and whether the symptoms will progress in severity. Older people with alcoholism are not at higher risk for more severe symptoms than younger patients, but they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Treatment for Mild to Moderate Withdrawal Symptoms

About 95% of people have mild to moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15% to 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients can nearly always be treated as outpatients. After being examined and observed, the patient is usually sent home with a four-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms become severe. If possible, a family member or friend should support the patient through the next few days of withdrawal.

Treatment for Delirium Tremens, Seizures, and Other Severe Symptoms

People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. They are usually first given intravenous anti-anxiety medications and their physical condition is stabilized. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to themselves or others.

Seizures are usually self-limited and treated only with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or whose seizures cannot be controlled. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Lidocaine (Xylocaine) may be given to people with disturbed heart rhythms.

Drugs Used for Mild to Moderate Withdrawal Symptoms

Benzodiazepines

Benzodiazepines are anti-anxiety drugs that inhibit nerve-cell excitability in the brain. They relieve withdrawal symptoms and make it easier for patients to remain in treatment. The drugs may be administered intravenously or orally, depending on the severity of symptoms. For most adults with alcoholism, the longer-acting drugs, such as diazepam (Valium) or chlordiazepoxide (Librium), are usually prescribed. To prevent seizures, the physician may give the patient an initial, or loading, dose of the long-acting drug diazepam with additional doses given every one to two hours thereafter over the period of withdrawal. This regimen can cause very heavy sedation. People with serious medical problems, particularly respiratory disorders, may be given repeated doses of shorter-acting benzodiazepines, such as lorazepam (Ativan) and oxazepam (Serax); these drugs can be withdrawn immediately at any sign of trouble. Some physicians question the use of any anti-anxiety medication for mild withdrawal symptoms. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe episodes with seizures and possible brain damage.

Benzodiazepines are usually not prescribed for more than two weeks or administered for more than three nights per week. Tolerance to these drugs may develop after as little as four weeks of daily use. Physical dependence may develop after just three months of normal dosage. People who discontinue benzodiazepines after taking them for long periods may experience rebound symptoms -- sleep disturbance and anxiety -- which can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms from the drugs, including stomach distress, sweating, and insomnia, that can last from one to three weeks. Common side effects are day-time drowsiness and a hung-over feeling. Respiratory problems may be exacerbated. Benzodiazepines are potentially dangerous when used in combination with alcohol. They should not be used by pregnant women or nursing mothers unless absolutely necessary.

Other Drugs for Mild to Moderate Withdrawal

Beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), may sometimes be used in combination with a benzodiazepine. This class of drugs is effective in slowing heart rate and reducing tremor. Other drugs being tested are clonidine (Catapres) and carbamazepine (Tegretol). When used by themselves, they do not, however, appear to be effective in reducing seizures or delirium. Chlormethiazole, a derivative of vitamin B1, is presently used in Europe and is showing promise in reducing agitation and seizures.

What Are the Long-Term Treatments for Alcoholism?

The two basic goals of long-term treatment are total abstinence and replacement of the addictive patterns with satisfying, time-filling behaviors that can fill the void in daily activity that occurs when drinking has ceased. Some studies have reported that some people who are alcohol dependent can eventually learn to control their drinking and do as well as those who remain abstinent. There is no way to determine, however, which people can stop after one drink and which cannot. Alcoholics Anonymous and other alcoholic treatment groups whose goal is strict abstinence are greatly worried by the publicity surrounding these studies, since many people with alcoholism are eager for an excuse to start drinking again. At this time, abstinence is the only safe route.

Inpatient versus Outpatient Treatment

People with mild to moderate withdrawal symptoms are usually treated as outpatients and assigned to support groups, counseling, or both. Inpatient treatment in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse is recommended for patients with a coexisting medical or psychiatric disorder and those who may harm themselves or others, who have not responded to conservative treatments, or who have a disruptive home environment. A typical inpatient regimen includes a physical and psychiatric work-up, detoxification, treatment with psychotherapy or cognitive-behavioral therapy, and an introduction to Alcoholics Anonymous. Because of the high cost of inpatient care, its advantages over outpatient care are currently being questioned. One study compared employed alcoholics who were either hospitalized, treated as outpatients with compulsory attendance at AA meetings, or allowed to choose their own treatment option -- including none at all. After two years, everyone experienced fewer job problems, but those in the inpatient group had significantly fewer rehospitalizations and remained abstinent longer than people in the other two groups. Another study analyzing drug and alcohol treatment programs found that 75% of inpatients completed therapy compared to only 18% of outpatients. Other studies, however, have shown no difference in results between inpatient and outpatient programs, and in one, the costs for AA were 45% lower than other outpatient options. Studies have attempted to uncover characteristics that might make people more likely to drop out of either outpatient or inpatient programs. One study found that people who drop out of outpatient treatments are more apt to be female, young, unskilled, or have more than one addiction. Another reported that those who leave inpatient treatment against medical advice tend to have jobs, to be college educated, and have a history of leaving treatment.

Psychotherapy and Cognitive-Behavioral Therapy

The two usual forms of therapy for alcoholics are cognitive-behavioral and interactional group psychotherapy based on the Alcoholics Anonymous 12-step program. In one study, all treatment approaches were, on average, equally effective as long as the individual program was competently administered. Those with fewer psychiatric problems, however, did best with the AA approach. This confirms an earlier study in which researchers categorized alcoholics as either Type A or Type B. Type A individuals became alcoholic at a later age, had less severe symptoms or fewer psychiatric problems, and had a better outlook on life than those with Type B. The people in the Type A group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy. Type B people became alcoholic at an early age, had a high family risk for alcoholism, more severe symptoms, and a negative outlook on life. This group did poorly with interactional group therapy but tended to do better with cognitive-behavioral therapy. This difference in response to the two forms of treatments held up after two years.

Interactional Group Psychotherapy (12-Step Program)

Alcoholics Anonymous (AA), founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well-known program for helping people with alcoholism. It offers a very strong support network using group meetings open seven days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation. AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy uses a structured teaching approach and may be better than AA for severe alcoholism. People with alcoholism are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. For example, patients might write a history of their drinking experiences and describe what they consider to be risky situations. They are then assigned activities to help them cope when exposed to "cues" -- places or circumstances that trigger their desire to drink. Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team; this gave them the opportunity to practice coping skills, develop supportive relationships, and engage in healthy alternative activities. In one study of patients with both depression and alcoholism, this therapeutic approach achieved 47% abstinence rates after six months compared to only 13% abstinence in patients who received standard treatments and relaxation techniques.

Medications to Aid in Abstinence

Disulfiram

Disulfiram (Antabuse) causes distressing symptoms, including flushing, headache, nausea, and vomiting, if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and last from half an hour to two hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for one to two weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. Studies have not shown the use of disulfiram to have any effect on staying abstinent, although one study found that the total number of drinking days was less in people who took the drug. The drug may also be more effective in married patients or those with other family members or caregivers, including AA "buddies", close by and vigilant to ensure that they take it.

Naltrexone

Naltrexone (ReVia) appears to block the pleasurable effects of alcohol and reduce cravings. When used with counseling or support groups, studies indicate that it may be very effective for people with low- to medium-risk for alcohol dependency. In one 10-week program, patients who had been abstinent only 37% of the time increased this rate to 89%, and the average number of drinks consumed when they did drink dropped from 9.5 to 2.5. The most common side effect of naltrexone is nausea, which is usually mild and temporary. High doses cause liver damage. The drug should not be administered to anyone who has used narcotics within a week to 10 days.

Acamprosate

Acamprosate (Campral) calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). In one European study, 18% of patients were still abstaining after a year compared to only 7% who did not take the drug. Acamprosate is fully effective after about a week of treatment. It may cause occasional diarrhea. At this time it is available only in Europe but is being tested in America. It should be used along with counseling. Combination therapy with naltrexone or disulfiram may be possible.

Antidepressant and Anti-anxiety Drugs

Depression is common among alcohol-dependent people and can lead to a higher relapse rate. Antidepressants may be helpful, particularly those that maintain elevated levels of serotonin in the brain, since alcoholism has been associated with low serotonin levels. Two studies have reported higher rates of abstinence, fewer heavy drinking days, and fewer drinks in severe alcoholics who took fluoxetine (Prozac), the most common antidepressant in a class known as serotonin reuptake inhibitors (SSRIs). Other SSRIs include sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Another small study reported that people given the tricyclic antidepressant desipramine (Norpramin, Pertofrane) -- whether or not they exhibited other symptoms of depression -- had fewer drinking days and a longer period between relapses than those not taking the drug. A unique anti-anxiety drug, buspirone (BuSpar), may also be beneficial for alcoholics, particularly if they also suffer from anxiety. The drug has few side effects and a low potential for abuse. It not only reduces anxiety, but also appears to have modest effects on alcohol cravings. In one study, alcoholics who took it had a slow return to alcohol consumption and fewer drinking days than those not on the drug.

Other Drugs

Isradipine, a calcium channel blocker, reduced cravings more effectively than naltrexone and the antidepressant paroxetine (Paxil) -- drugs used to maintain abstinence. Calcium channel blockers are used to treat high blood pressure and can have serious side effects, which should be discussed with a physician. Another drug being investigated for withdrawal and abstinence is gamma-hydroxybutyric acid (GHB). In one small study, 58% of subjects remained abstinent during a six-month period. The drug has a number of potentially very serious side effects, however.

Why Do People with Alcoholism Relapse?

Between 80% and 90% of people treated for alcoholism relapse -- even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. One study found that three factors placed a person at high risk for relapse: frustration and anger, social pressure, and internal temptation. Treatment of relapses, however, does not always require starting from scratch with detoxification or hospitalization; often, abstinence can begin the next day. Self-forgiveness and persistence are behaviors essential for permanent recovery.

Mental and Emotional Stress

Alcohol blocks out emotional pain and is often perceived as a loyal friend when human relationships fail. It is also associated with freedom and a loss of inhibition that offsets the tedium of daily routines. When the alcoholic tries to quit drinking, the brain seeks to restore what it perceives to be its equilibrium. The brain's best weapons against abstinence are depression and anxiety (the emotional equivalents of physical pain) that continue to tempt alcoholics to return to drinking long after physical withdrawal symptoms have abated. Even intelligence is no ally in this process, for the brain will use all its powers of rationalization to persuade the patient to return to drinking. It is important to realize that any life change may cause temporary grief and anxiety, even changes for the better. With time and the substitution of healthier pleasures, this emotional turmoil weakens and can be overcome.

Codependency

One of the most difficult problems facing a person with alcoholism is being around people who are able to drink socially without danger of addiction. A sense of isolation, a loss of enjoyment, and the ex-drinker's belief that pity -- not respect -- is guiding a friend's attitude can lead to loneliness, low self-esteem, and a strong desire to drink. Close friends and even intimate partners may have difficulty in changing their responses to this newly sober person and, even worse, may encourage a return to drinking. To preserve marriages to alcoholics, spouses often build their own self-images on surviving or handling their mates' difficult behavior and then discover that they are threatened by abstinence. Friends may not easily accept the sober, perhaps more subdued, comrade. In such cases, separation from these "enablers" may be necessary for survival. It is no wonder that, when faced with such losses, even if they are temporary, a person returns to drinking. The best course in these cases is to encourage close friends and family members to seek help as well. Fortunately, groups such as Al-Anon exist for this purpose.

Social and Cultural Pressures

The media portrays the pleasures of drinking in advertising and programming. The medical benefits of light to moderate drinking are frequently publicized, giving ex-drinkers the spurious excuse of returning to alcohol for their health. These messages must be categorically ignored and acknowledged for what they are -- an industry's attempt to profit from potential great harm to individuals.

Well-Connected Board of Editors

Harvey Simon, M.D., Editor-in-Chief
Massachusetts Institute of Technology; Physician, Massachusetts General Hospital

Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, M.D., Ph.D., Metabolism
Harvard Medical School; Associate Physician, Massachusetts General Hospital

Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Irene Kuter, M.D., D. Phil., Oncology
Harvard Medical School; Assistant Physician, Massachusetts General Hospital

Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

Carol Peckham, Editorial Director

Cynthia Chevins, Publisher

 

 

 

 

 

 

Alcohol Abuse vs. Alcohol Dependence

Q: What is the difference between alcohol abuse and alcohol dependence?

A: Alcohol abuse is described as any "harmful use" of alcohol.

The Diagnostic and Statistical Manual of Mental Disorders IV describes alcohol abusers as those who drink despite recurrent social, interpersonal, and legal problems as a result of alcohol use. Harmful use implies alcohol use that causes either physical or mental damage.

Those who are alcohol dependent meet all of the criteria of alcohol abuse, but the will also exhibit some or all of the following:

 
bulletNarrowing of the drinking repertoire (drinking only one brand or type of alcoholic beverage).

bulletDrink-seeking behavior (only going to social events that will include drinking, or only hanging out with others who drink).

bulletAlcohol tolerance (having to drink increasing amounts to achieve previous effects).

bulletWithdrawal symptoms (getting physical symptoms after going a short period without drinking).

bulletDrinking to relieve or avoid withdrawal symptoms (such as drinking to stop the shakes or to "cure" a hangover).

bulletSubjective awareness of the compulsion to drink or craving for alcohol (whether they admit it to others or not).

bulletA return to drinking after a period of abstinence (deciding to quit drinking and not being able to follow through).
Typically, those drinkers who are diagnosed as only alcohol abusers can be helped with a brief intervention, including education concerning the dangers of binge drinking and alcohol poisoning.

Those who have become alcohol dependent generally require outside help to stop drinking, which could include detoxification, medical treatment, counseling and/or self-help group support.

 

 

ADDICTION CRITERIA

* Taking the drug more often or in larger amounts than intended.

* Unsuccessful attempts to quit; persistent desire, craving.

* Excessive time spent in drug seeking.

* Feeling intoxicated at inappropriate times, or feeling withdrawal symptoms from a drug at such times.

* Giving up other things for it.

* Continued use, despite knowledge of harm to oneself and others.

* Marked tolerance in which the amount needed to satisfy increases at first before leveling off.

* Characteristic withdrawal symptoms for particular drugs.

* Taking the drug to relieve or avoid withdrawal.

Before applying a test of the nine criteria, the expert first determines if the symptoms have persisted for at least a month or have occurred repeatedly over a longer period of time.

Asked about the tobacco executives' testimony on addiction, Dr. Kozlowski said, "In a way, I can see how they could say that. It has to do with a mistaken image of what addiction is, and I have many well-educated, intelligent people say something like that to me. People often think of a person taking one injection of heroin and becoming hopelessly addicted for the rest of their lives. That is wrong."

In addition, he said, when people tend to think of the high that heroin produces, one that is about as intense as cocaine and alcohol, they cannot believe cigarettes are in the same category. And they are not. Even though in large doses nicotine can cause a strong high and hallucinations, the doses used in cigarettes produce only a very mild high.

But researchers now know, says Dr. Jack Henningfield, chief of clinical pharmacology at the Addiction Research Center of the Government's National Institute on Drug Abuse, that many qualities are related to a drug's addictiveness, and the level of intoxication it produces may be one of the least important.

If one merely asks how much pleasure the drugs produce, as researchers used to do and tobacco companies still do, then heroin or cocaine and nicotine do not seem to be in the same category. Dr. Kozlowki said, "It's not that cigarettes are without pleasure, but the pleasure is not in the same ball park with heroin."

But now, he said, there are more questions to ask. "If the question is How hard is it to stop? then nicotine a very impressive drug," he said. "Its urges are very similar to heroin."

Among the properties of a psychoactive drug - how much craving it can cause, how severe is the withdrawal, how intense a high it brings - each addicting drug has its own profile.

Heroin has a painful, powerful withdrawal, as does alcohol. But cocaine has little or no withdrawal. On the other hand, cocaine is more habit-forming in some respects, it is more reinforcing in the scientific terminology, meaning that animals and humans will seek to use it frequently in short periods of time, even over food and water.

Drugs rank differently on the scale of how difficult they are to quit as well, with nicotine rated by most experts as the most difficult to quit.

Moreover, it is not merely the drug that determines addiction, says Dr. john R. Hughes, an addiction expert at the University of Vermont. It is also the person, and the circumstances in the person's life. A user may be able to resist dependence at one time and not at another.

A central property of addiction is the user's control over the substance. With all drugs. including heroin, many are occasional users. The addictive property of the substance can be measured by how many users maintain a casual habit and how many are persistent, regular users.

According to large Government surveys of alcohol users, only about 15 percent are regular. dependent drinkers. Among cocaine users, about 8 percent become dependent. For cigarettes, the percentage is reversed. About 90 percent of smokers are persistent daily users, and 55 percent become dependent by official American Psychiatric Association criteria, according to a study by Dr. Naomi Breslau of the Henry Ford Health Sciences Center in Detroit. Only 10 percent are occasional users.

Surveys also indicate that two-thirds to four-fifths of smokers want to quit but cannot, even after a number of attempts. Dr. John Robinson, a psychologist who works for the R. J. Reynolds Tobacco Company, contests the consensus view of nicotine as addictive. Using the current standard definition of addiction, he said at a recent meeting on nicotine addiction, he could not distinguish "crack smoking from coffee drinking, glue sniffing from jogging. heroin from carrots and cocaine from colas."

It is not that Dr. Robinson and other scientists supported by tobacco companies disagree with the main points made by mainstream scientists. but that they define addiction differently. Dr. Robinson says intoxication that is psychologically debilitating is the major defining trait of an addicting substance. It is a feature that was part of standard definitions of the 1950's, and is still linked to popular ideas about addiction, but which experts now say is too simplistic and has been left behind as scientific evidence accumulates.

 

 

Q:  Is Alcoholism a Disease?

Yes. Alcoholism is a chronic, often progressive disease with symptoms that include a strong need to drink despite negative consequences, such as serious job or health problems. Like many other diseases, it has a generally predictable course, has recognized symptoms, and is influenced by both genetic and environmental factors that are being increasingly well defined. 

 

 

But it doesn't act like a disease!

One of the difficulties in recognizing alcoholism as a disease is it just plain doesn't seem like one. It doesn't look, sound, smell and it certainly doesn't act like a disease. To make matters worse, generally it denies it exists and resists treatment.

Alcoholism has been recognized for many years by professional medical organizations as a primary, chronic, progressive and sometimes fatal disease. The National Council on Alcoholism and Drug Dependence offers a detailed and complete definition of alcoholism but probably the most simple way to describe it is "a mental obsession that causes a physical compulsion to drink."

Mental obsession? Did you ever wake up in the morning with a song playing over and over in your head? It might have been a commercial jingle you heard on television, or a song from the radio, but it kept playing ... and playing and playing.

Remember what that was like? No matter what you did, that silly tune kept on playing. You could try to whistle or sing another song or turn on the radio and listen to another tune, but the one in your head just kept on playing. Think about it. There was something going on in your mind that you didn't put there and, no matter how hard you tried, couldn't get out!

That is an example of a simple mental obsession -- a thought process over which you have no control. Such is the nature of the disease of alcoholism.   When the drinking "song" starts playing in the mind of an alcoholic, he is powerless.   He didn't put the song there and the only way to get it to stop is to take another drink.

The problem is the alcoholic's mental obsession with alcohol is much more subtle than a song playing in his mind. In fact, he may not even know it's there. All he knows is he suddenly has an urge to take a drink -- a physical compulsion to drink.

Compounding the problem is the progressive nature of the disease. In its early stages, taking one or two drinks may be all it takes to get the "song" to stop. But soon it takes six or seven and later maybe ten or twelve. Somewhere down the road the only time the song stops is when he passes out.

The progression of the disease is so subtle and usually takes place over such an extended period of time, that even the alcoholic himself failed to notice the point at which he lost control -- and alcohol took over -- his life.

No wonder denial is an almost universal symptom of the disease. For those who have come to the realization that they do have a problem, help may be as close as the white pages of the telephone directory. But for those who need help and do not want it, intervention may be the only alternative.

 

 

Alcohol and Cognition

Research shows that alcohol adversely affects the brain. When health professionals encounter patients who are having cognitive difficulties, such as impaired memory or reasoning ability, alcohol use may be the cause of the problem. When treating patients who have abused alcohol, it may be of value to attempt to identify the level of any impairment and to modify the treatment accordingly.

Some researchers have investigated whether or not there is measurable alcohol-related cognitive impairment among nonalcoholic social drinkers. Their findings suggest a dose-response relationship between alcohol consumption and diminished scores on certain neuropsychological tests (e.g., Parker & Noble 1977; Parker et al. 1983). Statistically significant decreases in test performance have been found for people whose self-reported alcohol consumption was in the range of what was considered social drinking. This is not to say these people were clinically impaired, only that they exhibited certain performance deficits that correlated with alcohol consumption. It is important to note that similar correlations from other studies have not been found to be consistently significant. For example, the results of one general population study (Bergman et al. 1983) showed no correlation between self-reported alcohol consumption and neuropsychological test scores; other findings (Emmerson et al. 1988) failed to show a simple dose-response relationship. In a recent review of such studies, Parsons (1986) concluded that data on the relationship of cognitive impairment to amount of alcohol consumed by social drinkers are inconclusive.

Alcoholics in treatment present a different picture. Although most alcoholics entering treatment do not have decreased overall intelligence scores, approximately 45 to 70 percent of these patients have specific deficits in problem solving, abstract thinking, concept shifting, psychomotor performance, and difficult memory tasks (Parsons & Leber 1981; Eckardt & Martin 1986; Tabakoff & Petersen 1988). Such deficits usually are not apparent without neuropsychological testing. In addition, structural changes in the brains of alcoholics have been reported (Ron 1979; Wilkinson 1987), as well as reduced cerebral blood flow (Ishikawa et al. 1986) and altered electrical activity (Porjesz & Begleiter 1981), but there is not yet any clear evidence implicating these changes as the cause of observed cognitive deficits.

For the most severe alcoholics, serious organic cerebral impairment is a common complication, occurring in about 10 percent of patients (Horvath 1975). The diverse signs of severe brain dysfunction that persist after cessation of alcohol consumption have been conceptualized in terms of two organic mental disorders: alcohol amnestic disorder (memory disorder) and dementia associated with alcoholism (Lishman 1981; American Psychiatric Association 1987). Recently however, it has been recognized that these two disorders are not mutually exclusive and that some features of each often coexist in the same patient (Martin & Eckardt 1985). Alcohol amnestic disorder, commonly called Korsakoff's psychosis or Wernicke-Korsakoff syndrome, is characterized by short-term memory, impairments and behavioral changes that occur without clouding of consciousness or general loss of intellectual abilities. Dementia associated with alcoholism consists of global loss of intellectual abilities with an impairment in memory function, together with disturbance(s) of abstract thinking, judgment, other higher cortical functions, or personality change without a clouding of consciousness. It has been suggested that subcortical lesions due to nutritional (thiamine) deficiency are characteristic of Korsakoff's, whereas alcoholic dementia is associated more with cortical changes (Victor & Laureno 1978). There is some evidence that a genetic abnormality may predispose some people to Korsakoff's in the presence of excessive alcohol use and malnutrition (Blass & Gibson 1977; Mukherjee et aI. 1987).

Tarter and Edwards (1986) summarize evidence suggesting that neuropsychological impairment in alcoholics may occur for a number of reasons. The toxic effects of alcohol on the brain may cause impairment directly. In addition, some alcoholics may exhibit impairment as an indirect result of alcohol abuse, e.g., they may have experienced a craniocerebral trauma, they may be eating poorly and suffering nutritional deficits (such as thiamine or niacin deficiencies), or they may have cognitive impairments associated with liver disease.

Some alcoholics may have been cognitively impaired before they began drinking. There is some evidence that persons in groups considered to be at risk for alcoholism (e.g., children of alcoholics) are less adept at certain learning tests and visual-spatial integration than are persons in groups not deemed at risk for alcoholism; this area of research is still under active investigation.

Some researchers have observed that cognitive deficits in some alcoholics resemble those seen in normal elderly persons, leading to speculation that alcohol's effect on cognition may be explained as premature aging (Tarter 8 Edwards 1986). However, it is more likely that such deficits are independent of any deficits associated with normal aging (Grant et al. 1984; Cutting 1988).

Laying aside issues of etiology, evidence indicates that some cognitive impairment in alcoholics is reversible. Researchers (Albert et al. 1982; Grant et al. 1984; Goldman 1986, 1987) report apparent "spontaneous" recovery of cognitive function (recovery seen after the passage of time with no active intervention) among abstinent alcoholics, a result that may be due solely to the absence of alcohol but that also may be due in part to other changes, such as better nutrition and opportunities for social interaction provided in an alcohol treatment setting. There is some evidence that cognitive training and practice experience (remedial mental exercises) can facilitate recovery from impairment (Godfrey et al. 1985; Goldman 1986,1987).

Because even with prolonged abstinence many alcoholic patients with chronic organic mental disorders may exhibit only modest clinical improvement in brain functioning, there is a need for pharmacological interventions to complement behavioral methods. Recent findings that pharmacological intervention may be useful in restoring some cognitive ability (McEntee & Mair 1980) are encouraging.

Although degree of cognitive impairment may not be a clinically significant predictor of post-treatment alcohol consumption (Donovan et al. 1987; Eckardt et al. 1988), identifying cognitive impairment may have implications for successfully treating some patients. Particularly in the first weeks of abstinence during treatment, cognitive impairments may make it difficult for some alcoholics to benefit from the educational and skill development sessions that are important components of many treatment programs (McCrady & Smith 1986; McCrady 1987). For example, Becker and Jaffe (1984) reported that alcoholics who were tested soon after beginning abstinence were unable to recall treatment-related information presented in a film that was part of the regular treatment program. An implication of such findings is that information presented to alcoholics during the period of impairment in the early weeks of abstinence should be repeated at later stages in the treatment program. Alternatively, presentation of treatment-related information should be delayed until tests indicate some improvement in cognitive function.

Alcohol and Cognition - A Commentary by
NIAAA Director Enoch Gordis, M.D.

Awareness of alcohol's effects on cognition can help general health care providers identify alcoholics and refer them to appropriate treatment. Awareness also can assist the efforts of alcoholism treatment personnel to maximize the potential benefit of treatment for their patients.

In general health care situations, practitioners should use standard alcoholism assessment instruments to determine the extent of alcohol use by patients who show signs of cognitive dysfunction. Patients in whom alcohol use is identified as either a primary or a contributing cause of cognitive dysfunction must be referred to alcoholism treatment. Evidence suggests that some cognitive impairment in alcoholics is reversible. Moreover, cognitive deterioration will worsen with continued drinking.

In addition, alcoholism treatment personnel should know that alcohol-induced cognitive impairment may make it difficult during the first weeks of absence for some of their patients to benefit from exposure to the full range of treatment services. Although it may not be possible or necessary for treatment programs to administer extensive neuropsychiatric tests to all patients, a simple test of the patient's ability to benefit from the didactic elements of alcoholism treatment can be made. One test might be to determine what a patient remembers from an initial counseling session.

If there is evidence of cognitive deficiency, patients must be allowed time to recover adequate cognitive function so that, at a minimum, information provided during treatment can be retained. However, other important elements of rehabilitation, such as improving patient nutritional status and exposure to physical exercise and resocialization activities, can be undertaken immediately. As cognitive function improves, patients can begin to participate in such treatment components as individual and group therapy, educational programs, and introduction to Alcoholics Anonymous, with a better chance for understanding--and perhaps for acting on--the information provided.

 

 

Alcohol and Tolerance

Alcohol consumption interferes with many bodily functions and affects behavior. However, after chronic alcohol consumption, the drinker often develops tolerance to at least some of alcohol's effects. Tolerance means that after continued drinking, consumption of a constant amount of alcohol produces a lesser effect or increasing amounts of alcohol are necessary to produce the same effect (1). Despite this uncomplicated definition, scientists distinguish between several types of tolerance that are produced by different mechanisms.

Tolerance to alcohol's effects influences drinking behavior and drinking consequences in several ways. This Alcohol Alert describes how tolerance may encourage alcohol consumption, contributing to alcohol dependence and organ damage; affect the performance of tasks, such as driving, while under the influence of alcohol; contribute to the ineffectiveness or toxicity of other drugs and medications; and may contribute to the risk for alcoholism.

Functional Tolerance

Humans and animals develop tolerance when their brain functions adapt to compensate for the disruption caused by alcohol in both their behavior and their bodily functions. This adaptation is called functional tolerance (2). Chronic heavy drinkers display functional tolerance when they show few obvious signs of intoxication even at high blood alcohol concentrations (BAC's), which in others would be incapacitating or even fatal (3). Because the drinker does not experience significant behavioral impairment as a result of drinking, tolerance may facilitate the consumption of increasing amounts of alcohol. This can result in physical dependence and alcohol-related organ damage.

However, functional tolerance does not develop at the same rate for all alcohol effects (4-6). Consequently, a person may be able to perform some tasks after consuming alcohol while being impaired in performing others. In one study, young men developed tolerance more quickly when conducting a task requiring mental functions, such as taking a test, than when conducting a task requiring eye-hand coordination (4), such as driving a car. Development of tolerance to different alcohol effects at different rates also can influence how much a person drinks. Rapid development of tolerance to unpleasant, but not to pleasurable, alcohol effects could promote increased alcohol consumption (7).

Different types of functional tolerance and the factors influencing their development are described below. During repeated exposure to low levels of alcohol, environmental cues and processes related to memory and learning can facilitate tolerance development; during exposure to high levels of alcohol, tolerance may develop independently of environmental influences.

Acute tolerance. Although tolerance to most alcohol effects develops over time and over several drinking sessions, it also has been observed within a single drinking session. This phenomenon is called acute tolerance (2). It means that alcohol-induced impairment is greater when measured soon after beginning alcohol consumption than when measured later in the drinking session, even if the BAC is the same at both times (8-10).

Acute tolerance does not develop to all effects of alcohol but does develop to the feeling of intoxication experienced after alcohol consumption (4). This may prompt the drinker to consume more alcohol, which in turn can impair performance or bodily functions that do not develop acute tolerance.

Environment-dependent tolerance. The development of tolerance to alcohol's effects over several drinking sessions is accelerated if alcohol is always administered in the same environment or is accompanied by the same cues. This effect has been called environment-dependent tolerance. Rats that regularly received alcohol in one room and a placebo in a different room demonstrated tolerance to the sedative and temperature-lowering effects of alcohol only in the alcohol-specific environment (11). Similar results were found when an alcohol-induced increase in heart rate was studied in humans (12). When the study subjects always received alcohol in the same room, their heart rate increased to a lesser extent after drinking in that room than in a new environment.

Environment-dependent tolerance develops even in "social" drinkers in response to alcohol-associated cues. In a study analyzing alcohol's effects on the performance of an eye-hand coordination task, a group of men classified as social drinkers received alcohol either in an office or in a room resembling a bar. Most subjects performed the task better (i.e., were more tolerant) when drinking in the bar-like environment (13). This suggests that for many people, a bar contains cues that are associated with alcohol consumption and promote environment-dependent tolerance.

Learned tolerance. The development of tolerance also can be accelerated by practicing a task while under the influence of alcohol. This phenomenon is called behaviorally augmented (i.e., learned) tolerance. It first was observed in rats that were trained to navigate a maze while under the influence of alcohol (14). One group of rats received alcohol before their training sessions; the other group received the same amount of alcohol after their training sessions. Rats that practiced the task while under the influence of alcohol developed tolerance more quickly than rats practicing without prior alcohol administration.

Humans also develop tolerance more rapidly and at lower alcohol doses if they practice a task while under the influence of alcohol. When being tested on a task requiring eye-hand coordination while under the influence of alcohol, people who had practiced after ingesting alcohol performed better than people who had practiced before ingesting alcohol (15). Even subjects who only mentally rehearsed the task after drinking alcohol showed the same level of tolerance as those who actually practiced the task while under the influence of alcohol (15).

The expectation of a positive outcome or reward after successful task performance is an important component of the practice effect on tolerance development. When human subjects knew they would receive money or another reward for successful task perfmance while under the influence of alcohol, they developed tolerance more quickly than if they did not expect a reward (16). The motivation to perform better contributes to the development of learned tolerance.

Learned and environment-dependent tolerance have important consequences for situations such as drinking and driving. Repeated practice of a task while under the influence of low levels of alcohol, such as driving a particular route, could lead to the development of tolerance, which in turn could reduce alcohol-induced impairment (16). However, the tolerance acquired for a specific task or in a specific environment is not readily transferable to new conditions (17,18). A driver encountering a new environment or an unexpected situation could instantly lose any previously acquired tolerance to alcohol's impairing effects on driving performance.

Environment-independent tolerance. Exposure to large quantities of alcohol can lead to the development of functional tolerance independent of environmental influences. This was demonstrated in rats that inhaled alcohol vapors (19). In another study, mice demonstrated tolerance in environments different from the one in which the alcohol was administered (20). Significantly larger alcohol doses were necessary to establish this environment-independent tolerance than to establish environment-dependent tolerance (20)

Metabolic Tolerance

Tolerance that results from a more rapid elimination of alcohol from the body is called metabolic tolerance (2). It is associated with a specific group of liver enzymes that metabolize alcohol and that are activated after chronic drinking (21,22). Enzyme activation increases alcohol degradation and reduces the time during which alcohol is active in the body (2), thereby reducing the duration of alcohol's intoxicating effects.

However, certain of these enzymes also increase the metabolism of some other drugs and medications, causing a variety of harmful effects on the drinker. For example, rapid degradation of sedatives (e.g., barbiturates) (23) can cause tolerance to them and increase the risk for their use and abuse. Increased metabolism of some prescription medications, such as those used to prevent blood clotting and to treat diabetes, reduces their effectiveness in chronic drinkers or even in recovering alcoholics (24). Increased degradation of the common painkiller acetaminophen produces substances that are toxic to the liver (25) and that can contribute to liver damage in chronic drinkers.

Tolerance and the Predisposition to Alcoholism

Animal studies indicate that some aspects of tolerance are genetically determined. Tolerance development was analyzed in rats that were bred to prefer or not prefer alcohol over water (26,27). The alcohol-preferring rats developed acute tolerance to some alcohol effects more rapidly and/or to a greater extent than the non-preferring rats (26). In addition, only the alcohol-preferring rats developed tolerance to alcohol's effects when tested over several drinking sessions (27). These differences suggest that the potential to develop tolerance is genetically determined and may contribute to increased alcohol consumption.

In humans, genetically determined differences in tolerance that may affect drinking behavior were investigated by comparing sons of alcoholic fathers (SOA's) with sons of nonalcoholic fathers (SONA's). Several studies found that SOA's were less impaired by alcohol than SONA's (28,29). Other studies found that, compared with SONA's, SOA's were affected more strongly by alcohol early in the drinking session but developed more tolerance later in the drinking session (30). These studies suggest that at the start of drinking, when alcohol's pleasurable effects prevail, SOA's experience these strongly; later in the drinking session, when impairing effects prevail, SOA's do not experience these as strongly because they have developed tolerance (30). This predisposition could contribute to increased drinking and the risk for alcoholism in SOA's.

Alcohol and Tolerance--A Commentary by
NIAAA Director Enoch Gordis, M.D.

Tolerance can be a useful clue for clinicians in identifying patients who may be at risk for developing alcohol-related problems. For example, younger patients who are early in their drinking histories and who report that they can "hold their liquor well" may be drinking at rates that will place them at risk for medical complications from alcohol use, including alcoholism. The fact that tolerance to all of alcohol's effects does not develop simultaneously is also important; people who are mildly tolerant may exhibit more symptoms of impairment when faced with unfamiliar activities, such as driving in an unknown area, than when they are engaged in routine actions, such as driving home from work. Lastly, although we know that initial sensitivity to alcohol may play a role in the development of alcoholism, the role of tolerance in maintaining addiction to alcohol needs further exploration.

 

 

Withdrawal Symptoms

Withdrawal from alcohol dependence can bring on a variety of symptoms which can range from mild shakes to life-threatening delirium tremens and seizures. 

Alcohol Withdrawal
When heavy or frequent drinkers suddenly decide to quit "cold turkey" they will experience some physical withdrawal symptoms.

Alcohol Withdrawal Syndrome
The alcohol withdrawal syndrome is a cluster of symptoms observed in persons who stop drinking alcohol following continuous and heavy consumption.

Addiction Criteria
Nine criteria for determining if behavior has become addictive.

Alcohol Withdrawal Syndrome
Some people have mild shakiness and sweats. Some people hallucinate--they hear and see things that don't exist. The worst form of withdrawal is called "DTs" (delirium tremens).

Alcohol Withdrawal Seizures
Untreated, one-third of patients will go on to develop full-blown delirium tremens, and a small number will develop tonic-clonic status epilepticus.

Delirium Tremens
Delirium tremens (DT's) is an extremely serious problem which can appear in an alcohol dependent patient during alcohol withdrawal.

 

 

Hitting Bottom

 

For those suffering from the disease of alcoholism it seems to be an almost universal truth that before things can get better, they have to get worse -- sometimes a lot worse.

They call it "hitting bottom" -- the place an alcoholic must reach before he finally is ready to admit that he has a problem and reaches out for help.

After all, for the true alcoholic, it doesn't seem to him (or her) that he has a problem. He's just having a good time. If everybody would just get off his back, everything would be okay. He's got a disease, but it sure doesn't seem like one and the last thing that would ever occur to him is that he needs help.

Because alcoholism is a progressive disease, there comes a point at which even the most dedicated drunk decides that there just might be a problem.

Alcoholism does not stay in one place. It doesn't hit a certain stage and then level off. It keeps deepening, affecting him physically, mentally, morally and spiritually. On all of those levels he keeps getting worse until finally he hits bottom.

So where is bottom? Nobody really knows.

For some, getting that first DUI might be where the turning point comes. Getting locked up, even for a few hours, and facing the public humiliation of a court date is for some the only signal they need they have a problem.

For others, however, 10 drunk driving arrests have no affect whatsoever. Driving without a license and frequent visits to the local jail don't phase them at all.

Alcoholics have lost driver's licenses, jobs, careers, girlfriends, wives, family and children and have continued to deny they have a drinking problem.

It was always somebody else's fault. His wife just didn't understand him. The only reason he got that DUI was because he was driving a red vehicle and cops watch for red vehicles. He wouldn't have all the problems he's got if it weren't for those MADD mothers!

His boss was a real pain to put up with anyway. His career as a professional was going nowhere fast and besides he enjoys selling used cars -- gets to meet more people.

Some alcoholics go on for many years denying their downward spiral into social, economic and moral decline. But every alcoholic has a "bottom" out there to hit. A place where even the hardest of the hardcore drinkers finally admit that their lives have become unmanageable.  If this sounds familiar, there are a few questions that you might want to ask yourself about your own use of alcohol. It doesn't have to get any worse before you can find help putting your life back on track.

 

 



The partners of alcoholics often have serious social and psychological problems. However, some of their behavior may result in persistent alcohol related problems in their spouse or husband, or lead to the failure of treatment programs. Many physicians emphasize the importance of this by including the partner in family therapy, or by seeing the partner with or without the patient, for counseling to promote changes in the behavior which encourages their partner's alcoholism.

The partner of the alcoholic 

Many partners of alcoholics suffer anxiety, insomnia, tension and depression. They often feel a strong sense of guilt or anger and have a desire for vengeance, which they may take out on their children or colleagues at work.

The attitude of the partner 

In the therapeutic protocol, the partner may be as much a help as an obstacle. There is the supporting partner, on whom the alcoholic and the alcohol abuse specialist can count to help free the alcoholic from dependence, and the inducer partner, who in various ways and for various reasons, encourages the alcoholism of the other.

Often, the partner acts in such a way that the drinker is practically prevented from seeing the problems resulting from their alcohol consumption. For example, when the partner screens the alcoholic by making false excuses to employers for absenteeism, by paying off debts, or by being more attentive when the spouse is drunk than when they are sober. Only when the partner ceases to act as a protector can the drinker confront the real situation.

Another common situation is where the partner does not understand the drinker, gives constant reproaches, excessive surveillance, restrictions, threats, which in the majority of cases lead the alcoholic to drink more.

For reasons which are not clearly established, it seems that many alcoholic girls marry an alcoholic. These women often behave in such a way as to encourage continuation of their partner's alcohol abuse by making excuses and tolerating the situation.

With the help of alcohol abuse specialists, partners of alcoholics can overcome their anxieties and stop acting in a way which encourages their partner to drink.

The partner's role in successful withdrawal 

Many studies have emphasized the importance of the support of the partner and family. Encouragement given by the partner plays a key role in the withdrawal process, during which progress is too often accepted without comment, whilst failure is severely condemned. It is common for an alcoholic to stop drinking or reduce consumption because of changes occurring in the family - behavior is modified. Treatment has a greater chance of success in women if there is support from their spouse. However in almost half of cases, alcoholic women have a partner who also has an alcohol related problem, ensuring a close correlation between the behavior of them both.

 

 

 CODEPENDENCY

 

Why do I need help? He/she's the alcoholic!

 

Alcoholism is a disease that affects every member of the family, to the extent that the kids who make it into the Alateen rooms report they generally have more problems dealing with the non-drinking parent than they do the alcoholic.

What? But I don't have a problem! He... him... he's the alcoholic! He's the one who causes all the problems! He's the one in trouble all the time ...

True, but he's also predictable. Kids can read the alcoholic like a book. They know exactly when it's the right time to ask for extra money, or to go somewhere with their friends, and also know when it's time to make themselves scarce and get out of the way. They know the routine as far as the alcoholic is concerned. But they never know where the bedraggled non-drinking parent is coming from next.

One minute she (or he as the case may be) is screaming at the alcoholic -- threatening him with everything from from divorce to death -- and the next minute she may be compassionately rescuing him from the consequences of his latest episode -- dutifully cleaning up his messes, making excuses for him and accepting an increasing degree of unacceptable behavior.

The truth is the disease of alcoholism has affected her life, her attitude and her thinking perhaps more dramatically than it has the drinking spouse and she may not even realize it. Why? Because it crept up on her slowly.

A few years back, there was a story going around the 12-step rooms about a frog in the water. It goes like this:

If you put a frog into a pan of boiling water, it will jump out faster than the eye can see. But if you put the frog into a pan of water that is the frog's body temperature and then slowly turn up the heat the frog will stay in the water -- even to the point of boiling alive. Why?  Because the frog does not notice the gradual change in temperature.

Alcoholism works the same way... the heat is constantly turned up but nobody notices. Cunning and baffling! A progressive disease.   It may start out with casually accepting unacceptable behavior -- Oh, he didn't mean that, he just had too much to drink last night. A few years down the road the behavior has slowly grown more and more intolerable, but it is still being accepted and becomes the "norm."

She ends up with chaos in her own home that a few short years ago would have been unthinkable. If she looked out the window and saw the same kind of things taking place across the street at the neighbor's house, she would probably pick up the phone and call 9-1-1 to get those people some help!

As that same type of behavior becomes routine in her own home, the last thing that would occur to her is to pick up the telephone and get help. She has slowly been drawn into the thinking that the alcoholic should be protected. She has learned to cover for him, lie for him and hide the truth. She has learned to keep secrets, no matter how bad the chaos and insanity all around her has become.

Few who have been affected by the disease of alcoholism realize that by "protecting" the alcoholic with little lies and deceptions to the outside world, which have slowly but surely increased in size and dimension, she has actually created a situation that makes it easier for him to continue -- and progress -- in his downward spiral. Rather than help the alcoholic, and herself, she has actually enabled him to get worse.

The heat increased so gradually, over such an extended period of time, nobody noticed the water was beginning to boil and it was time to jump out of the pan.

The disease will continue to progress for the alcoholic until he is ready to reach out and get help for himself. Waiting for that to happen is not her only choice.

The other family members can begin to recover whether the alcoholic is still drinking or not. But it can't happen until somebody picks up that telephone and asks for help. There is hope and help out there.

 

Facts for Families
Pages that help sort out the confusion.

Family & Friends Support
Resources for those effected by someone else's drinking.

Denial Enabling Etc.
Dynamics of the family disease.

For the Children
Links for children in alcoholic homes.

Help for Parents
Tips and information for all parents.

Teens & Alcohol
Information about teenage drinking.

Nar-Anon Resources
For the friends and families of drug addicts.

 

 

ALCOHOL AND YOUTH

 

bulletThe median age at which children begin drinking is just over thirteen years.

 
bullet26% of eighth graders, 40% of tenth graders, and 50% of twelfth graders report having used alcohol in the past month.

 
bullet18% of eighth graders, 38% of tenth graders, and 52% of twelfth graders report having been drunk at least once in the last year.

 
bullet28% of high school seniors reported in 1994 that they had consumed five or more drinks at one sitting during the preceding two weeks.

 
bulletOne-quarter of sixth graders say it is "fairly easy" or "very easy" to get beer. 15% say it is as easy to get liquor. One study conducted in Washington, DC reported that 19- and 20-year old males were able to purchase a six-pack of beer in 97 out of 100 attempts.

 
bulletPurchase and public possession of alcohol by people under the age of 21 is illegal in all 50 states.

 
bullet56% of students in grades 5 to 12 say that alcohol advertising encourages them to drink.

 
bulletOver 80 percent of adults surveyed by the Bureau of Alcohol, Tobacco, and Firearms in 1988 believed that alcohol advertising influences underage youth to drink alcoholic beverages.

 

RISKS & CONSEQUENCES FOR YOUTH 

bulletAmong 9th-grade students, alcohol or other drug use, or a combination of substances, was the best predictor of early sexual activity and failure to use contraception. For youth, alcohol use more than any other single factor is responsible for more pregnancies, sexually transmitted diseases, and more HIV infections.

 
bulletHigh-school students who drink are four times more likely to have had sexual intercourse and twice as likely to have had four or more sex partners than non-drinkers, behaviors which increase the risk for HIV infection.

 
bulletMore than 2.6 million students do not know that a person can die from an overdose of alcohol.

 
bulletOne-third of high school seniors do not recognize the consumption of four or five drinks nearly every day as entailing "great risk".

 
bulletA projected 259,000 students think that wine coolers or beer cannot get a person drunk.

 
bulletDrinking among young people puts them at greater risk than their peers for involvement in crime as either actors or victims. Alcohol use is connected to provoking assailants, acting vulnerable, and failing to take normal, common-sense precautions to avoid being victimized.

 
bulletAlcohol use has been involved in as many as 50-65 percent of all suicides among youths.

 
bulletAlcohol is a factor in the three leading causes of death for 15-24 year olds: accidents, homicides, and suicides.

 
bulletIn 1994, more than 4000 drivers aged 16-24 were involved in fatal crashes involving alcohol.

 
bulletAlcohol use by college students is a factor in 40% of academic problems, 28% of dropouts, 80% of acts of vandalism.

 
bullet95% of violent crime on college campuses is alcohol-related. 90% of all reported campus rapes involve alcohol use by the victim or the perpetrator.