Alcohol Use and Abuse Addiction and Habituation

Alcohol Use and Abuse Addiction and Habituation				habits.
Problem and Solution.				ALCOHOL USE AND MISUSE
Summary: Although there is no definition of "addiction"				Most people who drink alcohol do so without negative
that is universally accepted, in general, addiction refers				consequences. Others may actually obtain a health
to a physiological and psychological dependency on a				benefit from its use. Some, however, drink in ways that
drug. While some drugs of abuse induce physiological				place themselves or others at risk for experiencing
addiction, others do not. Alternatively, some drugs that				alcohol-related problems. While no pattern of alcohol
are physiologically addictive generally are not abused				use is without risk, certain drinking patterns may help
(e.g., caffeine). Tolerance to drug effects, and				reduce risk significantly.
withdrawal symptoms upon abrupt cessation of use,				The Dietary Guidelines for Americans, issued jointly by
which develop over time, are characteristic features of				the U.S. Department of Agriculture and the U.S.
physiological addiction. "Habituation" is the term used to				Department of Health and Human Services, define
refer to psychological dependence on a drug. Some				moderate drinking as no more than two standard
drugs of abuse are highly rewarding because of their				drinks per day for men, and no more than one per day
influence on reinforcing neurobiological processes, but				for women and people sixty-five years of age and
they do not necessarily result in "tissue" related				older. A standard drink is 0.5 ounces of alcohol,
withdrawal symptoms. Cessation of such drugs may				equivalent to 12 ounces of beer, 5 ounces of wine, or
lead primarily to subjective craving due to previous				1.5 ounces of 80-proof distilled spirits. These guidelines
drug conditioning (perhaps true of some marijuana				suggest that moderate or low alcohol use is linked to a
users) and craving may be more readily evoked or				reduced risk for the occurrence of negative alcohol
deeply conditioned among some persons than others				consequences. For others, however, abstaining from all
("addictive personalities"). Primary methods of				alcohol consumption is the safest thing to do. Groups
assessment of addiction and habituation are				who should avoid all alcohol use include pregnant
completed through clinical interviews or self-report				women, children and adolescents, those planning to
surveys (e.g., American Psychiatric Association				drive or participate in other activities requiring alertness,
DSM-IV, World Health Organization ICD-10). Treatment				people who cannot maintain moderate alcohol use, and
paradigms for the cessation of addiction begin with				those who are using over-the-counter or prescription
initial detoxification or withdrawal, followed by inpatient				medicines that interact with alcohol.
or outpatient program participation (e.g., 12-step				Another way to understand drinking problems is to
programs, milieu, cognitive-behavioral, or behavioral).				examine definitions of alcohol misuse. The World
Pharmacological efforts (e.g., methadone maintenance)				Health Organization (WHO) defines alcohol misuse as
may be used as harm-reduction strategies among				alcohol use that places people at risk for problems,
those who seem unable to quit drug use.				including "at-risk use," "clinical alcohol abuse," and
It is estimated that approximately 15 percent of the				"dependence." At-risk alcohol use is the consumption
world's adults have serious substance abuse problems				of alcohol in a way that is not consistent with legal or
(not including nicotine addiction), and that this				medical guidelines, and it is likely to present risks of
percentage has remained fairly constant over the past				acute or chronic health or social problems for the user
twenty-five years. Of these substance abusers, about				or others. Examples include underage drinking; drinking
two-thirds abuse alcohol and one-third abuse other				by individuals with a family history of alcoholism or
substances, mainly marijuana, amphetamines, cocaine,				problem drinking; or drinking if one has a medical
and heroin. Approximately2.5 percent of the population				condition that could be worsened by drinking, such as a
abuse marijuana, 0.5 percent abuse stimulants, 0.3				stomach ulcer or liver disease. Clinical alcohol abuse is
percent abuse cocaine or opioids (such as heroin), and				a more serious type of misuse that results in one or
up to 0.8 percent abuse other substances (e.g.,				more recurrent, adverse consequences, such as failure
inhalants, depressants, hallucinogens). Sites of drug				to fulfill important obligations or the repeated use of
production and manufacturing, and distribution routes,				alcohol in physically dangerous situations. Alcohol
tend to identify regions at high risk for abuse.				dependence is the most severe type of alcohol
Drug abuse causes significant health-related				misuse and involves a chronic disorder characterized
consequences and financial losses to legitimate				by three or more symptoms within a twelve-month
economies. The financial cost to society is estimated				period. These symptoms include alcohol tolerance,
to be approximately $600 billion per year worldwide.				withdrawal, loss of control, and continued use despite
This does not include the cost of nicotine abuse, which,				knowledge of having a physical or psychological
through its influence on heart disease, lung cancer,				problem.
chronic obstructive lung disease, and numerous other				Negative consequences resulting from alcohol use are
consequences, is the number one behavioral killer of				estimated to affect more than 10 percent of the U.S.
people worldwide. Drugs of abuse are also associated				population, with many of these individuals going
with the production of psychotic symptoms (e.g.,				undetected. A number of brief screening tools are
paranoid ideation) and with injuries due to accidents				available to help detect possible alcohol problems. One
and violence. Approximately 50 percent of automobile				of the most widely used among these is the four-item
fatalities involve alcohol-impaired drivers, and many				CAGE questionnaire, which derives its name from the
auto crashes also involve chronic marijuana or				following four self-administrated questions:
amphetamine users.				1. Have you ever felt you should Cut down on your
In addition, each drug class is associated with a unique				drinking?
set of potential consequences. Some drugs of abuse				2. Have people Annoyed you by criticizing your
are likely to have lethal consequences (e.g., opiates and				drinking?
depressants), and some have a high potential for				3. Have you ever felt bad or Guilty about your
addiction. Health consequences can also vary by drug.				drinking?
For example, depressants, PCP, stimulants, steroids,				4. Have you ever had a drink first thing in the morning
and cannabis are associated with cardiovascular				to steady your nerves or to get rid of a hangover
diseases. Stimulant use is linked to seizure, digestion				(Eye-opener)?
problems, and lung problems. Documented				Answering "yes" to as few as one or two items on
consequences of marijuana use include lung damage				the CAGE questionnaire may indicate a drinking
and short-term memory problems. Dementia, seizure,				problem.
memory impairment, central and peripheral nervous				PREVALENCE
systems impairment, gastrointestinal diseases, and				In the United States, 44 percent of adults eighteen
cancers of the gastrointestinal tract are all				years of age and older are current drinkers, consuming
consequences of alcohol consumption. Steroid use is				at least twelve drinks in the last year. Meanwhile, 7.4
associated with high blood pressure, potential heart				percent, or approximately 14 million Americans,
attacks, liver tumors, transient infertility, and tendon				experience alcohol abuse or alcohol dependence.
degeneration. Inhalants are well-known causes of				Heavy episodic or binge drinking has remained at the
kidney, brain, and liver damage.				same approximate level of 16 percent for all adults
The development and maintenance of the addictive				since 1988, with the highest rate, 32 percent, among
process involves multiple pathways and levels of				young adults ages eighteen to twenty-five. Over
influence within biological, psychological, and sociological				one-half of adults report having a close family member
domains. Influences exogenous to the individual include				who has experienced alcoholism.
environmental, cultural, and social factors. Cultural and				As few as 5 percent of the heaviest drinkers
social norms, variations in drug use practices, and the				consume as much as 42 percent of the alcohol drunk
values and behaviors of parents, siblings, friends, and				in the United States, and 20 percent of drinkers
role models can all affect an individual's drug				account for nearly 90 percent of the alcohol
experiences. Processes contributing to individual				consumed. The bulk of the alcohol drunk in the United
differences in substance use include physiological				States, therefore, is consumed by a relatively small
susceptibility, as measured in genetics studies; affective				population of very heavy drinkers.
states; personality; and cognition-including expectancies				Alcohol is also the drug most frequently used by
and memory processes. Substance abuse versus				children and adolescents. In 1999, over half (52%) of
substance use is more strongly related to				eighth graders (14-year-olds) and 80 percent of twelfth
intra-personal processes (e.g., self-medication for				graders (18-year-olds) reported having used alcohol at
emotional distress) than social processes, although				least once. More problematic drinking occurs in 15
both are influential in the addictive process.				percent of eighth graders and 31 percent of twelfth
SUBSTANCE ABUSE AND DEPENDENCE				graders, who reported binge drinking (consuming five
Substance use pertains simply to the use of a drug.				or more drinks in a row) in the previous two weeks.
Substance misuse means using a drug for a purpose				Of American high school adolescents, over half (51%)
or in a manner in which it was not intended or				currently drink alcohol. In 1999, one in three high school
prescribed. Substance abuse is marked by an				students reported heavy episodic drinking of five or
accumulation of negative consequences resulting from				more drinks on at least one occasion during the
drug use. Substance use that leads to a decreased				previous thirty days. The prevalence of heavy drinking
level of performance in major life roles, or to				commonly increases through adolescence into early
dangerous actions, legal problems, or social problems,				adulthood.
indicates abuse. Substance dependence is a more				HEALTH OUTCOMES
severe form of drug abuse that also includes tolerance				Alcohol use has health and social consequences for
(the need for markedly increased amounts of the				those who drink, for those around them, and for the
substance to achieve the desired drug effect),				nation as a whole. Approximately 100,000 deaths each
withdrawal symptoms when stopping substance use,				year are attributed to alcohol use, making it the third
unpredictability of substance use, and an inability to				leading cause of preventable mortality in the United
control the use of a substance to the point that it				States. Worldwide, 750,000 deaths are attributed to
consumes one's daily life.				alcohol use each year. Alcohol-related deaths occur
Withdrawal symptoms vary from drug to drug. For				from cancer, cirrhosis of the liver, pancreatitis,
example, withdrawal from alcohol, sedatives, or				motor-vehicle crashes, falls, drowning, suicide, and
anxiolytic agents may involve autonomic reactivity,				homicide. Alcohol affects nearly every system in the
hand tremor, insomnia, nausea or vomiting, transient				body, and contributes to a range of medical problems,
illusions or hallucinations, psycho-motor agitation, anxiety,				including altered immune system functioning, bone
and grand mal seizures. Amphetamine or cocaine				disease, hypertension, stroke, cardiovascular disease,
withdrawal can include fatigue, unpleasant and vivid				reduced cognitive functioning, fetal abnormalities,
dreams, insomnia or hypersomnia, increased appetite,				traumatic injury, depression, gastrointestinal disorders,
and psychomotor retardation or agitation. For				and cancers of the neck, head, stomach, pancreas,
substance abusers, withdrawal is often a difficult				colon, breast, and prostate. Alcohol also produces
process with numerous symptoms, while abstaining				significant social problems, including domestic violence,
from drug use can lead to recovery from physical and				child abuse, marital and family disruption, violent crime,
psychological problems and an improvement in overall				motor-vehicle crashes, worksite productivity losses,
health.				absenteeism, and lowered school achievement. The
THE DRUG ABUSE CONTINUM				estimated cost of alcohol misuse in the United States
Conceptually, substance abuse can be seen as a				in 1998 was nearly $185 billion.
continuum, with individuals at one end being relatively				Young people are particularly vulnerable to acute
"disease-free" but engaging in maladaptive behaviors				alcohol effects due to their lower tolerance to alcohol,
over which they have some control. These individuals				their lack of experience with drinking, and drinking
may repetitively use drugs, and over time they may				patterns that often include heavy episodic drinking in
abuse drugs. They choose to live a certain lifestyle in				high-risk situations, such as during driving and sexual
which their maladaptive behavior may or may not				encounters. Leading causes of mortality and morbidity
result in other disease states associated with use (e.g.,				among youths include alcohol-related motor-vehicle
cirrhosis of the liver). If these individuals stop this				injuries, homicide, and suicide. Alcohol use among young
negative cycle they can, perhaps on their own, learn				people is associated with reduced scholastic
alternative coping mechanisms and self-efficacy.				achievement, increased delinquency, and the
Individuals at the other end of the continuum, however,				development of psychiatric problems later in life.
seemingly have no control over their use. Some				Alcohol has also been found to precede other illicit drug
individuals appear to lose control the first time they use				use, thereby serving as a "gateway" to other drug
drugs. For these individuals drug use is like a toggle				consumption, including marijuana and cocaine use.
switch that is either on or off. For them, total abstention				Women and the elderly are also at greater risk for
is the only alternative because they have no control				experiencing alcohol harm because of their lower
processes once the switch is turned on. They may				levels of body water, meaning that smaller amounts of
use until they die unless someone else can turn their				alcohol result in higher levels of intoxication than in
switch off and keep it off. There is no logic to this				younger men. Drinking during pregnancy has been
behavior, and no choice. Users of this type will often				linked to higher rates of miscarriage, stillbirth, and
ruin their own lives and the lives of those around them				premature births, and fetal alcohol syndrome-a set of
in their drive to use their drugs of choice. It seems that				birth defects caused by maternal consumption of
as one moves toward a more "at-risk" end of the				alcohol during pregnancy. For the elderly, drinking even
continuum there is less and less control over				modest amounts of alcohol may cause considerable
substance use.				problems due to chronic illness, interactions with
It is unclear what causes the difference in loss of				medications, and grief and loneliness from the death of
control among those at different points of the				loved ones.
continuum. Researchers do not understand the				At the same time, moderate to low levels of alcohol
process very well. They do know that other factors				consumption have been linked to a lower risk for heart
may exacerbate the process, including biologically				disease and stroke. These positive effects appear to
based differences in metabolic processes, different				be confined primarily, however, to middle-aged and
levels of susceptibility to the reinforcing effects of				older individuals in industrialized countries with high rates
drugs, personality disorders or depression, and an				of cardiovascular diseases. Individuals and populations
inability to tolerate frustration or emotional discomfort.				must weigh the risks and benefits of drinking to
Some processes are under individual control, but many				themselves and others, including such factors as the
are not, and it does appear that the less control the				situations under which drinking is to take place and the
individual has over these types of processes, the more				amount likely to be consumed, to determine the net
likely he or she is to fall into substance abuse.				results of drinking.
STAGES OF ALCOHOLISM AND DRUG ABUSE				SOLUTIONS
During the early stages of substance abuse, the				The burden of alcohol misuse is measured in a number
alcoholic or drug abuser experiences increasing				of ways, including the prevalence and incidence of
tolerance and use. Substance use at this stage is				deaths, injuries, and illnesses attributed to alcohol;
generally for purposes of self-medication. In the later				hospitalization rates; potential years of life lost to
stages of abuse, life becomes centered around				alcohol misuse; and quality of life indicators. Vast
obtaining, using, and recovering from drug use. Loss of				resources are expended each year in the United
control, ethical deterioration, and noticeable withdrawal				States to address the health and social problems
symptoms ensue. It is unclear, however, whether such				resulting from alcohol misuse. Because no single
a progression is inevitable.				solution can reduce all alcohol-related harm to
In a 1991 empirical review of the study of progression				individuals and populations, a comprehensive approach
in alcoholism, Jill Littrell found that approximately 60				using a range of strategies that address the multiple
percent of adolescent problem drinkers remit to				causes and dimensions of alcohol problems is needed.
nonproblematic levels of drinking when they reach their				These strategies should include educational
20s, and that 25 percent of young adults remit to				approaches-such as public health education and
nonproblematic levels of drinking before they reach				awareness programs, including school, family, and
age 35. Studies examining data on adult alcoholics who				community-based prevention programs; environmental
have undergone a variety of treatments as inpatients				approaches-such as controls on the price and
and outpatients during follow-up periods of up to				availability of alcohol, minimum age for purchase of
fifteen years provide a general profile of outcomes.				alcohol, legislative measures to curb driving under the
Between 25 and 35 percent remain abstinent, whether				influence of alcohol, and restrictions on the promotion,
or not they continue treatment. An additional 15 to 25				marketing, and advertising of alcohol; and health care
percent will be abstinent most of the time, with some				efforts-such as primary health care screening, advice
lapse periods. Approximately 6 to 9 percent will				by health care providers, preventive services, and
become nonproblematic or controlled drinkers				effective treatment using psychological
(particularly those who were lighter drinkers and				andpharmacological approaches.
suffered fewer negative consequences while drinking).				Dr.Kedar B. Karki
Another 20 to 33 percent become stable problematic				New Hope Rehabilitation Center Satdobato
drinkers, while 15 to 25 percent will die from				BIBLIOGRAPHY
alcohol-related causes.				Centers for Disease Control and Prevention (1999).
It is uncertain whether drug abusers follow a				Fact Sheet: Youth Risk Behavior Trends. Atlanta, GA:
progression similar to that of alcoholics. There probably				Author.
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in general, but more longitudinal studies are needed in				Alcoholism and Gender: Their Combined Effects on
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An interaction of biological, psychological, and				Health and Human Services (1995). Nutrition and Your
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social and physical surroundings, such as family drinking				Author.
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Alcohol Use and Abuse Addiction and Habituation