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Who Answers?Alcohol, or ethanol, is one of the most commonly used psychoactive substances in the world. In part because of its widespread use and acceptance, alcohol abuse and addiction are also very common. Nearly one-third of the U.S. population will experience alcohol addiction at some point in their life with fewer than 25% of those with it seeking.14 There are many signs of alcoholism to look for if you’re concerned that someone you love (or even yourself) is addicted to alcohol.
Knowing the Signs of Alcoholism
Perhaps the most noticeable way alcohol affects someone is on their behavior, which varies from person to person. Excessive drinking (blood alcohol ranges of .06 – 0.2) can cause some people to be loud and talkative, while others may become withdrawn. Some people become angry and aggressive, at times leading to abusive behavior and violence. Still, others may experience dramatic mood swings, with signs of boisterousness or aggression as well as withdrawal or severe depression.7
Genetics and Environmental Factors
How someone reacts to alcohol depends largely on their genetic makeup as well as their current and past environment. Genetic makeup can determine how someone metabolizes alcohol and how alcohol interacts with a person’s brain chemistry, leading at times to person-specific and sometimes unexpected behaviors.
It is also now well documented that alcoholism can be passed down through a person’s genes.19 Past and current environments can also strongly influence someone’s response to alcohol. Some individuals, for example, are exposed to environments that accept and even encourage heavy drinking while others have little or no exposure to alcohol use or abuse.
For this reason, it’s important to look for signs of alcoholism in those who have had family members who have been alcoholics.
Amount of Alcohol Consumed
Another important factor when considering alcohol’s effects and looking for the first signs of alcoholism is how much is consumed. Recommendations for alcohol use usually stipulate no more than two “standard drinks” per day for men and 1 standard drink per day for women.16
Women are advised to drink less for a number of reasons, including the fact that they generally weigh less and do not metabolize alcohol the same way as men. Women also have proportionally less body water compared to men, even when taking into consideration differences in size and weight. These factors mean that alcohol is more concentrated in women’s blood than in men’s.17
When Does Alcohol Use Become Abuse?
A “standard drink” is considered as:
- 12 oz of beer, 5% alcohol by volume
- 8-9 fl oz of malt liquor
- 5 oz of wine, 12% alcohol by volume
- 1.5 oz of spirits, 40% alcohol by volume
These numbers are important to keep in mind because the term “drink” can be misleading. For example, when someone orders a “double” or pours significantly more than 1.5 oz of distilled spirits into a single glass, they might actually be consuming more than “a drink”.9
Some alcoholic beverages may also contain much more alcohol than the “standard” amount. Alcohol can be as high as 8-12% by volume in some beers, for example. Many cocktails, including mojitos, margaritas, or martinis, contain more than 1 standard drink in a single glass. Port, a sweet dessert wine, contains approximately 18% – 20% alcohol by volume. These are examples of when calculating alcohol consumption isn’t always straightforward. Factoring in these differences, however, is important when making distinctions between healthy or unhealthy drinking habits.
Unhealthy Drinking Habits: One of the First Signs of Alcoholism
“Unhealthy” levels of alcohol consumption can be difficult to evaluate, especially when considering society’s widespread use and acceptance of alcohol. Under the umbrella of unhealthy levels of alcohol consumption are a number of different terms, categorized by severity.
On the lower end of severity is alcohol misuse. Alcohol misuse is a pattern of heavier drinking (or “binge drinking”)—defined as five or more drinks in one occasion for men, four or more for women—that can lead to social, legal, or health problems.15 Alcohol abuse is a continued pattern of alcohol misuse despite social, legal, or health problems it is causing.7
Alcoholism, also known as alcohol dependence or addiction, is defined as the body’s physical need or dependence on alcohol. There is also “Alcohol Use Disorder (AUD)”, which is a term used by mental health professionals to diagnose individuals with alcohol problems. AUD can capture symptoms of either or both alcohol abuse and dependence and is diagnosed by severity (mild, moderate, or severe). Severe AUD and alcoholism are considered interchangeable.19 For purposes of clarity, the terms alcoholism or alcohol addiction will be used for the remainder of this article.
Common Signs of Alcoholism
Alcohol misuse may result in intoxication and some social or health problems. This, however, is not the same as alcohol addiction or alcoholism. Alcoholism involves moderate to severe impairments in psychological, social, and physical health functioning that alcohol misuse doesn’t. Some psychological signs of alcoholism include:
- Cravings for alcohol
- Drinking more than intended
- Continued drinking in spite of the mental and physical health complications drinking is causing (e.g., liver or heart disease, malnutrition, depression, alcoholic ketoacidosis)
- Engaging in unsafe behaviors while intoxicated (e.g., driving or operating machinery under the influence, having unprotected sex, etc.)
Functional signs of alcoholism include:
- Impairment to occupational functioning (e.g., job loss, working drunk or hungover)
- Relationship impairments (e.g., friendships, parental roles, romantic relationships)
- Spending excess money and/or time obtaining or consuming alcohol
Physical signs of alcoholism include withdrawal symptoms, such as:
- Tremors or “shakes”
- Anxiety
- Insomnia
- Rapid heart rate
- Fatigue
- Headache
- Nausea or vomiting
It is important to note that while alcohol withdrawals occur largely without medical complication, they can be very dangerous. In a subsect of individuals, alcohol withdrawals can reach an extreme state of severity called Delirium Tremens. Symptoms of Delirium Tremens include:
- Agitation
- Fever
- Seizures
- Confusion
- Hallucinations (seeing or hearing things that aren’t there)
Delirium Tremens is a state of emergency and should be addressed immediately.18 Generally, withdrawal symptoms and the prevention of Delirium Tremens are best addressed with supervised detoxification. Even if someone is not at risk for Delirium Tremens, supervised detoxification can help prevent relapse, which is common during withdrawal.
First Signs of Alcoholism To Look For
It is important to note that while alcohol misuse and addiction are not the same things, alcohol misuse is a risk factor for developing alcohol addiction.2 Predicting whether any one person will become addicted to alcohol is nearly impossible but there are some early warning signs and risk factors that are worth considering.
Perhaps most importantly is to examine the social, psychological, and physical effects alcohol is causing. Whoever it is that you may be concerned about, is that person isolating, withdrawing, or cutting off ties with people close to them? Are their relationships hurting or deteriorating? Are they gaining or losing weight? Do they look more disheveled or more poorly groomed? Are they struggling at work or struggling to take care of themselves? Are there any reasons to believe that alcohol might be impacting their physical health (e.g., blood pressure, heart health, liver functioning)? Do they appear down or blue, anxious, or more aggressive than usual? Yes to any of these questions may indicate a problem.
Risk factors that lie beyond what effects alcohol is causing are factors like genetics and mental illness. Alcoholism is highly heritable, meaning that it is commonly passed down through genes. It is estimated that 50% of the risk in developing alcoholism is attributable to genes.17
Mental illnesses like depression, anxiety, bipolar disorder, and schizophrenia, also put people at higher risk for developing alcohol addiction.12 On the flip side, addiction can also create or make mental health symptoms worse,13 making a return to healthy drinking that much more difficult. Alcoholism is considered to be one of the highest risk factors for suicide.1
Treatment for Alcoholism
Approximately 70% of individuals with alcohol addiction or risky drinking behavior experience “natural recovery”, meaning recovery without treatment.14 This statistic is misleading, however, because the majority are lower-risk drinkers vs those with a severe alcohol problem.14 Additionally, individuals who do experience “natural recovery” may do so only after inflicting significant damage to their physical or social health.
Confronting someone about their alcohol abuse or addiction can be difficult for a number of reasons. People who feel ashamed about their abuse of or addiction to alcohol may hide their drinking. They may also downplay the problems it’s causing.
Even when signs of problem drinking or alcoholism are more apparent, individuals often deny needing treatment. This can be because they don’t want to stop drinking or because they are afraid of confronting the problems their drinking is causing. For these reasons, some individuals isolate themselves and break off contact with those that they know would assist them in seeking help. Thus, it is important to remember that decisions about treatment for alcoholism, or any addiction for that matter, should involve the person in need of treatment.
If someone is unsure about treatment, motivational interviewing may be a good first step. Motivational interviewing is a non-judgmental therapeutic approach that encourages individuals to examine their problematic alcohol use and evaluate their need for treatment. It can, also in some cases, reduce drinking frequency.10
Once someone has decided to seek treatment, selecting the appropriate course will depend on the individual; both their preference for treatment and the severity of their drinking. Problematic alcohol use that hasn’t turned into an addiction, especially if withdrawal symptoms are not present, can be treated with behavioral therapy only. Individuals who regularly consume high quantities of alcohol, however, may require increased levels of care. Because these individuals are more likely to experience withdrawal symptoms, including the rare but potentially fatal symptoms of delirium tremens, they should receive medically supervised detox.
Detox
Supervised detoxification is a detox method that is medically monitored to ensure comfort, prevent relapse, and address any physical or psychological complications that arise during withdrawal. Medications received during the detoxification process will depend on the individual’s health status, including the presence of specific withdrawal symptoms and the functioning of organ systems like the kidneys and liver.
A common class of medication used during detox from alcohol is benzodiazepines (e.g., Librium). Benzodiazepines like Librium help decrease the severity of withdrawal symptoms by balancing out uneven levels of neurotransmitters caused by prolonged, heavy drinking. Benzodiazepines also calm the body, which becomes agitated during the state of withdrawal from alcohol.6
Medically supervised detox is part of a general approach to addiction treatment called medically-assisted treatment, or MAT. MAT is supported by the scientific community as a way of successfully treating alcohol and other drug addiction and can involve supervised detoxification, treatment planning, and counseling.
Once an individual has completed or neared completion of supervised detox, other medications may be introduced to reduce cravings for alcohol and prevent relapse. The two most effective and commonly prescribed medications are Acamprosate and Naltrexone. Naltrexone has the added benefit of reducing the euphoric feelings that accompany alcohol when consumed. It does this by blocking opioid receptors in the brain which contribute to alcohol’s pleasure-causing effects.11
Medications and Therapy
Other medications that are sometimes used to treat alcoholism are Disulfiram, Gabapentin, and Topiramate. Disulfiram is an Antabuse medication that has been approved to treat alcoholism since 1949.4 Disulfiram blocks the enzyme responsible for metabolizing a toxic component of alcohol. The result is a cluster of undesirable effects (e.g., nausea, vomiting, flushing) that occur when alcohol is consumed. Topiramate and Gabapentin are both anti-seizure medications that are prescribed off-label for alcoholism. Both medications are thought to reduce cravings.11
Medications for treating alcoholism are not considered stand-alone treatments. Behavioral therapy is also encouraged during treatment for alcoholism. Results show that therapy and medication in combination have the lowest rates of relapse.10 Therapy for alcohol addiction varies but the most studied and effective is cognitive behavioral therapy, or CBT.10 CBT examines and works to modify thoughts, emotions, and behaviors associated with alcohol use.
References
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2. Grant, B. F., Chou, S. P., Saha, T. D., Pickering, R. P., Kerridge, B. T., Ruan, W. J., … & Hasin, D. S. (2017). Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013: results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry, 74(9), 911-923.
3. Hermann, D., Hirth, N., Reimold, M. et al. (2017). Low μ-Opioid Receptor Status in Alcohol Dependence Identified by Combined Positron Emission Tomography and Post-Mortem Brain Analysis. Neuropsychopharmacol 42, 606–614.
4. Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. JAMA Psychiatry, 320(8), 815-824.
5. McCarty, C. A., Wymbs, B. T., King, K. M., Mason, W. A., Stoep, A. V., McCauley, E., & Baer, J. (2012). Developmental consistency in associations between depressive symptoms and alcohol use in early adolescence. Journal of studies on alcohol and drugs, 73(3), 444-453.
6. Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., … & Addolorato, G. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353-365.
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8. National Institute on Alcohol Abuse and Alcoholism. (n.d.). Cocktail Calculator Rethinking Drinking – NIAAA. Retrieved December 07, 2020.
9. National Institute on Alcohol Abuse and Alcoholism. (2020). Women and Alcohol. Retrieved December 06, 2020.
10. Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: a systematic review and meta-analysis. JAMA network open, 3(6), e208279-e208279.
11. Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … & McIntyre, J. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86-90.
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13. Schuckit, M. A. (2006). Comorbidity between substance use disorders and psychiatric conditions. Addiction, 101, 76-88.
14. Tucker, J. A., Chandler, S. D., & Witkiewitz, K. (2020). Epidemiology of Recovery From Alcohol Use Disorder. Alcohol research: current reviews, 40(3), 02.
15. U.S. Centers for Disease Control and Prevention. (2018). Alcohol & Substance Misuse. Retrieved December 7, 2020.
16. U.S. National Library of Medicine. (2020, November 09). Alcohol. Retrieved December 05, 2020.
17. U.S. National Library of Medicine. (2020, November 02). Alcohol Use Disorder (AUD). Retrieved December 05, 2020.
18. U.S. National Library of Medicine. (2019, January 10). Alcohol withdrawal: MedlinePlus Medical Encyclopedia. Retrieved December 7, 2020.
19. Verhulst, B., Neale, M. C., & Kendler, K. S. (2015). The heritability of alcohol use disorders: a meta-analysis of twin and adoption studies. Psychological medicine, 45(5), 1061–1072.