Posted on February 27, 2024

There are 10 different classes of drugs each having a different pharmacologic mechanism, but have been identified as drugs of choice in substance abuse disorders.This month let’s look deeper into alcohol and its effects.

All drugs of abuse affect the brain’s reward system or pathways.
Alcohol, food and other drugs of abuse have similar effects on dopamine receptors.
The development of addiction, including alcohol, is affected by genetic predisposition and influenced by alterations in the rewarding chemicals released per dose.^1-5

Historical Background

From the earliest days of colonial settlement to the present, Americans have been drinking alcohol.

In 1741, Benjamin Franklin, when listing the thirteen cardinal virtues, started with “Temperance: Drink not to elevation.”

Dr. Benjamin Rush, a signer of the Declaration of Independence who is also known as the “father of American psychiatry”, became alarmed by what he viewed as rampant health problems caused by alcohol, and he called for temperance.

He described addiction and identified alcohol as an addictive substance.

With accurate precision, Dr. Rush, a citizen of the Enlightenment Age, described alcohol use disorder, which is now included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Dr. Rush suggested using whippings, bleeding, shame, emetics, oaths, and plunging the patient into cold water as methods to treat alcoholism.

American attitudes about alcohol have flip-flopped from a free marketplace in the 18^th and 19^th centuries, to Prohibition in the 1920s, to the repeal of Prohibition in the 1930s, to lowering of the legal drinking age in most states during the 1960s and early 1970s, and a return to the 21-year-of-age limit with the National Minimum Drinking Age Act of 1984.

For centuries, alcohol has been part of our social fabric and part of holidays and traditions.

Simultaneously, our society has either shunned or punished those who succumbed to alcohol abuse, treating dependence as a legal issue or a moral failing rather than as a mental health problem.

On one hand, alcohol is readily and cheaply accessible, safe for most people, and an important sector of our economy. However, we also understand that some individuals are at a high risk of losing control over alcohol.

Current Estimates and Costs of Alcohol Use

90% of adults in the United States have had some experience with alcohol.⁶People drink alcohol for a variety of reasons:

The pleasurable feeling that often accompanies drinking, including reduced tension and/or anxiety.
Enjoyment of the taste.
Social inclusion.
Self-medication.
Peer pressure.
Behavioral and physical addiction.

About 40% of people who drink have experienced an alcohol-related problem.⁶ Between 3% and 8% of women and 10% to 15% of men will develop alcohol use disorder at some point in their lives.

While alcohol use disorders can develop at any age, repeated
intoxication at an early age increases the risk of developing an alcohol use disorder.⁶

Usually, dependence develops in the mid-twenties through age forty.

Alcohol use disorder generally reduces the lifespan by 26 years.¹³

Alcohol is just about everywhere. It is one of the most dangerous of the abused drugs.

It interferes with judgment and performance.
Promotes aggressive behavior.
It is associated with accidents and fatalities.
Alcohol changes brain structure, function and chemical makeup.
It is often found in the blood tests of perpetrators of violent behavior like murder and in brutal domestic violence disputes.
Pregnant mothers who use alcohol put their unborn babies at risk for Fetal Alcohol Spectrum Disorder (FASD) that can cause brain damage and other abnormalities.
Even small amounts of alcohol elevates one’s mood, reduces anxiety, and makes one tired.
Very large amounts of alcohol can produce respiratory depression, that can be followed by coma and death.
Long-term complications of alcohol use is liver disease (fatty liver and liver cirrhosis).
Heavy drinkers, who stop, can experience a severe withdrawal syndrome called delirium tremens (the “DTs”).
Depending on care, health problems, and level of addiction, 5% to 15% of people in withdrawal may actually die.

The DSM-5 defines alcohol use disorder, also known as alcohol abuse and/or dependence, as a problematic pattern of use that includes two or more of the following criteria over a one-year period ⁷:

People often consume alcohol in larger amounts or over a longer period than they intended.
A persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent on activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Cravings or a strong desire or urge to use alcohol.
Recurrent alcohol use results in a failure to fulfill major role obligations at work, school or home.
Continues alcohol use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
They continue to use alcohol despite being aware that it likely caused or worsened their persistent problem.
Tolerance.
Withdrawal.

Alcohol use disorder is extremely amenable to brief intervention. Brief intervention by a healthcare professional usually includes giving the person information about problems associated with excessive drinking and advising them to cut down on their drinking or abstain.

Without intervention, 10% will likely progress to dependence and 50% to 60% will continue to experience problems over the next five years.^8,9
Alcohol use disorder is a primary and chronic disease that is progressive and often fatal. It is not a symptom of another physical or mental condition.
It is a disease in itself, like cancer or heart disease, with a very recognizable set of symptoms that are shared by others with the same disorder.
About 29.5 million people in the United States met DSM-5 criteria for alcohol use disorder in 2022.¹⁰

Complications Associated with Alcohol Use Disorder

Liver Disease:

The liver becomes a vulnerable organ to alcohol consumption because it metabolizes alcohol prior to elimination from the body.

Men who drink as few as 6 drinks a day (Standard drink: 1.5 ounces of 80-proof distilled spirits, 5 ounces of table wine, or 12 ounces of standard beer) are at risk of developing liver damage.^11,12

The most common manifestation among persons with alcohol use disorder is “fatty liver.”

Among heavy drinkers (five or more drinks on the same occasion on each of 5 or more days in the past 30 days)¹³, the incidence of fatty liver is almost universal. For some, fatty liver may precede the onset of alcoholic cirrhosis.

Alcoholic hepatitis is a condition that may cause jaundice (yellowing of the skin and whites of the eyes), fever, loss of appetite (anorexia) and right upper-quadrant pain.

Between 10% and 35% of heavy drinkers develop alcoholic hepatitis.
10% to 20% develop cirrhosis.^14,15
More than 60% of people who develop alcoholic hepatitis and cirrhosis will die within four years.
Drinking 12 beers a day for 20 years has been associated with a 50% incidence of cirrhosis. We do not know which individuals will develop cirrhosis.
Studies have shown that women develop liver disease faster than men.^15,16
Women also have a higher incidence of alcoholic hepatitis and higher mortality rate from cirrhosis.¹⁷

Alcohol use disorder is also a strong predictive factor for the development of hepatocellular cancer.¹⁸

The presence of other hepatic risk factors, including hepatitis C, fatty liver disease, smoking, and obesity, further increases this risk.

Liver Transplantation

The leading indication for liver transplantation in the United States is chronic hepatitis C.¹⁹ Cirrhosis because of alcoholic liver disease is the second most common cause for a person to require liver transplantation.

Alcohol/Acetaminophen (Tylenol)

Chronic heavy drinking appears to activate the enzyme CYP2E1, which may be responsible for transforming the over-the-counter pain reliever acetaminophen (Tylenol) into toxic metabolites that can cause liver damage.²⁰

Even when acetaminophen is taken in standard therapeutic dose, liver damage has been reported in this population.^21,22

A review of studies for individuals with alcohol use disorder, indicate the liver damage may result from taking as little as 2.6 grams of acetaminophen (four to five “extra-strength” pills) taken over the course of the day by persons consuming varying amounts of alcohol.²³

The damage caused by alcohol-acetaminophen interaction is more likely to occur when acetaminophen is taken after, rather than before, the alcohol has been metabolized.²⁴

Cardiovascular Disorders:

Alcohol can have a detrimental effect on the heart including²⁵:

A decrease in myocardial contractility (decreased ability of the heart to contract).
Hypertension (high blood pressure).
Atrial (upper chambers of the heart) and ventricular (lower chambers of the heart) arrythmias.
Secondary nonischemic dilated cardiomyopathy (form of heart failure).
Elevated pulse.

Vitamin Deficiency, Alcohol and Cardiovascular Disease

Studies have shown that abnormally high blood levels of the amino acid homocysteine increase the risk for cardiac and other vascular diseases.²⁶
Vitamins like folate, B12, and B6 are required for homocysteine disposal within cells.
The lower the concentration of these and other vitamins, the greater the concentration of homocysteine.
Researchers have found that malnourished persons with alcohol use disorder and liver diseases suffer from deficiencies in B6 and folate.
Lowering homocysteine with B vitamin supplementation may reduce cardiovascular risk.^27,28
Further research is necessary to determine whether abstinence and recovery reverses the risk of cardiovascular disease, and whether folate and vitamin B12 and B6 should be nutritional supplements for persons with alcohol use disorder.²⁹

Cancer:

Heavy drinking increases the risk of cancer of the upper gastrointestinal and respiratory tracts.³⁰
Almost 50% of cancers of the mouth, pharynx and larynx and approximately 75% of esophageal cancers in the United States are associated with chronic, excessive alcohol consumption.^31,32,33
One study found that combining alcohol consumption with tobacco use significantly increased the risk of esophageal cancer, up to 130-fold.^34,35
Alcohol increases production of estradiol, and increased levels of estradiol have been linked to an increased risk of breast cancer in women who drink.³⁶

Gastrointestinal Disorders:

Alcohol produces irritation and inflammation of the mucosal lining of the gastrointestinal tract and influences the motility (movement) in the esophagus, stomach, and small bowel.³⁷
Ulceration may occur with excessive alcohol use.
The well-known alcohol related “heartburn” is because of esophageal reflux with esophagitis that commonly occurs with irritation and inflammation of the gastroesophageal junction (where the end of the esophagus joins the top of the stomach).
Patients who have undergone gastric bypass surgery for obesity have higher breath-alcohol levels after drinking the same amount as other people.³⁸

Chronic Pancreatitis:

Alcohol consumption is the leading cause of chronic pancreatitis, accounting for approximately 70% of cases in the United States. However, fewer than 10% of heavy alcohol drinkers develop the disease.^39-43

Individuals with alcohol use disorder may develop diabetes mellitus or hyperglycemia because of chronic pancreatitis, which eventually destroys the islet cells in the pancreas.

Once alcohol-induced chronic pancreatitis has developed, ingestion of even small amounts of alcohol can result in severe flare-up requiring hospitalization.

Malnutrition:

Excessive drinking may interfere with the absorption, digestion, metabolism, and utilization of nutrients, particularly vitamins.

Individuals with alcohol use disorder often use alcohol as a source of calories to the exclusion of other food sources, which may also lead to nutrient deficiency and malnutrition.

In the late stage of the disease, a person may develop anorexia (loss of appetite), and refuse to eat.
Persons with alcohol use disorder account for a significant proportion of patients hospitalized for malnutrition.⁴⁴
Direct toxic effects of alcohol on the small bowel causes a decrease in the absorption of water-soluble vitamins (e.g., thiamine, folate, B6).
The effects of alcohol are dose dependent and the results of malnutrition, malabsorption, and ethanol toxicity.⁴⁵
Vitamins A,C, D, E, K, and the B vitamins are deficient in some individuals with alcohol use disorder.
These vitamins are involved in wound healing and cell maintenance.
Because vitamin K is necessary for blood clotting, deficiencies can cause delayed clotting and result in excess bleeding.
Vitamin A deficiency can be associated with night blindness.
Vitamin D deficiency is associated with softening of the bones.
Deficiencies of other vitamins involved in brain function can cause severe neurologic damage (e.g., deficiencies of folic acid, pyridoxine (vitamin B6), thiamine (vitamin B1), iron and zinc).
Thiamine deficiency (vitamin B1) from chronic heavy alcohol consumption can lead to devastating neurologic complications, cerebellar degeneration, dementia and peripheral neuropathy.⁴⁶

Infectious Diseases:

Alcohol abuse is a major risk factor for many infectious diseases, especially pulmonary infections.⁴⁷
Studies have shown that alcohol abuse increases the risk for acute respiratory distress syndrome and chronic obstructive pulmonary disease (COPD).^48-51
Pneumonia, tuberculosis and other pulmonary infections are frequent with alcohol use disorder.⁵²
Acute and chronic alcohol abuse also increase the risk for aspiration pneumonia.

Sleep Disorders:

Although some people believe that alcohol helps them sleep, chronic excessive drinking can induce sleep disorders by disrupting the sequence and duration of sleep states and by altering total sleep time, as well as the time required to fall asleep.^53,54

Specifically, drinking within one hour of bedtime appears to disrupt the second half of the sleep period.⁵⁵ The person may sleep poorly during the second half of sleep, awakening from dreams and returning to sleep with difficulty, resulting in daytime fatigue and sleepiness.^56,57
Individuals with alcohol use disorder may be at risk for increased sleep apnea, a disorder in which the upper air passage narrows or closes during sleep.^57-60
The combination of alcohol, obstructive sleep apnea, and snoring increases a person’s risk for heart attack, arrhythmia, stroke, and sudden death.⁶¹
Obstructive sleep apnea significantly increases the risk of stroke or death from any cause, independent of other risk factors, including hypertension.^62,63

Nervous System Dysfunction:

The most common neurologic abnormality among persons with alcohol use disorder is dementia syndrome, which manifests primarily as impairment in recent memory, and more subtle fluctuations in abstractions, calculations, and other aspects of cognitive function.

One specific neurologic complication resulting from thiamine deficiency is Wernicke-Korsakoff Syndrome, which involves delirium, clouded sensorium, confusion, ophthalmoplegia (paralysis of the extraocular muscles that control the movements of the eye), nystagmus (an involuntary eye movement which may cause the eye to move rapidly from side to side, up and down, or in a circle, and may slightly blur vision) and ataxia (impaired balance or coordination due to damage to the brain, nerves or muscles).⁶⁴

The acute effects of alcohol on the nervous system are signs people commonly think of when they envision an intoxicated person:

Slurred speech.
Loss of coordination.
Unsteady gait.
Impairment of attention or memory.
Nystagmus.
Stupor.
Coma.

The impairment of the central nervous system is directly proportional to the BAC (Blood Alcohol Concentration: The percentage of alcohol present in the bloodstream). A blood sample or a breath sample, collected by a “Breathalyzer“ provides the measurement. The national legal limit for intoxication is a BAC of 0.08.

Complications Specific to Women

On average, women show the effects of alcohol more immediately, more intensely, and for longer periods of time than men.
They achieve higher concentrations of alcohol in the blood after drinking the same amounts of alcohol.⁶⁵
Women also produce a lower level of the enzyme to break down alcohol.
Female hormones make women’s bodies more susceptible to alcohol at certain times of the menstrual cycle.
Women tend to be shorter and weigh less than men. Because women generally have a higher percentage of body fat, they reserve alcohol in the body for longer periods of time. This is important because when a person consumes a large amount of alcohol, their body stores it in fatty tissue.
Neurophysiology (nervous system function) is more compromised in women with alcohol use disorder than men.⁶⁶

Fetal Alcohol Spectrum Disorder

The dangers of drinking while pregnant are well-documented. Pregnant women who drink risk the chance of their child developing FASD.⁶⁷

For a deeper look into FASD and issues surrounding drinking alcohol and drug use while pregnant, please refer to the December 2023 article for Insights, Substance Use Disorder and the Unborn.

The Centers for Disease Control and Prevention (CDC) reported in 2020 that 11.3% of pregnant women 18 to 44 years of age used alcohol and 4.0% were binge drinkers. According to the CDC, drinking while pregnant costs the United States $5.5 billion annually. Additionally, an estimated 6 to 9 out of 1,000 U.S. school children may have FASD.⁶⁷ Binge drinking among pregnant women during the first trimester increased from 10.8% in 2015-2016, to 12.6% in 2019.⁶⁸

FASD is 100% preventable when pregnant women abstain from drinking alcohol.^69,70

Effects on Families:

Living with a non-recovering family member with alcohol use disorder can contribute to stress for all members of a family.

Children raised in these families have different life experiences than children raised in nonalcoholic families.
Children living with a non-recovering alcoholic score lower on measures of family cohesion, intellectual cultural orientation, active recreational orientation, and independence.
They experience higher levels of conflict within the family.
Many children of alcoholics feel that other family members are distant and noncommunicative, which may impede their developmental growth in healthy ways.
Alcohol use disorder usually has strong negative effects on marital relationships.
Separated and divorced men and women were three times as likely as married men and women to say they had been married to a person with alcohol use disorder or problem drinker.

Child Abuse

The majority of studies suggest an increased prevalence of alcohol use disorder among parents who abuse children.

Existing research suggests that alcoholism is more strongly related to child abuse than are other disorders, such as parental depression, but the most important factor is whether the abusive parent was abused as a child or witnessed a parent or sibling being abused.

Although several studies report very high rates of alcoholism among parents of incest victims, much additional research in this area is needed.^71,72

Violence:

Among some individuals, excess alcohol consumption is associated with the risk of violent behavior.

Alcohol may encourage aggression or violence by disrupting normal brain function, especially in levels of serotonin.

There is considerable overlap among nerve cell pathways in the brain that regulate aspects of aggression, sexual behavior, and alcohol consumption. Alcohol may weaken brain mechanisms that normally restrain impulsive behaviors, including inappropriate aggression.

Traffic Accidents:

10,142 people died in alcohol-related traffic fatalities in 2019, accounting for 28% of all traffic-related deaths in the United States.⁷³
Of the 1,233 traffic fatalities that year among children 0 to 14 years of age, 214 (17%) involved an alcohol-impaired driver.⁷⁴
U.S. adults admitted to 111 million episodes of alcohol-impaired driving, and law enforcement apprehended nearly 1.1 million drivers for driving under the influence.⁷⁴
The CDC estimates that 29 people in the United States die in alcohol-related crashes every day.⁷⁴
In a study of persons who have been convicted of driving while impaired, 85% of women and 91% of men reported a lifetime alcohol use disorder.⁷⁵

Psychiatric comorbidity may be a key element distinguishing driving under the influence (DUI) offenders from others and in distinguishing repeat offenders from first-time offenders.⁷⁶

Detecting Alcohol Use Disorders

Medical professionals give the diagnosis of alcohol use disorder (AUD) to problem drinking, describing it as severe.

About 14.4 million adults 18 years of age and older in the United States have an AUD, including 9.2 million men and 5.3 million women.⁷⁷

In addition, about 401,000 adolescents 12 to 17 years of age had an alcohol use disorder.

Screening Instruments for Detecting Alcohol Use Disorder

A variety of screening instruments are available to detect unhealthy alcohol use by adults.

After conducting a systematic evidence review of trials published between 1985 and 2011 on screening and behavioral counseling interventions for unhealthy alcohol use in adults, the U.S. Prevention Services Task Force (USPSTF) recommends that clinicians screen all patients 18 years of age or older for alcohol abuse using one of the following tools:

Abbreviated three-question AUDIT-Consumption (AUDIT-C):

This is a screening tool that can help identify persons who are at-risk drinkers, who may not be alcohol dependent, or who have active alcohol use disorders, including abuse or dependence.⁷⁸

1. How often do you have a drink containing alcohol?

0 Never

1 Monthly or less

2 2 to 4 times a month

3 2 to 3 times a week

4 4 or more times a week.

2. How many standard drinks containing alcohol do you have on a typical day?

0 Never

1 3 or 4

2 5 or 6

3 7 or 8

4 10 or more

3. How often do you have six or more drinks on one occasion?

0 Never

1 Less than monthly

2 Monthly

3 Weekly

Single Alcohol Screening Question (SASQ):

The SASQ consists of one question⁷⁹: “How many times in the past year have you had X or more drinks in a day?

The question is individualized based on sex, with X being five for men and four for women. A response of more than one is considered positive and requires additional assessment.

Treatment

Treatment works even if someone is coerced, or the court mandates it for alcohol use disorder.

People who decide to stop drinking will find the treatment and support they need to quit, remain sober, and regain their lives. However, as with treatment for any other disease, it is important to have a good idea of the options available to make informed choices.

Phases of Treatment

Phase 1: Assessment and evaluation of disease symptoms and accompanying life problems, including co-occurring medical and psychiatric conditions, acute stabilization of comorbid conditions, making treatment choices, and developing a plan.

Phase 2: Residential treatment or therapeutic communities, regular outpatient treatment, medications to help with alcohol craving and to discourage alcohol use, medications to treat concurrent psychiatric illnesses, treatment of concurrent medical conditions, trauma and family therapy, 12-step programs, other self-help and mutual-help groups.

Phase 3: Maintaining sobriety and relapse prevention with ongoing outpatient treatment as needed, facilitated group meetings, contingency management, 12-step programs, other self-help and mutual-help groups.

Drug testing frequently, randomly and for-cause should be a mandatory component of all phases. Transition from one phase to the next should not be based on time but on individual symptoms and progress.

Conclusion

Like cancer and many other chronic diseases, alcohol use disorder progresses.
People with alcohol use disorder experience physical, emotional, and other changes in their lives and relationships.
These changes may worsen if individuals continue drinking and do not start treatment.
Left untreated, alcohol use disorder may lead to premature death through overdose or through damage to the brain, liver, heart, and many other organs.
Excess alcohol consumption is highly associated with suicide, motor vehicle accidents, violence, and other traumatic events.⁸⁰
People with untreated alcohol use disorder often lose their jobs, their families, their relationships, and other freedoms that were once important to them.
Early identification and brief intervention can often prevent alcohol problems.

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Written by Cynthia Blair RN MA–February 2024

Original Publication: https://www.soulsharbordallas.org/2024/02/alcohol-and-alcohol-use-disorder/