Alcohol Use and Abuse Addiction and Habituation

Alcohol Use and Abuse Addiction and Habituation

Problem and Solution.

Summary: Although there is no definition of "addiction" that is universally accepted, in general, addiction refers to a physiological and psychological dependency on a drug. While some drugs of abuse induce physiological addiction, others do not. Alternatively, some drugs that are physiologically addictive generally are not abused (e.g., caffeine). Tolerance to drug effects, and withdrawal symptoms upon abrupt cessation of use, which develop over time, are characteristic features of physiological addiction. "Habituation" is the term used to refer to psychological dependence on a drug. Some drugs of abuse are highly rewarding because of their influence on reinforcing neurobiological processes, but they do not necessarily result in "tissue" related withdrawal symptoms. Cessation of such drugs may lead primarily to subjective craving due to previous drug conditioning (perhaps true of some marijuana users) and craving may be more readily evoked or deeply conditioned among some persons than others ("addictive personalities"). Primary methods of assessment of addiction and habituation are completed through clinical interviews or self-report surveys (e.g., American Psychiatric Association DSM-IV, World Health Organization ICD-10). Treatment paradigms for the cessation of addiction begin with initial detoxification or withdrawal, followed by inpatient or outpatient program participation (e.g., 12-step programs, milieu, cognitive-behavioral, or behavioral). Pharmacological efforts (e.g., methadone maintenance) may be used as harm-reduction strategies among those who seem unable to quit drug use.

It is estimated that approximately 15 percent of the world's adults have serious substance abuse problems (not including nicotine addiction), and that this percentage has remained fairly constant over the past twenty-five years. Of these substance abusers, about two-thirds abuse alcohol and one-third abuse other substances, mainly marijuana, amphetamines, cocaine, and heroin. Approximately2.5 percent of the population abuse marijuana, 0.5 percent abuse stimulants, 0.3 percent abuse cocaine or opioids (such as heroin), and up to 0.8 percent abuse other substances (e.g., inhalants, depressants, hallucinogens). Sites of drug production and manufacturing, and distribution routes, tend to identify regions at high risk for abuse.

Drug abuse causes significant health-related consequences and financial losses to legitimate economies. The financial cost to society is estimated to be approximately $600 billion per year worldwide. This does not include the cost of nicotine abuse, which, through its influence on heart disease, lung cancer, chronic obstructive lung disease, and numerous other consequences, is the number one behavioral killer of people worldwide. Drugs of abuse are also associated with the production of psychotic symptoms (e.g., paranoid ideation) and with injuries due to accidents and violence. Approximately 50 percent of automobile fatalities involve alcohol-impaired drivers, and many auto crashes also involve chronic marijuana or amphetamine users.

In addition, each drug class is associated with a unique set of potential consequences. Some drugs of abuse are likely to have lethal consequences (e.g., opiates and depressants), and some have a high potential for addiction. Health consequences can also vary by drug. For example, depressants, PCP, stimulants, steroids, and cannabis are associated with cardiovascular diseases. Stimulant use is linked to seizure, digestion problems, and lung problems. Documented consequences of marijuana use include lung damage and short-term memory problems. Dementia, seizure, memory impairment, central and peripheral nervous systems impairment, gastrointestinal diseases, and cancers of the gastrointestinal tract are all consequences of alcohol consumption. Steroid use is associated with high blood pressure, potential heart attacks, liver tumors, transient infertility, and tendon degeneration. Inhalants are well-known causes of kidney, brain, and liver damage.

The development and maintenance of the addictive process involves multiple pathways and levels of influence within biological, psychological, and sociological domains. Influences exogenous to the individual include environmental, cultural, and social factors. Cultural and social norms, variations in drug use practices, and the values and behaviors of parents, siblings, friends, and role models can all affect an individual's drug experiences. Processes contributing to individual differences in substance use include physiological susceptibility, as measured in genetics studies; affective states; personality; and cognition—including expectancies and memory processes. Substance abuse versus substance use is more strongly related to intra-personal processes (e.g., self-medication for emotional distress) than social processes, although both are influential in the addictive process.

SUBSTANCE ABUSE AND DEPENDENCE

Substance use pertains simply to the use of a drug. Substance misuse means using a drug for a purpose or in a manner in which it was not intended or prescribed. Substance abuse is marked by an accumulation of negative consequences resulting from drug use. Substance use that leads to a decreased level of performance in major life roles, or to dangerous actions, legal problems, or social problems, indicates abuse. Substance dependence is a more severe form of drug abuse that also includes tolerance (the need for markedly increased amounts of the substance to achieve the desired drug effect), withdrawal symptoms when stopping substance use, unpredictability of substance use, and an inability to control the use of a substance to the point that it consumes one's daily life.

Withdrawal symptoms vary from drug to drug. For example, withdrawal from alcohol, sedatives, or anxiolytic agents may involve autonomic reactivity, hand tremor, insomnia, nausea or vomiting, transient illusions or hallucinations, psycho-motor agitation, anxiety, and grand mal seizures. Amphetamine or cocaine withdrawal can include fatigue, unpleasant and vivid dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. For substance abusers, withdrawal is often a difficult process with numerous symptoms, while abstaining from drug use can lead to recovery from physical and psychological problems and an improvement in overall health.

THE DRUG ABUSE CONTINUM

Conceptually, substance abuse can be seen as a continuum, with individuals at one end being relatively "disease-free" but engaging in maladaptive behaviors over which they have some control. These individuals may repetitively use drugs, and over time they may abuse drugs. They choose to live a certain lifestyle in which their maladaptive behavior may or may not result in other disease states associated with use (e.g., cirrhosis of the liver). If these individuals stop this negative cycle they can, perhaps on their own, learn alternative coping mechanisms and self-efficacy. Individuals at the other end of the continuum, however, seemingly have no control over their use. Some individuals appear to lose control the first time they use drugs. For these individuals drug use is like a toggle switch that is either on or off. For them, total abstention is the only alternative because they have no control processes once the switch is turned on. They may use until they die unless someone else can turn their switch off and keep it off. There is no logic to this behavior, and no choice. Users of this type will often ruin their own lives and the lives of those around them in their drive to use their drugs of choice. It seems that as one moves toward a more "at-risk" end of the continuum there is less and less control over substance use.

It is unclear what causes the difference in loss of control among those at different points of the continuum. Researchers do not understand the process very well. They do know that other factors may exacerbate the process, including biologically based differences in metabolic processes, different levels of susceptibility to the reinforcing effects of drugs, personality disorders or depression, and an inability to tolerate frustration or emotional discomfort. Some processes are under individual control, but many are not, and it does appear that the less control the individual has over these types of processes, the more likely he or she is to fall into substance abuse.

STAGES OF ALCOHOLISM AND DRUG ABUSE

During the early stages of substance abuse, the alcoholic or drug abuser experiences increasing tolerance and use. Substance use at this stage is generally for purposes of self-medication. In the later stages of abuse, life becomes centered around obtaining, using, and recovering from drug use. Loss of control, ethical deterioration, and noticeable withdrawal symptoms ensue. It is unclear, however, whether such a progression is inevitable.

In a 1991 empirical review of the study of progression in alcoholism, Jill Littrell found that approximately 60 percent of adolescent problem drinkers remit to nonproblematic levels of drinking when they reach their 20s, and that 25 percent of young adults remit to nonproblematic levels of drinking before they reach age 35. Studies examining data on adult alcoholics who have undergone a variety of treatments as inpatients and outpatients during follow-up periods of up to fifteen years provide a general profile of outcomes. Between 25 and 35 percent remain abstinent, whether or not they continue treatment. An additional 15 to 25 percent will be abstinent most of the time, with some lapse periods. Approximately 6 to 9 percent will become nonproblematic or controlled drinkers (particularly those who were lighter drinkers and suffered fewer negative consequences while drinking). Another 20 to 33 percent become stable problematic drinkers, while 15 to 25 percent will die from alcohol-related causes.

It is uncertain whether drug abusers follow a progression similar to that of alcoholics. There probably is some validity to a notion of progression for drug use in general, but more longitudinal studies are needed in this area. It is possible that such a progression might simply express the accumulation of consequences one endures each time one takes a chance by drinking or using drugs. As opposed to the stages outlined above, a substance abuser may simply incur more problems over time, along with an increased tolerance for alcohol or other drugs of abuse.

Ethyl alcohol, or ethanol, is the most commonly used drug in the world. Pharmacologically, alcohol is classified as a central nervous system depressant. Like other depressants, in small doses alcohol slows heart rate and respiration, decreases muscular coordination and energy, dulls the senses, and lowers inhibitions—resulting in feelings of relaxation and greater sociability. Large amounts of alcohol can result in depression of the various body systems, resulting in coma or death. The immediate physical effects of alcohol depend on the amount and frequency of drinking, while the mental and emotional effects are influenced by the mood of the drinker and the setting in which drinking takes place.

Two physical effects resulting from prolonged, heavy alcohol use include tolerance and withdrawal. Alcohol tolerance refers to the need for increased amounts of alcohol to achieve the same level of intoxication. For example, five or six drinks may be needed to achieve the same effects produced by one or two drinks when the individual first began drinking. Alcohol withdrawal, on the other hand, refers to a number of physical and psychological reactions an individual experiences when significantly reducing or stopping prolonged heavy drinking. Symptoms of withdrawal include nausea, vomiting, anxiety, and hand tremors.

An interaction of biological, psychological, and environmental factors come into play in the development of drinking behaviors and problems. For example, some individuals may be genetically predisposed to alcohol problems, but whether or not they actually experience negative alcohol consequences will also depend upon their immediate social and physical surroundings, such as family drinking patterns and alcohol availability, as well as their drinking habits.

ALCOHOL USE AND MISUSE

Most people who drink alcohol do so without negative consequences. Others may actually obtain a health benefit from its use. Some, however, drink in ways that place themselves or others at risk for experiencing alcohol-related problems. While no pattern of alcohol use is without risk, certain drinking patterns may help reduce risk significantly.

The Dietary Guidelines for Americans, issued jointly by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services, define moderate drinking as no more than two standard drinks per day for men, and no more than one per day for women and people sixty-five years of age and older. A standard drink is 0.5 ounces of alcohol, equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits. These guidelines suggest that moderate or low alcohol use is linked to a reduced risk for the occurrence of negative alcohol consequences. For others, however, abstaining from all alcohol consumption is the safest thing to do. Groups who should avoid all alcohol use include pregnant women, children and adolescents, those planning to drive or participate in other activities requiring alertness, people who cannot maintain moderate alcohol use, and those who are using over-the-counter or prescription medicines that interact with alcohol.

Another way to understand drinking problems is to examine definitions of alcohol misuse. The World Health Organization (WHO) defines alcohol misuse as alcohol use that places people at risk for problems, including "at-risk use," "clinical alcohol abuse," and "dependence." At-risk alcohol use is the consumption of alcohol in a way that is not consistent with legal or medical guidelines, and it is likely to present risks of acute or chronic health or social problems for the user or others. Examples include underage drinking; drinking by individuals with a family history of alcoholism or problem drinking; or drinking if one has a medical condition that could be worsened by drinking, such as a stomach ulcer or liver disease. Clinical alcohol abuse is a more serious type of misuse that results in one or more recurrent, adverse consequences, such as failure to fulfill important obligations or the repeated use of alcohol in physically dangerous situations. Alcohol dependence is the most severe type of alcohol misuse and involves a chronic disorder characterized by three or more symptoms within a twelve-month period. These symptoms include alcohol tolerance, withdrawal, loss of control, and continued use despite knowledge of having a physical or psychological problem.

Negative consequences resulting from alcohol use are estimated to affect more than 10 percent of the U.S. population, with many of these individuals going undetected. A number of brief screening tools are available to help detect possible alcohol problems. One of the most widely used among these is the four-item CAGE questionnaire, which derives its name from the following four self-administrated questions:

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

Answering "yes" to as few as one or two items on the CAGE questionnaire may indicate a drinking problem.

PREVALENCE

In the United States, 44 percent of adults eighteen years of age and older are current drinkers, consuming at least twelve drinks in the last year. Meanwhile, 7.4 percent, or approximately 14 million Americans, experience alcohol abuse or alcohol dependence. Heavy episodic or binge drinking has remained at the same approximate level of 16 percent for all adults since 1988, with the highest rate, 32 percent, among young adults ages eighteen to twenty-five. Over one-half of adults report having a close family member who has experienced alcoholism.

As few as 5 percent of the heaviest drinkers consume as much as 42 percent of the alcohol drunk in the United States, and 20 percent of drinkers account for nearly 90 percent of the alcohol consumed. The bulk of the alcohol drunk in the United States, therefore, is consumed by a relatively small population of very heavy drinkers.

Alcohol is also the drug most frequently used by children and adolescents. In 1999, over half (52%) of eighth graders (14-year-olds) and 80 percent of twelfth graders (18-year-olds) reported having used alcohol at least once. More problematic drinking occurs in 15 percent of eighth graders and 31 percent of twelfth graders, who reported binge drinking (consuming five or more drinks in a row) in the previous two weeks. Of American high school adolescents, over half (51%) currently drink alcohol. In 1999, one in three high school students reported heavy episodic drinking of five or more drinks on at least one occasion during the previous thirty days. The prevalence of heavy drinking commonly increases through adolescence into early adulthood.

HEALTH OUTCOMES

Alcohol use has health and social consequences for those who drink, for those around them, and for the nation as a whole. Approximately 100,000 deaths each year are attributed to alcohol use, making it the third leading cause of preventable mortality in the United States. Worldwide, 750,000 deaths are attributed to alcohol use each year. Alcohol-related deaths occur from cancer, cirrhosis of the liver, pancreatitis, motor-vehicle crashes, falls, drowning, suicide, and homicide. Alcohol affects nearly every system in the body, and contributes to a range of medical problems, including altered immune system functioning, bone disease, hypertension, stroke, cardiovascular disease, reduced cognitive functioning, fetal abnormalities, traumatic injury, depression, gastrointestinal disorders, and cancers of the neck, head, stomach, pancreas, colon, breast, and prostate. Alcohol also produces significant social problems, including domestic violence, child abuse, marital and family disruption, violent crime, motor-vehicle crashes, worksite productivity losses, absenteeism, and lowered school achievement. The estimated cost of alcohol misuse in the United States in 1998 was nearly $185 billion.

Young people are particularly vulnerable to acute alcohol effects due to their lower tolerance to alcohol, their lack of experience with drinking, and drinking patterns that often include heavy episodic drinking in high-risk situations, such as during driving and sexual encounters. Leading causes of mortality and morbidity among youths include alcohol-related motor-vehicle injuries, homicide, and suicide. Alcohol use among young people is associated with reduced scholastic achievement, increased delinquency, and the development of psychiatric problems later in life. Alcohol has also been found to precede other illicit drug use, thereby serving as a "gateway" to other drug consumption, including marijuana and cocaine use.

Women and the elderly are also at greater risk for experiencing alcohol harm because of their lower levels of body water, meaning that smaller amounts of alcohol result in higher levels of intoxication than in younger men. Drinking during pregnancy has been linked to higher rates of miscarriage, stillbirth, and premature births, and fetal alcohol syndrome—a set of birth defects caused by maternal consumption of alcohol during pregnancy. For the elderly, drinking even modest amounts of alcohol may cause considerable problems due to chronic illness, interactions with medications, and grief and loneliness from the death of loved ones.

At the same time, moderate to low levels of alcohol consumption have been linked to a lower risk for heart disease and stroke. These positive effects appear to be confined primarily, however, to middle-aged and older individuals in industrialized countries with high rates of cardiovascular diseases. Individuals and populations must weigh the risks and benefits of drinking to themselves and others, including such factors as the situations under which drinking is to take place and the amount likely to be consumed, to determine the net results of drinking.

SOLUTIONS

The burden of alcohol misuse is measured in a number of ways, including the prevalence and incidence of deaths, injuries, and illnesses attributed to alcohol; hospitalization rates; potential years of life lost to alcohol misuse; and quality of life indicators. Vast resources are expended each year in the United States to address the health and social problems resulting from alcohol misuse. Because no single solution can reduce all alcohol-related harm to individuals and populations, a comprehensive approach using a range of strategies that address the multiple causes and dimensions of alcohol problems is needed. These strategies should include educational approaches—such as public health education and awareness programs, including school, family, and community-based prevention programs; environmental approaches—such as controls on the price and availability of alcohol, minimum age for purchase of alcohol, legislative measures to curb driving under the influence of alcohol, and restrictions on the promotion, marketing, and advertising of alcohol; and health care efforts—such as primary health care screening, advice by health care providers, preventive services, and effective treatment using psychological and

pharmacological approaches.

Dr.Kedar B. Karki

New Hope Rehabilitation Center Satdobato Lalitpur

drkarki_kedar@yahoo.com

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