Alcoholism

Alcoholism is a term with multiple and sometimes conflicting definitions, but with no formal recognition of the divergence of meaning. In common and historical usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages despite the health problems and negative social consequences it causes. Medical definitions describe alcoholism as a
disease which may result in a persistent difficulty in controlling alcohol consumption. Alcoholism may also refer to a preoccupation with or compulsion toward the consumption of alcohol and/or an impaired ability to recognize the negative effects of excessive alcohol consumption. Although not all of these definitions specify current and on-going use of alcohol as a qualifier, some do, as well as remarking on the long-term effects of consistent, heavy alcohol use, including dependence and symptoms of withdrawal.

While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, emotional health and genetic predisposition have been identified.

Identification and diagnosis
Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared to the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify.
Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.

Screening
Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.

The Alcolhol Dependence Data Questionnaire is a more sensitive diagnostic test than the CAGE test. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.
The Michigan Alcohol Screening Tes (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses, driving under the influence being the most common.

The Alcohol Use Disorders Identification Test AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions - a high score earning a deeper investigation.

The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments . It concords well with the AUDIT questionnaire but is administered in a fifth of the time.

A number of free websites provide anonymous self-screening for harmful or hazardous alcohol use, including Alcohol Screen.Org and this online version of AUDIT.

Genetic predisposition testing
Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut indicate that alcoholism does not have a single cause—including genetic—but that genes do play an important role "by affecting processes in the body and brain that interact with

one another and with an individual's life experiences to produce protection or susceptibility." They also report that less than a dozen alcoholism-related genes have been identified, but that more likely await discovery.
At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.

Some writers posit that alcohol was discovered to be a replacement for polluted drinking water in early urban societies. In these conditions, alcohol's antibacterial properties offset its health risk, and the slow death of cirrhosis of the liver was preferred to an early death from waterborne disease. This caused a selection pressure on the genes of humans who had abandoned the hunter-gatherer lifestyle towards people with genes which were not prone to over consumption and drunkenness. Over generations, the descendants of these first farmers and urban dwellers became dominated by individuals who could drink more beer more often. This theory explains why some groups who continued a predominately hunter-gatherer culture, such as Native Americans or Australian Aborigines, have such high rates of alcoholism today.

Treatments
Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.
Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.

Effectiveness
The effectiveness of alcoholism treatments varies widely. When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own. Based on information from Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism, the February 2007 issue of Newsweek reported that "A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed."

Detoxification
Main article: Alcohol detoxification

Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.

Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.

Group therapy and psychotherapy
After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.
The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service, including Alcoholics Anonymous,LifeRing Secular Recovery, Rational Recovery,Smart Recovery,Al-Anon/Alateen and Women for Society

Rationing and moderation
Rationing and moderation programs such as Moderation Management and The HAMS Harm Reduction Network do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking.

Medications
Although not necessary for treatment of alcoholism, a variety of medications may be prescribed as part of treatment. Some may ease the transition to sobriety, while others cause physical hardship to result from the use of alcohol. In most cases the desired effect is to have an alcoholic abstain from drinking.

Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hang over symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast acting and long lasting uncomfortable hang over. This discourages an alcoholic from drinking in significant amounts while they take the medicine. Heavy drinking while on antabuse can cause severe illness and death.

Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction , combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction. Naltrexone comes in two forms. Oral naltrexone, originally but no longer available as the brand ReVia, is a pill form and must be taken daily to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.

Piracetam appears to be effective in treating alcoholism or its symptoms in clinical studies. Piracetam appears to reduce levels of lipofuscin in the rat brain. (Lipofuscin accumulation is common symptom of aging and alcoholism).

Acamprosate (also known as Camprall) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse...Campral proved superior to placebo in maintaining abstinence for a short period of time..." While effective alone, it is often paired with other medication treatments like naltrexone with great success.Acamprosate reduces glutamate release. The COMBINE study was unable to determine the presence of efficacy for Acamprosate.

Sodium oxybate is the sodium salt of gamma-hydroxybutyric acid (GHB). It is used for both acute alcohol withdrawal and medium to long-term detoxification. This drug enhances GABA neurotransmission and reduces glutamate levels. It is used in Italy in small amounts under the trade name Alcover.

Baclofen has been shown in animal studies and in small human studies to enhance detoxification.This drug acts as a GABA B receptor agonist and this may be beneficial.

Nutritional therapy
Preventative treatment of alcohol complications includes long-term use of a multivitamin as well as such specific vitamins as B12 and folate.
While nutritional therapy is not a treatment of alcoholism itself, it treats the difficulties that can arise after years of heavy alcohol use. Many alcohol dependents have insulin resistance syndrome, a metabolic disorder where the body's difficulty in processing sugars causes an unsteady supply to the blood stream. While the disorder can be diminished by a hypoglycemic diet, this can affect behavior and emotions, side-effects often seen among alcohol dependents in treatment. The metabolic aspects of such dependence are often overlooked, causing poor treatment outcomes.