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The production of wine probably originated around 4000 to 6000 B.C. in the mountainous region between the Black and Caspian seas. Commercial wine production was well under way by 1500 B.C. (Courtwright, 2001). Alcohol is probably the oldest drug known to human beings. It was easy for primitive people to discover that fruits and juices, left to stand in a warm place, soon ferment into alcoholic mixtures. The first person to learn about the psychoactive properties of alcohol drank, or simply had to eat or drink, old fermented fruit or juice. Production of alcohol depends upon a one-celled organism called yeast that is found almost everywhere. Yeast feeds on sugar, making alcohol and carbon dioxide as by-products. To grow yeast cells, you need water, sugar and warmth. The yeast cells continue growing until they use up all of the sugar, or until the rising alcohol content kills them. That’s why the alcoholic content of wine can only rise so high before fermentation stops. Alcohol is a deadly poison and in high enough quantities, it kills all living things, including the yeast cells that produce it (Weil & Rosen, 1998). The extent of addiction in the world is horrific. Substance abuse is the nation’s number one health problem. Over a lifetime, 27% of the population will suffer from a substance abuse disorder (Kessler, McGonagle Zhao, Nelson, Hughes, Eshleman, et al., 1994). Twenty five percent of Americans will die of some form of substance abuse. Ninety five percent of alcoholics die of their disease, approximately 26 years earlier than their normal life expectancy. Heavy drinking contributes to illnesses in each of the top three causes of death: heart disease, cancer and stroke. Approximately two-thirds of American adults drink an alcoholic beverage during the course of a year, and at least 13.8 million Americans develop problems associated with drinking. Fifty percent of cases involving major trauma are alcohol related. Fifty percent of homicides are alcohol related. Forty percent of assaults are alcohol related. One hundred thousand Americans die of alcohol problems each year. More than 40% of those who start drinking at age 14 or younger become alcoholic. In 1998, the cost of alcohol abuse was over 185 billion dollars. Over many years of following alcohol and drug use, studies find that 80% of high school seniors have tried alcohol, 32% have gotten drunk in the last thirty days, 49% have smoked marijuana and 63% have smoked cigarettes. The average 18-year-old has seen 100,000 television commercials encouraging him or her to drink. The patients who are most vulnerable to excessive alcohol and drug abuse are young adults between the ages of 18-25. They have the highest incidence of alcohol and drug use, but no age group is omitted from falling victim to the problem. More alcoholism is being found in the elderly now that more baby boomers are retiring. Classical alcoholism takes about 15 years to develop, but it can happen much quicker in adolescents and young adults. With all of this bad news, we have strong evidence that treatment works. For every dollar spent on recovery, the economy saves seven dollars in health care and cost to society. Most patients who work the program of recovery stay clean and sober (Gordis, 2003; Stein, 2001; Monitoring the Future Study, 2000; NIAAA, 1997). Alcohol Problems Are Very Common Alcohol is the primary drug of abuse by clients in most treatment settings, so you will see a lot of them no matter what kind of work you do. About one in ten Americans currently has an alcohol problem. Alcoholism generally develops slowly over a person’s lifetime. Alcoholism is not caused by psychological problems; it is a primary disease. It can begin at any age, and it often occurs in individuals who have little psychosocial pathology (Vaillant, 2003). More than 18 million patients currently need alcohol treatment and only one forth ever get treatment for a number of reasons, such as lack of availability, lack of space, limited funding, or because drinkers may not want to admit they need treatment. In 1997, 87% of patients were in outpatient treatment, 11% were in 24-hour rehabilitation, and 2% were in 24-hour detoxification units. More than two thirds of the funding for alcohol and drug treatment facilities come from public sources. Private insurance pays for about 14% of services, and the patients pay for about 10%. There is no excuse for not being able to find an inpatient or outpatient program of recovery. Addiction professionals are getting creative as the needs for treatment increase. A new Internet program (http://www.egetgoing.com) offers excellent outpatient treatment and aftercare at home through the use of a computer. So even if the patient lives in a part of the world where there is no treatment or aftercare, good treatment is still available. Alcoholics Anonymous meetings are also available online at http://www.aa-intergroup.org (U.S. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 1999; Stein, 2001). Alcohol Problem Destroy Families Alcohol problems cluster in and destroy families. More than half of current drinkers have a family history of alcoholism. Three out of ten adults report that drinking has been a cause of trouble in their family. Alcohol abuse can destroy families in many ways. More than 40% of separated or divorced women were married to or lived with a problem drinker. More than three fourths of female victims of nonfatal, domestic violence reported that their assailant had been drinking or using drugs. More than 18 million alcohol abusers need treatment but few get it (Stein, 2001). Children of alcoholics demonstrate a three- to four-time increased risk of developing the disorder. Twin studies strongly suggest a powerful genetic link. Generally, it seems that alcoholism is caused by 40% genetic factors and the remaining 60% by factors we don’t understand (Heath, Bucholz, Madden, et al., 1997; Schuckit, 1987; Anthenelle & Schuckit, 1998). Genetic researchers are engaged in identifying the genes that cause vulnerability to addiction, but the task is difficult because alcoholism is considered to be a polygenetic disorder that is related to many different genes, each of which contributes only a portion of the vulnerability (Gordis, 2003). Alcohol Problems Contribute To Crime About half of state prison inmates and 40% of federal prisoners incarcerated for committing violent crimes report they were under the influence of alcohol or drugs at the time of their offense. Over all, about three-quarters of all prisoners in 1997 were involved in alcohol or drug abuse in some way in the time leading up to their current offense. In 1995, there were 51,737 federal prisoners and 224,900 state prisoners who were incarcerated because of alcohol or drug abuse (U.S. Department of Justice Statistics, 1997). Alcohol disorders and alcohol-related problems are more common among men than women (Kessler et al., 1994), but women with alcoholism are more prone to a fulminate clinical course. Women are more likely to die of cirrhosis and violence caused by alcohol abuse and die 11 years earlier than their male counterparts (Krasner, Davis, Portman et al., 1977). Individuals in stable marriages have the lowest incidence of lifetime prevalence of alcoholism, 8.9%, as opposed to co-habiting adults who have never been married, 29.2% (Helzer, Burnam & McEvoy, 1991). The only racial group that seems to have some protection from alcoholism is Asians. This could be the result of the discomfort of a flushing response present in many of these individuals when they drink (Hsu, Loh, Chen, Chen, Yu, & Cheng, 1996). There are higher rates of alcoholism in the unemployed, laborers and those of lower socioeconomic status, those that drop out of high school and those who entered college but failed to earn a degree, and those under more stress (Crum, 1998). Alcohol Kills Cells Continual use of alcohol can lead to erosive gastritis, which can limit the absorption of nutrients and vitamins associated with several serious neurological and mental disorders, including brain damage, memory loss, loss of sexual responsiveness, sleep disturbances and psychosis such as Wernike’s Encephalopathy and Korsakoff’s syndrome. Alcohol Causes Fetal Alcohol Syndrome Fetal alcohol syndrome and fetal alcohol effects (see Appendix 19) are the leading causes of mental retardation in the country. At least 762,000 children are born each year exposed to alcohol during pregnancy. Once ingested and absorbed into the maternal bloodstream, alcohol readily crosses the placenta and enters the fetal circulation. It is found in the amniotic fluid, even after ingestion of a moderate dose. Alcohol is eliminated from the amniotic fluid at a rate that is one half the rate at which it is eliminated from the maternal blood; therefore, it remains in the fetal circulation after it is no longer in the mother’s bloodstream. It is estimated that approximately one of every three to four mothers exposes her fetus to the potentially harmful effects of alcohol. Fetal Alcohol Syndrome is the leading preventable cause of mental retardation and neurobehavioral defects in North America (Pagliaro & Pagliaro, 2002). The signs and symptoms of fetal alcohol syndrome have been established by the Fetal Alcohol Study Group of the Research Society on Alcoholism and incorporate the following criteria (Pagliaro & Pagliaro, 2002):
Many of your patients will have a less severe form of alcohol-induced brain damage called fetal alcohol effects. The behavioral and neurological problems associated with prenatal exposure to alcohol in the absence of the symptoms of full-blown fetal alcohol syndrome are termed alcohol-related neurodevelopmental disorder or fetal alcohol effects. Patients with fetal alcohol effects won’t have the full syndrome but they will have neurological and behavior problems due to alcohol-related brain damage. Children with fetal alcohol problems often have short attention spans and are described as hyperactive or impulsive. Maladaptive behaviors are common and include poor judgment, failure to consider consequences of one’s actions, and difficulty perceiving social cues (Gordis, 2003; Streissguth, 1998). The Fetal Alcohol Behavior Scale (see Appendix 18) is helpful in uncovering fetal alcohol syndrome and fetal alcohol effects in your patients. You must make sure that you have evidence of maternal drinking before you can diagnose this problem. Many of your patients will have a mild to moderate form of this brain damage and they will need more structure in recovery. Alcohol has poisoned their brain and they will need an advocate in the community to buffer problems with society (Streissguth, A.P., Bookstein, F.L. Barr, H.M., Press, S., and Sampson, P.D., 1998). If you don’t think alcohol is a poison, take an egg and drop it into Everclear, which is 95% pure alcohol. The egg will instantly turn white as it cooks. This is a good demonstration for your patients. It allows them to see the poisonous effect of their drug of choice. People with fetal alcohol effects may have normal intelligence, but they have defects in their brain and behavior. They can do some things some days but are unable to do the same thing the next day. They have difficulty generalizing. A rule they learn in one situation may not transfer to other situations. They have difficulty learning from past experiences and they have difficulty learning how the past affects the future. They tend to be very nice, people-oriented patients, but they keep relapsing. Does this sound like anyone you know? There are probably patients that you are seeing now that have this disorder and many will be incapable of working a self-directed program of recovery. These patients will need a mentor or a structured facility for the rest of their lives. The mentor is usually someone in the family or community who can act as an advocate for the patient in recovery. These patients are very frustrating to work with until you figure out what the problem is and change the treatment plan to incorporate this condition (Streissguth, 1998). Type 1 and Type 2 Alcoholism Type 1 alcoholism accounts for about 75% of alcoholics and is characterized by the following signs and symptoms:
Type 2 alcoholism is characterized by the following signs and symptoms:
Type 1 alcoholics do much better in treatment and, because of long-standing antisocial behaviors and attitudes, type 2 alcoholics usually need long-term structure to maintain sobriety (Woodward, 1998). Alcohol and all drugs trigger the mesolimbic dopamine reward system and the endogenous opioid system, which reward drinking. This is what addicts the brain and makes it impossible to stop drinking. If an alcoholic stops drinking on their own, at the very least they are going to feel restless, irritable, and discontent. Only alcohol will move the patient back toward a feeling of peace. Addiction is a Brain Disease The brain of someone addicted to alcohol is a changed brain. The chronic use of any mood-altering chemical first chemically changes the brain as the cells respond to the poison by producing counteracting chemical compounds that reduce the effects on the cell. If the use continues, the brain changes in structure and, finally, it changes in genetics. In chronic alcohol abuse, the body produces chemical, structural, and genetic changes that do the opposite of what the drug is doing. Alcohol is a depressant so the body produces chemicals, structures and, finally, genetics to stimulate the brain. The alcohol is depressing the central nervous system, the brain picks this up as being abnormal, so the brain changes to counteract the drinking. Alcoholics lose brain cells and using MRIs professionals can see the loss of brain tissue by the widening of the spaces in the sulci and ventricles of the brain. You can see in the below image that the alcoholics brain is smaller.
Society views alcoholics as responsible for their problems. To some extent, this is true. Like most of their peers, the alcohol abuser made the early choice to drink but once addiction kicks in, choice is removed. The person must drink to feel normal. Twenty percent of alcoholics who try to quit drinking on their own without medical management die of alcohol withdrawal delirium. First, the person drinks to feel better but after neuroadaptation has changed the brain; the patient must drink to live. Alcohol and drugs change the brain and thereby produce uncontrollable, compulsive drinking. If the alcoholic stops drinking, he or she goes into a biochemical storm called withdrawal. Most addicts would prefer to stop using, but this proves to be very difficult--even impossible--without treatment. Almost all drugs activate the mesolimbic dopamine reward system in the brain. The alcoholic cannot move back and forth between alcohol abuse and alcoholism because their brain has changed. The functioning that normally allows the patient to exercise choice is disrupted (Leshner, 1998; Koob, G.F., 1996). All drugs of abuse activate brain reward pathways that are very old from an evolutionary point of view. These pathways mediate an individual’s response to natural rewards, such as food, sex, and social interaction. Drugs of abuse activate these reward pathways with great power not seen under normal environmental conditions (Nestler, 2001; Everitt & Wolf, 2002; Koob, Sanna & Bloom, 1998). Repeated alcohol exposure causes neuroadaptation in the brain’s reward pathways, which results in drinking more alcohol. This is the quickest way for an alcoholic to feel normal again and it causes long-term memories related to alcohol use that produce intense cravings, even after long-term abstinence. Environmental cues can reactivate the brain’s reward pathway and this can lead to relapse (Nestler, 2003). Alcohol bathes every cell in the body but its major neurological effects occur in the brain. Over the past 20 years, a great deal of progress has been made in understanding the sites and mechanisms of alcohol’s effect on the brain. A consensus is emerging that ligand-gated ion channels represent a likely site for the acute effects of alcohol on neuronal function. Needless to say, the general effects of alcohol on the body are extremely complex (Woodward, 2003). Alcoholism is a Medical Emergency This is the only way to think about alcoholism accurately. You are dealing with a person who is dying. Evidence says that 68% of those people who come to a trauma center have an alcohol or drug problem. Thirty percent of patients in acute care hospitals are addicted. Alcoholics spend four times the amount of time in a hospital as non-drinkers, mostly from drinking-related injuries. Up to 20% of visits to primary care physicians are related to substance abuse problems. Yet doctors almost never recognize the alcohol problem. “Sadly, although physicians are the professionals most often cited by patients and families as the ‘most appropriate’ source of advice and guidance about issues related to the use of alcohol, tobacco and other drugs, they also are reported to be the ‘least helpful’ in actually addressing these issues. Most diagnoses of alcohol abuse and addiction are missed by physicians, and even if a diagnosis is made, many physicians do not know how to develop an organized treatment plan,” (Conigliaro, Reyes, Parran & Schultz, 2003, p.325). About 10% of the time addiction is recognized as the cause of the problem that brought the patient into the health care system. A cut on your head probably won’t kill you. A broken bone probably won’t kill you. An ulcer probably won’t kill you. But alcoholism will kill you if you allow it to continue. The death certificate might list a motor vehicle accident, a heart attack, or a stroke. It might be called cirrhosis or cancer, but the cause is addiction. The accident happened because the patient was intoxicated. The murder happened because the person was drunk. The person died of liver failure from alcohol abuse. Alcoholism is a murderer, and it will kill your patient. The only hope the patient has is you. You are the only one who suspects the problem. I don’t know what your job is, but the patient’s only hope is you. You might be the nurse, clergy, EMT, paramedic, police officer, ambulance driver, teacher, counselor, child, or spouse, but you see the truth and no body else does. If you remain silent, the serial killer will murder again and again and again (Stein, 2001).
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