Alcohol: Drug or Social Amenity?

DECEMBER 01, 2008
Jeannette Y. Wick, RPH, MBA, FASCP

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 concerns.

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 moderation.

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 moderate drinking as 2 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 risk-lowering habits.

Abstinence Versus Controlled Drinking

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 neck cancer.9

Pharmacologic Moderation or Abstinence

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 immensely.

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

    Under Study
    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


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