Ms. Wick is a senior clinical research
pharmacist at the National Cancer
Institute, National Institutes of Health,
Bethesda, Maryland. The views expressed
are those of the author and not those of
any government agency.
Individuals today drink two
thirds less than they did in the
1780s—when alcohol was a pharmacopeial
staple, a community ritual,
and a safer beverage than tainted
water or spoiled milk.1 National surveys
indicate that US alcohol consumption
and sales have decreased
since the 1980s.2 Regardless, alcohol
dependence and abuse are continuing
Understanding alcohol and problem
drinking is like assembling a bicycle
without directions—befuddling. Studies
use conflicting methodologies and
inconsistent definitions. People with
alcohol problems may be unreliable
historians. The relationship between
health risks and alcohol consumption is
nonlinear. Clinicians often misdiagnose
alcohol-related conditions, and considerable
debate exists on abstinence versus
A Matter of Degree
Individuals who meet 3 of the criteria
in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth
Edition (DSM-IV) are considered alcohol
dependent (Table). Abusers are not
dependent, but drink despite emotional,
occupational, physical, psychological,
or social problems.3 Abuse includes
binge drinking or drinking too much too
often without dependency.
When discussing alcohol,
sex and age are significant.
Men of any age are more likely
to drink than women peers.4
A recent study determined
that in the United States,
alcohol abuse disproportionately
affects the youth (31%
of problem drinkers), and
young adults rarely seek help
for drinking; periodic heavy
drinking is common.5
What's One Drink?
The Department of Health
and Human Services (HHS)
defines 1 drink as 0.5 oz or 15
g of alcohol (eg, 12 oz of beer,
5 oz of wine, 1.5 oz of 80-proof
distilled spirits). HHS defines
drinks daily for men and 1 for
women and heavy consumption
as any amount above
moderate levels.6 Men absorb
and metabolize alcohol faster
and have a larger volume of distribution,
so drink-for-drink, men's blood alcohol
levels are lower than women's.
Twenty years of daily alcohol intake
of 72 oz of beer, 1 L of wine, or 8 oz
of distilled spirits will lead to scarring,
fibrosis, and portal vein hypertension
in men. In women, the risk threshold
is 50% to 75% lower, and even through
abstinence, the elevated risk persists.7
The leaner body mass of the elderly
increases their sensitivity to alcohol;
their medical conditions and concurrent
drugs also are concerns. HHS recommends
that elders consume no more
than 1 drink daily.6
Benefits of Alcohol
Whereas alcohol increases the risk for
many conditions, studies link low-tomoderate
alcohol intake with a lower
risk for some conditions. This creates
a J-shaped alcohol?risk relationship
(Figure), which indicates that for some
conditions (eg, coronary artery disease,
thrombotic disease), abstainers are
at a higher risk than moderate drinkers.
Moderate drinking, therefore, may
be beneficial. It potentially improves
ulcerative colitis, macular degeneration,
and upper respiratory infection.8-15
Interpretation of these findings is complicated,
however, because moderate
drinkers often have other, unidentified
Abstinence Versus Controlled
Most Americans consider alcoholism a
progressive, irreversible disease marked
by loss of control. US health care providers
have traditionally preferred treatment
models that favor abstinence,
and most still avoid recommending
controlled drinking or moderation.
Abstinence advocates insist that controlled
drinking merely excuses alcoholism
and that eventually, individuals
will drink heavily again. Other models
acknowledge controlled drinking, citing
research findings that up to 75% of heavy
drinkers are not chemically dependent,
but abusers. Drinkers themselves may
be uninterested in abstinence and
may prefer to try controlled drinking.
Moderation advocates also suggest that
the American medical superstructure's
focus on abstinence has precluded funding
to study alternatives.6,16,17
Heavy drinkers often reduce their
alcohol consumption without formal
interventions or programs. Most experts
indicate that alcohol abuse decreases
with age. Spontaneous remission, treatment
interventions, and earlier alcoholrelated
mortality partially explain the
trend. Evidence suggests that women
may control drinking more successfully
than men, and moderate drinking might
be achievable for stress-triggered drinkers.
6,16,17 Many experts believe severely
dependent drinkers are more successful
with abstinence approaches, but moderation
is appropriate for those with
moderate problems.18,19 For people who
avoid Alcoholics Anonymous?type approaches
because of their reliance on a
higher power and unyielding structure,
interventions and developing cognitive
behavioral skills such as coping skills,
contracts, and consumption-reduction
strategies work better.6,16,17
Regardless, Risks Exist
Alcohol's circular and progressive effects
begin with an assault on the gastrointestinal
system, where it harms the
mucosa and impairs vitamin absorption.
Avitaminosis may cause neurologic
damage. Anemias, created by
inefficient, ineffective blood synthesis,
challenge the heart, lungs, and liver.
Elevated lipids follow, raising the spector
of cardiovascular problems. These
problems destroy baseline health and
invite infection. Concurrent smoking
and daily drinking triple the risk of cirrhosis
and increase the risk of head and
Pharmacologic Moderation or
In the past few years, drug treatments
have increased the likelihood that
people with alcohol problems find less
costly, more convenient, office-based
help.20 Indeed, office-based may be
this field's new buzz word. The ideal
pharmacologic intervention for alcohol
dependence or abuse would decrease
the craving, block the reinforcement
that intoxication delivers, and be free of
side effects. Although no such agent is
available, progress is being made, and
coupled with brief or ongoing behavioral
interventions, these drugs can help
people with drinking problems improve
their health prospects and quality of life
Tested in multicenter, placebo-controlled,
clinical trials with >4500 patients,
acamprosate increased abstinence rates
when used with multidisciplinary psychosocial
or behavioral therapies; however,
study findings have been inconsistent.
Mild side effects include diarrhea.21
Disulfiram produces an unpleasant alcohol intolerance by blocking acetaldehyde oxidation, increasing circulating acetaldehyde levels up to 10 times higher than normal. Alcohol exposure causes flushing, throbbing headache, nausea, vomiting, and respiratory symptoms. Patients must be highly motivated. Therapy can cause hepatic dysfunction, and chronic use of disulfiram is rare.22
Criteria for Alcohol Dependence
An alcohol-dependent person must meet 3 of the following criteria:
Persistent desire to drink or unsuccessful attempts at moderation
Inability to exercise control over drinking once begun
Withdrawal symptoms or avoidance of withdrawal
Tolerance—the need to increase intake to experience a high
Spending too much time drinking or recovering from drinking
Giving up or reducing normal activities in favor of drinking
Continuing to drink in the presence of a physical or psychological problem exacerbated by drinking
Adapted from reference 3.
Approved in 1995 for alcoholism, naltrexone tempers alcohol's euphoric effects. Available orally and as a monthly injection, naltrexone should not be started until patients are abstinent for 4 days. The best candidates are patients who have been drinking for <20 years, have strong family histories of alcoholism, experience strong cravings, are employed, and have a spouse or a similar social support system.20,23
Nalmefene is a newer opioid antagonist lacking agonist activity or abuse potential. Its bioavailability and half-life are better than naltrexone's; it causes no dose-dependent liver toxicity and binds more competitively with opioid receptor subtypes thought to reinforce drinking.24 Topiramate's ability to affect multiple systems seems to decrease alcohol cravings, especially in people with severe,
chronic alcohol dependence.25,26 Other agents with potential include baclofen27 and ondansetron.28-30
- Gibert Murdoch C. Domesticating Alcohol: Man, Women and Alcohol in America, 1870-1940. Baltimore, MD: The Johns Hopkins Press; 2006.
- Shute N. The drinking dilemma. U.S. News & World Report. 1997;123:54-64.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). 4th ed. Washington, DC: APA Press; 2000.
- Grant BF. Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: results of the National Longitudinal Alcohol Epidemiologic Survey. J Stud Alcohol. 1997;58:464-473.
- Moss HB, Chen CM, Yi HY. Subtypes of alcohol dependence in a nationally representative sample. Drug Alcohol Depend. 2007;91:149-158.
- U.S. Department of Health and Human Services. 10th Special Report to the U.S. Congress on Alcohol and Health. June 2000, NIH publication number 00-1583.
- Maher JJ. Exploring alcohol's effects on liver function. Alcohol Health Res World. 1997;21:5-12.
- Klatsky AL, Armstrong MA, Friedman GD. Alcohol and mortality. Ann Intern Med. 1992;117:646-654.
- Rimm EB, Giovannucci EL, Willett WC, et al. Prospective study of alcohol consumption and risk of coronary disease in men. Lancet. 1991;338:464-468.
- Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med. 1997;337:1705-1714.
- Scherr PA, LaCroix AZ, Wallace RB, et al. Light to moderate alcohol consumption and mortality in the elderly. J Am Geriatr Soc. 1992;40:651-657.
- Gaziano JM, Buring JE, Breslow JL, et al. Moderate alcohol intake, increased levels of high-density lipoprotein and its subfractions, and decreased risk of myocardial infarction. N Engl J Med. 1993;329:1829-1834.
- Suh I, Shaten BJ, Cutler JA, Kuller LH. Alcohol use and mortality from coronary heart disease: the role of high-density lipoprotein cholesterol. The Multiple Risk Factor Intervention Trial Research Group. Ann Intern Med. 1992;116:881-887.
- Pahor M, Guralnik JM, Havlik RJ, et al. Alcohol consumption and risk of deep venous thrombosis and pulmonary embolism in older persons. J Am Geriatr Soc. 1996;44:1030-1037.
- Obisesan TO, Hirsch R, Kosoko O, Carlson L, Parrott M. Moderate wine consumption is associated with decreased odds of developing age-related macular degeneration in NHANES-1. J Am Geriatr Soc. 1998;46:1-7.
- Walitzer KS, Connors GJ. Thirty-month follow-up of drinking moderation training for women: a randomized clinical trial. J Consult Clin Psychol. 2007;75:501-507.
- Hersey B. The controlled drinking dilemma: A review of four decades of acrimony. www.doctordeluca.com/library/abstinenceHR/FourDecadesAcrimony-print.htm. Accessed February 17, 2003.
- Humphreys K, Klaw E. Can targeting nondependent problem drinkers and providing internet-based services expand access to assistance for alcohol problems? A study of the moderation management self-help/mutual aid organization. J Stud Alcohol. 2001;62:528-532.
- Linke S, Murray E, Butler C, Wallace P. Internet-based interactive health intervention for the promotion of sensible drinking: patterns of use and potential impact on members of the general public. J Med Internet Res. 2007;9:e10.
- Kuehn BM. New therapies for alcohol dependence open options for office-based treatment. JAMA. 2007;298:2467-2468.
- Mason BJ, Crean R. Acamprosate in the treatment of alcohol dependence: clinical and economic considerations. Expert Rev Neurother. 2007;7:1465-1477.
- Johnson BA. Update on neuropharmacological treatments for alcoholism: Scientific basis and clinical findings. Biochem Pharmacol. 2008;75:34-56.
- Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2000;:CD001867.
- Karhuvaara S, Simojoki K, Virta A, et al. Targeted nalmefene with simple medical management in the treatment of heavy drinkers: a randomized double-blind placebo-controlled multicenter study. Alcohol Clin Exp Res. 2007;31:1179-1187.
- Johnson BA, Rosenthal N, Capece JA, et al. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007;298:1641-1651.
- Ma JZ, Ait-Daoud N, Johnson BA. Topiramate reduces the harm of excessive drinking: implications for public health and primary care. Addiction. 2006;101:1561-1568.
- Addolorato G, Leggio L, Ferrulli A, et al. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet. 2007;370:1915-1922.
- Dawes MA, Johnson BA, Ait-Daoud N, Ma JZ, Cornelius JR. A prospective, open-label trial of ondansetron in adolescents with alcohol dependence. Addict Behav. 2005;30:1077-1085.
- Johnson BA, Ait-Daoud N, Ma JZ, Wang Y. Ondansetron reduces mood disturbance among biologically predisposed, alcohol-dependent individuals. Alcohol Clin Exp Res. 2003;27:1773-1779.
- Johnson BA, Roache JD, Ait-Daoud N, Zanca NA, Velazquez M. Ondansetron reduces the craving of biologically predisposed alcoholics. Psychopharmacology (Berl). 2002;160:408-413.