Alcohol is a drug, social lubricant, and agent of abuse; alcohol abuse and dependence exist along a continuum, and different approaches can help.
Ms. Wick is a senior clinical researchpharmacist at the National CancerInstitute, National Institutes of Health,Bethesda, Maryland. The views expressedare those of the author and not those ofany government agency.
Individuals today drink twothirds less than they did in the1780s—when alcohol was a pharmacopeialstaple, a community ritual,and a safer beverage than taintedwater or spoiled milk.1 National surveysindicate that US alcohol consumptionand sales have decreasedsince the 1980s.2 Regardless, alcoholdependence and abuse are continuingconcerns.
Understanding alcohol and problemdrinking is like assembling a bicyclewithout directions—befuddling. Studiesuse conflicting methodologies andinconsistent definitions. People withalcohol problems may be unreliablehistorians. The relationship betweenhealth risks and alcohol consumption isnonlinear. Clinicians often misdiagnosealcohol-related conditions, and considerabledebate exists on abstinence versusmoderation.
Individuals who meet 3 of the criteriain the Diagnostic and StatisticalManual of Mental Disorders, FourthEdition (DSM-IV) are considered alcoholdependent (Table). Abusers are notdependent, but drink despite emotional,occupational, physical, psychological,or social problems.3 Abuse includesbinge drinking or drinking too much toooften without dependency.
When discussing alcohol,sex and age are significant.Men of any age are more likelyto drink than women peers.4A recent study determinedthat in the United States,alcohol abuse disproportionatelyaffects the youth (31%of problem drinkers), andyoung adults rarely seek helpfor drinking; periodic heavydrinking is common.5
The Department of Healthand Human Services (HHS)defines 1 drink as 0.5 oz or 15g of alcohol (eg, 12 oz of beer,5 oz of wine, 1.5 oz of 80-proofdistilled spirits). HHS definesmoderate drinkingas 2drinks daily for men and 1 forwomen and heavy consumptionas any amount abovemoderate levels.6 Men absorband metabolize alcohol fasterand have a larger volume of distribution,so drink-for-drink, men's blood alcohollevels are lower than women's.
Twenty years of daily alcohol intakeof 72 oz of beer, 1 L of wine, or 8 ozof distilled spirits will lead to scarring,fibrosis, and portal vein hypertensionin men. In women, the risk thresholdis 50% to 75% lower, and even throughabstinence, the elevated risk persists.7The leaner body mass of the elderlyincreases their sensitivity to alcohol;their medical conditions and concurrentdrugs also are concerns. HHS recommendsthat elders consume no morethan 1 drink daily.6
Whereas alcohol increases the risk formany conditions, studies link low-tomoderatealcohol intake with a lowerrisk for some conditions. This createsa J-shaped alcohol?risk relationship(Figure), which indicates that for someconditions (eg, coronary artery disease,thrombotic disease), abstainers areat a higher risk than moderate drinkers.Moderate drinking, therefore, maybe beneficial. It potentially improvesulcerative colitis, macular degeneration,and upper respiratory infection.8-15Interpretation of these findings is complicated,however, because moderatedrinkers often have other, unidentifiedrisk-lowering habits.
Most Americans consider alcoholism aprogressive, irreversible disease markedby loss of control. US health care providershave traditionally preferred treatmentmodels that favor abstinence,and most still avoid recommendingcontrolled drinking or moderation.Abstinence advocates insist that controlleddrinking merely excuses alcoholismand that eventually, individualswill drink heavily again. Other modelsacknowledge controlled drinking, citingresearch findings that up to 75% of heavydrinkers are not chemically dependent,but abusers. Drinkers themselves maybe uninterested in abstinence andmay prefer to try controlled drinking.Moderation advocates also suggest thatthe American medical superstructure'sfocus on abstinence has precluded fundingto study alternatives.6,16,17
Heavy drinkers often reduce theiralcohol consumption without formalinterventions or programs. Most expertsindicate that alcohol abuse decreaseswith age. Spontaneous remission, treatmentinterventions, and earlier alcoholrelatedmortality partially explain thetrend. Evidence suggests that womenmay control drinking more successfullythan men, and moderate drinking mightbe achievable for stress-triggered drinkers.6,16,17 Many experts believe severelydependent drinkers are more successfulwith abstinence approaches, but moderationis appropriate for those withmoderate problems.18,19 For people whoavoid Alcoholics Anonymous?type approachesbecause of their reliance on ahigher power and unyielding structure,interventions and developing cognitivebehavioral skills such as coping skills,contracts, and consumption-reductionstrategies work better.6,16,17
Alcohol's circular and progressive effectsbegin with an assault on the gastrointestinalsystem, where it harms themucosa and impairs vitamin absorption.Avitaminosis may cause neurologicdamage. Anemias, created byinefficient, ineffective blood synthesis,challenge the heart, lungs, and liver.Elevated lipids follow, raising the spectorof cardiovascular problems. Theseproblems destroy baseline health andinvite infection. Concurrent smokingand daily drinking triple the risk of cirrhosisand increase the risk of head andneck cancer.9
In the past few years, drug treatmentshave increased the likelihood thatpeople with alcohol problems find lesscostly, more convenient, office-basedhelp.20 Indeed, office-based may bethis field's new buzz word. The idealpharmacologic intervention for alcoholdependence or abuse would decreasethe craving, block the reinforcementthat intoxication delivers, and be free ofside effects. Although no such agent isavailable, progress is being made, andcoupled with brief or ongoing behavioralinterventions, these drugs can helppeople with drinking problems improvetheir health prospects and quality of lifeimmensely.
Tested in multicenter, placebo-controlled,clinical trials with >4500 patients,acamprosate increased abstinence rateswhen used with multidisciplinary psychosocialor 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
An alcohol-dependent person must meet 3 of the following criteria:
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