Alcohol Use Disorder (Alcoholism)

What is alcohol use disorder?

In an alcohol use disorder (AUD, commonly called alcoholism), excessive alcohol use causes symptoms affecting the body, thoughts and behavior. A hallmark of the disorder is that the person continues to drink despite the problems that alcohol causes. There is no absolute number of drinks per day or quantity of alcohol that defines an alcohol use disorder, but above a certain level, the risks of drinking increase significantly.

Here are some defining characteristics of alcohol dependence:

Drinking more than intended. Loss of control over the amount of alcohol used.
Desire to stop drinking, but inability to do so.
Excessive time spent getting or using alcohol, or recovering from its effects.
Craving, or preoccupation with drinking.
Problems stemming from alcohol use; ignoring those problems; drinking despite obvious hazards, including physical danger.
Retreating from important work, family or social activities and roles.
Tolerance — The need to drink more and more alcohol to feel the same effects, or the ability to drink more than other people without getting drunk.
Withdrawal symptoms — After stopping or cutting back on drinking, symptoms are anxiety, sweating, trembling, trouble sleeping, nausea or vomiting, and, in severe cases, physical seizures and hallucinations. The person may drink to relieve or avoid such symptoms.

A person with alcohol use disorder has come to rely on alcohol physically, psychologically and/or emotionally. The brain adapts to the presence of alcohol and undergoes persistent changes. When alcohol use suddenly stops, the body is not accustomed to being alcohol free. The internal environment changes drastically, causing symptoms of withdrawal.

Excessive alcohol use can be associated with many psychological, interpersonal, social, economic and medical problems. It can increase the risk of depression and suicide. It can play a role in violent crimes, including homicide and domestic violence (abuse of a spouse or child). It can lead to traffic accidents and even accidents involving intoxicated pedestrians who decide to walk home after drinking. AUD also can lead to unsafe sexual behavior, resulting in accidental pregnancy or sexually transmitted diseases.

Alcohol use disorder increases the risk of liver disease (hepatitis and cirrhosis), heart disease, stomach ulcers, brain damage, stroke and other health problems. In pregnant women who drink alcohol, there is also the danger that the child will develop fetal alcohol syndrome, a cluster of health problems including unusually low birth weight, facial abnormalities, heart defects and learning difficulties.

Alcohol problems come about from a combination of biological tendencies and environmental influences.

Biology. People with a family history of alcohol use disorder are at greater risk for developing the illness themselves. For example, if a parent has AUD, a child has a four-times greater risk of becoming a problem drinker. This is partly due to inheriting genes that increase vulnerability, perhaps by governing a person's physical responses to alcohol or the experience of intoxication. Sometimes alcohol is used to blot out feelings arising from an underlying depression or anxiety disorder.
Environment. Alcohol may be a big part of a person's social group or may have been a part of family life (sometimes quite destructively). A person may turn to alcohol to get relief from stress (which frequently backfires, because the drinking causes problems of its own). Family support and healthy friendships can reduce the risk.

Symptoms of alcohol use disorder

Alcohol use disorder can involve any of the following symptoms or behaviors:

long episodes of intoxication
drinking alone
work problems or financial problems caused by drinking
losing interest in food
carelessness about personal appearance
blackouts
driving drunk
hurting oneself or someone else while intoxicated
hiding liquor bottles and glasses to hide the evidence of drinking
mood or personality changes.

Because large amounts of alcohol can be toxic to the body (for example, the cardiovascular, gastrointestinal or nervous systems), problem drinking also may cause physical symptoms:

morning nausea or shaking
signs of malnutrition due to a poor diet
abdominal pain or diarrhea
a flushed red color to the face and palms
numbness, weakness or tingling in the arms or legs
unusually frequent accidental injuries, especially falls.

Diagnosing alcohol use disorder

Even though alcohol related disorders are very common, relatively few individuals recognize the problem and get help. Therefore, screening is very important, whether primary care physicians or friends and family do it.

One commonly asked simple screening question helps identify the disorder:

(Men) five or more drinks in a day?
(Women) four or more drinks in a day?

The limits are different for women and men because of known differences in how alcohol is absorbed, distributed and eliminated from the body. Thus, the risk goes up for men who drink more than four standard drinks in a day (or more than 14 in a week); for women, there is a lower limit of three drinks in a day (and seven drinks in a week).

Almost always, people feel nervous or defensive about their drinking, which is one reason this very common problem so often goes undetected or unaddressed. Therefore, primary care physicians often make a point of use time during a visit to provide education about drinking and its dangers.

As a screening test, the single question about drinking patterns is as good as slightly more detailed ones, such as the CAGE questions. But these may be easier for concerned family members and friends to ask, since they may hesitate to ask direct questions about quantity.

The word "CAGE" is a device for remembering the questions (see the highlighted words):

Do you worry that you might need to CUT down on drinking?
Do you feel ANNOYED because other people have criticized your drinking?
Do you feel GUILTY about drinking?
Do you need a morning EYE OPENER drink to steady your nerves or to fight a hangover?

Another screening questionnaire used by physicians is the 10-question AUDIT (Alcohol Use Disorders Identification Test) developed by the World Health Organization.

As much shame as symptoms may trigger, drinking problems are an understandable human predicament. The best strategy is to be frank in response to a doctor's questions.

During an office visit, a health care professional will likely focus on the following.

Ask whether a person has alcohol-related problems at work, at home or with the law, such as getting into fights or driving while intoxicated.
Ask about physical symptoms of alcoholism.
Perform a physical examination that can reveal signs of poor nutrition and alcohol-related liver or nerve damage.
Order blood tests to check for anemia, vitamin deficiencies and abnormal levels of liver chemicals.

The NIAAA has a very helpful set of resources for the general public and for clinicians. They are all easily available online at www.niaaa.nih.gov.

Expected duration of alcohol use disorder

For most people who have an alcohol use disorder, the first alcohol-related life problems usually appear in the mid-20s to early 40s. Left untreated, AUD often persists and gets worse over time. Up to 30% of people with alcohol use disorder do manage to abstain from alcohol or control their drinking without formal treatment.

Preventing alcohol use disorder

There is no absolute way to prevent alcoholism. Screening is important, because early detection and treatment can prevent dangerous complications.

Treating alcohol use disorder

Treatment used to be limited to self-help groups such as Alcoholics Anonymous (established in 1935). Now there are a variety of evidence-based treatments, including psychotherapy and medication, to treat alcohol use disorders.

The first task is recognizing the problem. The well-known phenomenon of denial, which is a common part of the illness, often turns the illness into a chronic one. Unfortunately, the longer the illness persists, the harder it is to treat.

A doctor or substance abuse expert may be able to help a person look at the consequences of drinking. A nonjudgmental approach to the discussion is essential. If an individual is beginning to think about alcohol as a problem worth trying to solve, educational groups may provide support for weighing the pros and cons of drinking.

It is never easy for family members and friends to talk about a drinking problem. A professional may have to help loved ones — kindly, but realistically — talk to the drinker about the painful impact that drinking has on them.

Once an individual commits to stop drinking, the physician will watch out for and treat withdrawal symptoms. Depending on the amount and duration of drinking and any symptoms, detoxification (often simply called "detox") from alcohol can be done as an outpatient, or as an inpatient in a hospital or drug treatment facility. During the withdrawal process, the doctor may prescribe a class of antianxiety drugs called benzodiazepines for a short period in order to reduce withdrawal symptoms.

After weaning from alcohol, medication in some cases can help reduce cravings. Two medications that fit in this category are naltrexone and acamprosate. As an alternative, sometimes the drug disulfiram may be prescribed. Disulfiram does not reduce craving, but it creates an incentive not to drink, because drinking alcohol while taking it causes nausea and vomiting. An antiseizure drug called topiramate may diminish the reinforcing effects of alcohol. Alcohol treatment is an "off-label" use of topiramate, which means the FDA has not formally approved it for this use. Also not approved by the FDA, there is limited evidence that baclofen, a drug used to treat muscle spasticity, could help people quit alcohol use.

After detoxification, many people with alcohol disorders need some form of long-term support or counseling to remain sober. Recovery programs focus on teaching a person with alcoholism about the disease, its risks, and ways to cope with life's usual stresses without turning to alcohol. Psychotherapy may help a person understand the influences that trigger drinking. Many patients benefit from self-help groups such as Alcoholics Anonymous (AA), Rational Recovery or SMART (Self Management and Recovery Training).

Other mental health disorders can increase the risk of drinking. Depression and anxiety frequently occur along with an alcohol use disorder. It is very important to get treatment for such disorders if they are contributing to the problem.

A doctor may order additional tests to find out whether alcohol-related damage to the liver, stomach or other organs has occurred. A healthy diet with vitamin supplements, especially B vitamins, is helpful.

When to call a professional

Call your doctor whenever you or someone you love has an alcohol-related problem. Remember, alcoholism is not a sign of weakness or poor character. It is an illness that can be treated. The sooner treatment begins, the easier alcoholism is to treat.

Prognosis

About 30% of people with alcohol use disorder are able to abstain from alcohol permanently without the help of formal treatment or a self-help program. For the rest, the course of the illness is very varied. Two of three people seeking treatment do reduce their intake and improve their overall health. Some people will go through periods where they remain sober, but then relapse. Others have a hard time sustaining any period of sobriety.

It is clear, however, that the more sober days you have, the greater the chance that you will remain sober. Another motivating fact: remaining sober can increase life expectancy by 15 or more years.