What do typical problem drinkers look like? A tough biker thrown out of a bar for starting fights? A couple whose raucous conflicts spill into their front yard and wake the neighborhood? A homeless man dressed in rags, stumbling down the sidewalk, clutching a bottle of cheap vodka? Maybe. But they could also look like you, or your friends, or your family, or your coworkers.
The reality is that there is no “typical” appearance for someone with Alcohol Use Disorder (AUD). In fact, roughly half of the patients who come to the hospital for alcohol withdrawal are both middle-class and otherwise highly functional people.
Though the amount of alcohol consumed is a factor in screening for AUD, how people drink, their attitudes and behaviors surrounding drinking, and the point at which alcohol use begins to affect a person’s life are central to diagnosis. These people feel the urge to drink as powerfully as for water and food, sometimes even substituting alcohol for food and becoming vitamin deficient. Alcohol is the driving force in the life of an AUD sufferer, and often it takes the risk of losing family, friends, jobs, and even life itself before they are willing to accept treatment.
Because a certain degree of alcohol use is acceptable in our society (as opposed to heroin or cocaine), problematic drinking can be difficult to spot for the untrained eye. People who have been drinking excessively may be socially uninhibited, slurring their words, and exhibit a stumbling gait. Though it is no longer part of the diagnostic criteria, legal consequences from risky behavior like drunk driving and physical altercations are another sign of uncontrollable drinking. Having a naturally high tolerance is another warning sign, as people with this genetic predisposition have a higher risk of developing AUD.
Causes and risk factors
Alcohol is a deeply ingrained part of American culture. In fact, 56.9% of American adults (18+) revealed they drank alcohol in the past month, and 6.8% – about 16.3 million – met criteria for Alcohol Use Disorder. These figures reflect the high availability of alcohol and cultural acceptability of drinking in our country.
Men at higher risk
Roughly twice as many men have Alcohol Use Disorder as women. Men are also more prone to early-onset AUD (diagnosis in late teens to early 20s). Early problem drinking is associated with antisocial behaviors and high levels of impulsivity, which share a common genetic basis with AUD.
Children of people with Alcohol Use Disorder have three to four times the probability of developing AUD. Risk increases with greater numbers of and closer genetic relation to family members with AUD. Genes for altered alcohol metabolism cause increased pleasure and decreased sedation from alcohol consumption. This accounts for at least 50% of the risk for AUD.
Problem drinking in parents creates an environment of stress, neglect, and poor parent-child attachment. This leads children to associate with peers who drink, and use of alcohol early in adolescence increases the risk of AUD in adulthood.
A dangerous anxiety remedy
Alcohol affects the brain in a way similar to benzodiazepines, a major class of anti-anxiety medications. It is no surprise that 44% of AUD patients also suffer from anxiety disorders. Patients with a family history of anxiety are more likely to find relief of anxiety from alcohol, but withdrawal from its effects generates even more anxiety, propelling the cycle of use.
Depressive and bipolar disorders, which appear in 50% of AUD patients, also share genetic variations with AUD. These genes relate to executive functions like planning, attention, working memory, and delaying reward. Both depressed and AUD patients have trouble with attention and decision making thanks to this shared genetic background.
Diagnosing Alcohol use Disorder
What counts as a “drink”?
A standard question in any physician’s office is, “How much do you drink?” But first, what is one drink anyway? A standard drink is 12 oz of 5% alcohol beer, 5 oz of 12% alcohol wine, or a 1.5 oz shot of 40% alcohol.
How much is too much?
For healthy, non-pregnant adults age 21-65, low risk drinking for men is maximum 4 drinks in a day and 14 in a week and, for women, no more than 3 drinks in a day and 7 in a week. Binge drinking is more than 4 drinks for women or 5 drinks for men in 2 hours.
People might have Alcohol Use Disorder if they:
- Drink increasing amounts or drink for longer than originally intended
- Want or try to cut down but can’t
- Spend inordinate amounts of time finding, drinking, and recovering from alcohol
- Have a strong drive to continue drinking
- Have problems in major life domains, such as education, work, and home life because of alcohol
- Continue to drink even in the face of social and relationship issues caused by alcohol
- Give up work obligations, hobbies, and friendships to drink alcohol
- Drink alcohol at times that put themselves and others in harm’s way
- Continue to drink in spite of direct physical and mental health consequences
- Develop tolerance to alcohol, needing increased amounts to achieve the same ‘buzz’
- Experience a characteristic withdrawal (nausea, vomiting, anxiety, sweating, tremor, insomnia, agitation, hallucinations, seizures) and often drink more to dull the symptoms
Diagnosis requires at least two symptoms over the course of one year. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more. Patients are in early remission if they have had none of those criteria for at least three months and not more than one year. Late remission extends beyond one year.
Treating Alcohol Use Disorder
Alcohol is one of the few drugs whose withdrawal can kill, so don’t try to go it alone. Furthermore, if you are heavy drinker, even just cutting down suddenly can trigger withdrawal. In fact, the most common place people are treated for alcohol withdrawal is the emergency room, often after trying to detox alone without knowing the dangers. Benzodiazepines are the treatment of choice, and doses are calibrated based on symptom severity.
These programs provide the most accessible form of treatment because they are both ubiquitous and free. Alcoholics Anonymous (AA), the original 12 step program, offers different meetings types for patients from a wide variety of backgrounds: women only, youth-focused, beginners meetings, and LGBT friendly. Women For Sobriety provides a sanctuary for recovery support specifically for women that focuses on coping skills and esteem building. For people who dislike the spiritual component of 12 step programs, SMART Recovery (Self-Management and Recovery Training) is a cognitive-behavioral approach. Patients with both Alcohol Use Disorder and another mental illness (called “dual diagnosis”) may benefit from Double Trouble in Recovery, which is a 12 step program adapted to welcome discussion of mental disorders alongside AUD.
Cognitive Behavioral Therapy targets triggers for drinking and helps patients deal with tempting situations by building a repertoire of skills, such as thought replacement, talking about cravings, and urge surfing. It treats the dysfunctional thought processes surrounding the urge to drink by helping patients find alternatives to drinking and redirecting the cravings to more constructive pastimes.
In Motivational Interviewing (MI), clinicians empower patients to identify the problems linked to their drinking and how they would like their lives to be different so that the drive to change comes from within, rather than some outside force.
Pharmacology can help
Though there is no single pill that cures AUD, several medications can work in concert with counseling and behavioral modifications to help maintain sobriety.
- Antabuse (disulfuram) deters drinking by causing nausea, vomiting, and flushing if the patient drinks. The downside to this medication is it must be taken daily to work, and if patients really want to drink, they simply stop the medication.
- ReVia (naltrexone daily), Vivitrol (naltrexone injection lasting thirty days), and Campral (acamprosate) help decrease cravings.
- Anticonvulsants such as Neurontin (gabapentin) and Topamax (topiramate) also reduce risk of relapse and the duration and severity of relapses that do occur.
Managing Alcohol Use Disorder
A short screening tool
If you think you may have a problem with alcohol, this short series of questions known as CAGE can help point you in the right direction.
- C Have you ever felt you should cut down on your drinking?
- A Have people annoyed you by criticizing your drinking?
- G Have you ever felt bad or guilty about your drinking?
- E Have you ever had an eye opener, a drink first thing in the morning to steady your nerves or to get rid of a hangover?
If you answered “yes” to two or more of these questions, see a doctor for further evaluation.
Red flags for problematic drinking include liver failure, heart failure, throat and stomach bleeding, and mouth, throat, and breast cancers. Heavy alcohol use frequently leads to folate and thiamine deficiencies, which can lead to anemia and chronic brain degeneration, respectively. Maintaining a good diet of fruits and vegetables (and/or adding a multivitamin) may help mitigate the damaging effects of AUD temporarily, but this is not by any means a pass to ignore problem drinking.
Drinking and pregnancy don’t mix
Maternal drinking during pregnancy causes Fetal Alcohol Syndrome (FAS). These children have distinct facial characteristics, like small head circumference, small eye openings, a short nose, a thin upper lip, and skin folds at the corners of the eyes. FAS also slows fetal growth and leads to cognitive-behavioral abnormalities, including learning disabilities and general developmental delay. New data in animal studies of FAS also suggest that heavy paternal alcohol consumption prior to conception can alter the expression of sperm DNA and contribute to FAS.
Commit to committing
If you choose to go to Alcoholics Anonymous (AA) or other peer support programs, try several different meetings to find one that fits your situation. If you find a meeting that suits you, make a commitment; AA recommends new attendants try 90 meetings in their first 90 days. New visitors to AA should ask about getting a sponsor (approach the meeting leader or any experienced member for assistance). Sponsors are members farther along in the process of recovery (at least a year sober) who help guide newcomers through their undertaking of sobriety.
Resources for families
Al-Anon (and it’s adolescent-focused relative, Alateen) offer a safe place for friends and family members of patients to share their stories and offer mutual support through an adapted 12 step process. Adult Children of Alcoholics is a 12 step group for adults whose parents had problems with drinking during their formative years and are now suffering the repercussions of such a disordered childhood. Families of patients with Alcohol Use Disorder also frequently benefit from marriage and family counseling to help heal the rifts caused by drinking and help patients maintain sobriety.
Don’t withdraw alone
If you are physically dependent on alcohol (you start having withdrawal symptoms after stopping drinking for a day), don’t try to quit without medical supervision. Relative to other drugs, withdrawal from alcohol is by far the most dangerous. Left untreated, alcohol withdrawal can progress to Delirium Tremens, the so-called “DTs”. Delirium Tremens includes all the possible symptoms of alcohol withdrawal and is most notable by the complete, utter confusion that strikes these patients. This syndrome is fatal in 5-10% of cases and requires hospitalization, sedation, and intensive care.