Alcoholism Recovery Issues

Alcoholism is a complex disease with physical, social and psychological consequences – not only for alcoholics but also for people closest to them.  In the past, alcoholism was often viewed as a moral weakness or character flaw; it was thought that the person could stop drinking if he or she really wanted to.  It wasn't until 1970 that people began to understand and accept that alcoholism is a life-threatening, chronic disease involving psychological and physical dependence on alcohol.

There is a distinction between alcoholism and alcohol abuse.  The latter is a less severe problem; unlike alcoholics, alcohol abusers do not develop physical withdrawal or compulsive alcohol use.  However, like alcoholics, their drinking has negative health, economic and social effects.  Both alcoholics and alcohol abusers need treatment, although the goals differ.  In most cases of alcohol abuse, the goal is to limit drinking, while for alcoholism, it is to stop drinking altogether.

Incidence; Causes and Development

According to estimates from the federal government's National Institute on Alcohol Abuse and Alcoholism, 6% of men and 3% of women are alcoholics.  That translates to nearly 8 million alcoholics in the United States; as many as 1.5 million of them seek treatment each year.

Why some people become alcoholics remains a mystery, although most scientists now agree that a combination of genetic and environmental factors increases a person's vulnerability.

Some researchers divide alcoholism into two types.  Type I, the most common, occurs in both men and women and is associated with adult-onset alcohol dependence.  This form, also known as milieu-limited alcoholism, appears to be the result of genetic predisposition and environmental provocation, that is, the development of alcoholism in these cases is an interaction between inherited predisposition and the person's life situations.

Type II – or male-limited – alcoholism, on the other hand, is due mainly to genetics.  It occurs only in men, usually with early onset in the teen years, and is more difficult to treat.  Type II alcoholics tend to exhibit antisocial, aggressive behavior.  It has been suggested that there may be a third type similar to Type II but without the antisocial behavior.

People often realize a friend or family member has alcoholism through the consequences of drinking, such as arrests for drunk driving or problems at work, including chronic absenteeism.  Alcoholics' spouses may demand they leave the house.  Later in the disease, they may be hospitalized for liver disease or pancreatitis.

Denial of these and other negative effects of alcohol in their lives is common in alcoholics and those close to them.  But sometimes the negative occurrences can serve as a catalyst for getting the alcoholic into treatment.  In most cases an illness or ultimatum from the spouse or other family member, boss, doctor, or judge is the driving force.

Signs and Symptoms

Based on the American Psychiatric Association's 4th edition of Diagnostic and Statistical Manual of Mental Disorders, NIAAA recognizes four signs of alcoholism:

• Loss of control over drinking.  Alcoholics may intend to have two or three drinks, but before they know it, they are on their 10th.
• Continued use of alcohol despite social, medical, family and work problems.
• Increased alcohol tolerance over time, i.e. needing more alcohol to become intoxicated.
• Withdrawal symptoms when alcoholics stop drinking after a period of heavy drinking.  The symptoms include anxiety, agitation, increased blood pressure and, in extreme cases, seizures.  These symptoms may persist for several days.

People do not need to have all four signs to be diagnosed as alcoholic.  Those who have significant problems controlling their drinking and functioning in social situations because of alcohol may be considered alcoholics without the physical signs, tolerance and withdrawal.

Treatment and Prevention

Some alcoholics enroll in inpatient and outpatient alcoholism treatment programs and supplement that with regular attendance at AA and other self-help group meetings.  Others find success with AA and similar self-help groups alone.  Some turn to psychotherapy.  Some quit drinking completely on their own.

For some alcoholics, treatment begins with "detoxification" which is the medical management of acute alcohol withdrawal.  This can be done in the hospital or on an outpatient basis and usually lasts one to seven days.

The FDA has approved two anti-anxiety drugs, Valium (diazepam) and Librium (chlordiazepoxide), for treating alcohol withdrawal effects.  Some doctors also prescribe other drugs in the same chemical class, also approved for treating anxiety.  These drugs help decrease the symptoms of alcohol withdrawal, including anxiety and tremors, and reduce the risk of serious consequences of withdrawal, such as seizure and delirium.  Dosages are based on the severity of patients' symptoms.  Use of these drugs beyond the withdrawal phase is not advised for alcoholics because of the drugs' abuse potential and alcoholics' addictive inclination.

Once sober, patients can begin rehabilitation.  While enrolled, patients attend classes and participate in individual, group and family counseling sessions.  The activities aim to educate patients about alcoholism, help them recognize that they have the disease, and help them adjust to a life without alcohol.  Patients often are introduced to self-help groups, such as AA.  Family members often get involved, too, and may be referred to Al-Anon, a self-help group for family members of alcoholics.

Following this intensive program, patients are often encouraged to continue with some type of aftercare program for at least one year.  This might include AA, individual or group psychotherapy, or a center-sponsored program that continues on a smaller scale the same type of activities offered during the intensive treatment.

Alcoholics also may be helped in their recovery with one of two drugs approved for discouraging alcohol intake.  Antabuse (disulfiram), when combined with even small amounts of alcohol causes unpleasant effects such as facial flushing, throbbing headache, nausea, vomiting, and increased blood pressure and heart rate.  The drug's effectiveness depends on patient motivation: Those who want to drink simply stop taking the drug.

A 1986 study found that Antabuse did not improve abstinence rates, length of time to relapse, or psychosocial functioning any more than counseling alone.  But, patients on Antabuse who continued to drink drank less frequently than relapsed patients who did not receive the medication.

The second drug, ReVia (naltrexone), acts on the opioid receptors in the brain to help prevent relapse and reduce alcohol cravings in those who drink.  In a 12-week study of 70 alcoholic men, 23% of the ReVia-treated patients relapsed, compared with 54% of those receiving placebo.  Of those who drank during the study, 50% of those on ReVia relapsed to heavy drinking, compared with 95% of those receiving placebo.  A separate study of 104 alcoholic men and women found that patients who took ReVia were about twice as successful in quitting drinking as patients who received placebo.

However, because ReVia was tested in conjunction with supportive therapy, FDA approved its use only as an adjunct to supportive therapy (such as group therapy) in treating alcoholism.  Studies show the drug is nonaddictive.  But it can cause liver toxicity when given at doses higher than recommended.  Therefore, it is not recommended for people with active hepatitis and other liver diseases.