Alcohol: Clinical Aspects

Introduction

Alcohol is one of the oldest and the most widely used psychoactive substances in the world, second only to caffeine. The use of alcohol is a part of most cultures worldwide, and it is recognized that there are both positive and negative aspects of alcohol consumption. Positive aspects might include the socialization, stimulation of appetite, more rapid onset of sleep, and reduction in the incidence of heart disease. The negative aspects include poor judgment, liver disease, hypertension, memory problems, and even death. Of course, as with all drugs, there is a risk of addiction to alcohol, which exacerbates the negative aspects of alcohol use and leads to its own sequelae of complications and disorders. The National Institute on Alcohol Abuse and Alcoholism notes that “men who drink 5 or more standard drinks in a day (or more than 14 per week) and women who drink 4 or more in a day (or more than 7 per week) are at increased risk for alcohol-related problems.”

The six levels of alcohol use are abstention, experimentation, social or recreational use, habituation, abuse, and, finally, addiction. Abstention is nonuse. Experimentation is the use of alcohol for curiosity and without any subsequent alcohol-seeking behavior. Social or recreational use of alcohol involves sporadic infrequent drinking without any real pattern. Habituation involves drinking with an established pattern, but without any major negative consequences. Abuse of alcohol is the continuation of drinking despite negative consequences. Finally, addiction involves a compulsion to drink, an inability to stop drinking, and the progression of major life dysfunction with continued use. ^. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has consolidated these last two levels of alcohol use to a diagnosis of alcohol use disorder (AUD), which is then rated by severity. ^.

In the United States, the per-capita consumption of alcohol from beer, wine, and spirits combined in 2013 was 2.34 gallons. This value was unchanged from 2012 but represents the highest per-capita consumption since before 1990. Essentially, after a steady decrease in the mid- to late 1990s, there has been a general increase in per-capita consumption of alcohol since 1999. ^.

Alcohol use is a significant cause of morbidity and mortality in the United States and worldwide. The World Health Organization reports that the deaths of 3.3 million men and women around the globe were attributable to alcohol consumption, making alcohol use the leading risk factor for premature death and disability among persons ages 15 to 49. In 2014, 16.3 million adults had a past year alcohol use disorder in the United States. Mortality rates follow drinking levels. A European study of 25 countries found that a rise of 1 L per capita in alcohol intake was associated with a 1% rise in all causes of morbidity. The global economic burden of alcohol was estimated to be in the range of $210–665 billion in 2002. The Centers for Disease Control and Prevention (CDC) estimated this figure at $232.5 billion in 2006 in the United States alone.

In the United States, more than 50% of adults have a close family member who is dependent on alcohol. More than 25% of youths younger than the age of 18 years are aware of a relative who is dependent on alcohol. Alcohol dependence runs in families.

The burden of the alcohol dependence disease is not equal across all regions. The disease impact of alcohol dependence is greatest in regions where the per-capita consumption is highest, such as Latin America, as compared with the Middle East. In addition, other factors, such as increasing economic growth, have raised the risk of alcohol dependence in Europe.

Alcohol consumption increases the risk of harm or death in the context of the operation of heavy machinery, fires, falls, and water activities. In the United States, approximately 40% of all traffic fatalities are alcohol related. Trauma and aggressive behavior are associated highly with alcohol consumption less than 6 hours before the event.

Alcohol-Related Disorders

Alcohol is associated with many physical and mental disorders. Perhaps the most well-documented physical disorder is alcohol-related liver disease. Alcohol-induced fatty liver disease and obesity are both associated with progression to cirrhosis. In the United States, more than 600,000 individuals have cirrhosis; about 20%–25% of these cases are attributed to excessive alcohol consumption. Typically, the development of cirrhosis requires the consumption of at least 30 grams of ethanol daily for women and 50 grams daily for men for at least 5 years. In addition, the presence of hepatitis C virus in the context of alcohol dependence is associated with increased rates of cirrhosis. Women have an increased incidence of liver cirrhosis compared to men with the same amount of alcohol consumption and their dose-dependent increase in risk is steeper. Globally, esophageal cancers, head and neck cancers, and liver cancers are of great concern, and are associated with alcohol use disorders.

Individuals with mental illness are susceptible to alcohol use disorders. This, in part, may be due to attempts to self-medicate underlying anxiety, depression, mania, or psychosis. However, drinking alcohol in excess tends to worsen underlying psychiatric illness. Excessive use of alcohol is associated with a poorer chance of recovery from anxiety and depressive disorders. Bipolar disorders and other impulse control disorders are associated with high rates of alcohol dependence. Dually diagnosed individuals have a poorer prognosis than those with just one of these disorders. Drinking more than 29 drinks per week can double the risk of a psychiatric disorder. Neurocognitive disorders such as Alzheimer’s dementia or multiinfarct dementia, can be worsened or be caused by alcohol, and the relationship between the two can be difficult to determine. Alcohol use disorders are common in individuals with schizophrenia and worsen symptoms of the disease. Unfortunately, individuals with mental illness tend to underreport their use of alcohol and remain untreated as a result.

Age at Onset of Drinking Behavior

The age at onset of drinking has a significant role in outcomes. An individual who starts drinking before the age of 15 years is approximately four times more likely to develop alcohol dependence, and this rate increases the earlier the onset of drinking. Data collected from the 2015 National Survey on Drug Use and Health found that 8.7 million 12 to 20 year olds were past-month drinkers, of which 5.3 million reported binge drinking and 1.3 million reported heavy use. Furthermore, according to the Monitoring the Future survey in 2015, 10% of 8th graders, 22% of 10th graders, and 35% of 12th graders reported past-month alcohol consumption. The risk of developing alcohol dependence and a more relapsing illness is greater in adolescents than in adults. Notably, between 20% and 30% of early alcohol drinkers progress to heavy drinking in adulthood. Children who drink often have behavioral problems, especially conduct disorders. Frequently, adolescents, much like adults, are self-medicating for anxiety and depression.

Alcohol dependence is a heterogeneous disorder and consists of subtypes, each with “varying degrees of biological and psychosocial antecedents.” The relationship between biological vulnerability, the environment, and their interactions in the development of alcohol dependence is the subject of active research. Current evidence suggests that alcoholism is 50%–60% determined genetically in both men and women. The term “psychiatric pharmacogenetics” has now entered the alcohol literature. Its purpose is to use genetic testing to predict, on an individual level, which treatment will be efficacious.

Contrary to conventional wisdom, there are a number of studies showing that alcohol dependence is not always a chronic and progressive disease. This assertion is based on longitudinal studies and national surveys. It appears that persons who develop alcohol dependence in middle age have the most stability in terms of the disease. In this population, alcoholism can be a chronic remitting disease. In contrast, individuals who develop alcoholism after the age of 50 years will often decrease their drinking as they age. Of interest, alcohol dependence in persons over 65 years of age continues to increase in the United States.

The 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions analyzed recovery rates of alcohol-dependent adults over a 1-year period. This population tended to be middle-aged, white males who were well educated (60% college educated); thus the generalizability is limited. More than half of the 4422 adults had experienced the onset of alcohol dependence between the ages of 18 and 24, and only 25% had ever received any treatment for alcohol problems. At 1 year, 35.9% were fully recovered (17.7% low-risk drinkers plus 18.2% abstainers), 25% were still dependent, 27.3% were in partial remission, and 11.8% were asymptomatic drinkers. Only 25% of the group had ever received any type of treatment.

Effects of Ethnicity, Gender, Place of Residence, and Religion on Alcohol Consumption

Ethnicity is a complex and multifaceted construct, and often the terms used by demographers do not reflect the different subgroups. For example, Korean Americans and Chinese Americans are both considered as Asian, but drinking patterns are quite distinct between these two groups. A study conducted in 2004 found a lower rate of alcohol dependence in Chinese-American college students (5%) as compared with Korean-American college students (13%). First-generation Mexicans and native-born Mexicans behave differently in their drinking patterns. Whites have the highest consumption levels, followed by Latinos and, then, Blacks. There is considerable ethnic disparity in the progression of drinking behavior. White men peak first (18–25 years), followed by Hispanic and Black men, with peak ages between 26 and 30 years. Although levels of drinking tend to be low among native-born Latinos, acculturation stress increases alcohol abuse and dependence with migration and first-generation populations. Ethnicity and socioeconomic status are also tied to the level of drinking.

Currently, women have nearly the same rates of alcohol dependence as men. This is in contrast with 1940, when men were more than twice as likely to be dependent on alcohol. Of interest, women often have a more severe disease course—perhaps due to reduced access to care, a greater time period before seeking treatment, or both.

Despite common misperceptions, the extent of drinking among Native Americans varies tremendously by tribe. The proportion of Native Americans who reported being current drinkers ranged from a low of 30% to a high of 84%. This wide range of reported drinking behavior is indicative of considerable variance between the alcohol use in Native American tribes. Furthermore, it has been reported that Northern reservations have a higher incidence of hospital admittance for an alcohol-related medical problem than Southern reservations (111/1000 versus 11/1000, respectively). On some Native American reservations, high quantities of alcohol are consumed per episode, but the frequency of binge drinking is low.

Location also matters. Urban and suburban dwellers have higher rates of dependence compared with their rural counterparts. Drinking styles also differ.

Religion appears to be an important determinant for drinking. Jews, Episcopalians, and Baptists living in rural areas show low rates of alcohol dependence compared with the general population.

Clinical Picture

Alcoholism can present in a multitude of ways, and at times its clinical effects can be subtle. Although there is no typical clinical pattern for an individual’s progression from excessive drinking to alcohol dependence, there are certain themes that prevail. These are based on the pathophysiology of alcohol.

An early manifestation of excessive drinking is intoxication. This can begin with one’s peers or by the influence of an older individual or family member. Some individuals note stress, depressed mood, or negative affect as a driving force, although at times it is elation. For others, there is an urge to drink, or craving. Although the concept of craving appears simple, the craving literature has found it difficult to define with consensus. When alcohol consumption leads to repeated bouts of intoxication and becomes a fixed pattern of behavior, the likelihood of alcohol-related problems increases.

As the body adapts to excessive alcohol consumption, tolerance develops. With tolerance, an increasingly greater amount of alcohol consumption is needed to obtain the same physiological effects. This can manifest as worsening grades or sick days among college students and workers and, for both, an increase in stress within interpersonal relationships, often characterized by greater irritability and moodiness. Furthermore, driving while under the influence of alcohol becomes more likely, and can lead to legal complications as well as morbidity and mortality to drivers, passengers, and other bystanders.

Heavy drinking can lead to blackouts, a failure to recall the events around the intoxication, due to the brain’s inability to process and lay down the memory in the hippocampus.

Hangovers, which are associated with headaches and nausea, can manifest the next morning after a bout of heavy drinking. Often, as duties and responsibilities lapse, attention to hygiene can wane, and the chronic drinker’s demeanor and behavior change. Memory lapses or forgetfulness may become more evident. In addition, the chronic excessive drinker may report guilt, remorse, and self-loathing after consuming alcohol and might conceal his or her drinking in order to avoid dealing with others. Such individuals tend to minimize the severity of their drinking behavior and its impact on others.

When drinking is being concealed, social isolation tends to occur, and to block or dampen guilt and anxiety, “relief drinking” can happen. Relief drinking may serve not only to temper these feelings but also to transiently reduce the resulting insomnia. Relief drinking might also temporarily ameliorate withdrawal symptoms upon drinking cessation (often starting within a few hours), which are the consequence of sympathetic nervous system hyperactivity. These symptoms can include tremulousness and anxiety and can proceed to a spectrum of serious withdrawal patterns, including delirium tremens. Despite any painful consequences such as loss of relationships, employment, legal entanglements, and physical and psychological complications, drinking can become the individual’s sole goal. The physical features of the disease are described below.

Signs and Symptoms