Chemical Dependency: Alcoholism
Center for Continuing Dental Education
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For many people, the facts about alcoholism are not clear. What is alcoholism, exactly? How does it differ from alcohol abuse? When should a person seek help for a problem related to his or her drinking?
For most people, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use--up to two drinks per day for men and one drink per day for women and older people (a standard drink is one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits) -- is not harmful for most adults. Nonetheless, a substantial number of people have serious trouble with their drinking. Currently, nearly 14 million Americans--1 in every 13 adults--abuse alcohol or are alcoholic. Several million more adults engage in risky drinking patterns that could lead to alcohol problems. In addition, approximately 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.
The consequences of alcohol misuse are serious--in many cases, life-threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx. It can also cause liver cirrhosis, immune system problems, brain damage, and harm to a fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes, recreational accidents, and on-the-job accidents and also increases the likelihood of homicide and suicide. In purely economic terms, alcohol-use problems cost society in excess of $166 billion per year. In human terms, the costs are incalculable.
Almost 1 in 5 adult Americans (18%) lived with an alcoholic while growing up. 76 million Americans (43% of the US population) have been exposed to alcoholism in their family. There are an estimated 26.8 million children of alcoholics (COA) in the US, and more than 11 million are under the age of 18.
Aside from the likelihood of developing alcohol problems themselves, these children often have emotional disturbances, conduct disorders and may do poorly in school. The consequence of this is that these children will likely suffer some form of dysfunction in their adult lives as a result of growing up in alcoholic family systems.
Families with alcohol and drug problems are involved in 90 percent of the cases of child abuse. Alcohol abuse is specifically associated with physical maltreatment of children.
Children of mothers categorized as problem drinkers had twice the risk of serious physical injury as children of mothers who didn't drink.
Children of mothers who were problem drinkers married to men rated as moderate to heavy drinkers had a 2.7 times higher risk of serious physical injury compared with parents who were nondrinkers.
The National Association for Children of Alcoholics (NACOA) has developed the following basic facts about children of alcoholics:
An estimated 28 million Americans have at least one alcoholic parent.
Approximately 1/3 of all alcoholics have an alcoholic parent.
Children of alcoholics are at the highest risk of developing alcoholism themselves or marrying an alcoholic.
In up to 90 percent of child abuse cases, alcohol is a significant factor.
Children of alcoholics are frequently victims of incest, child neglect, and other forms of violence and exploitation.
Alcoholism, aka "alcohol dependence syndrome," is a disease that is characterized by the following elements:
Craving: A strong need, or compulsion, to drink
Loss of control: The inability to limit drinking once a person has begun
Physical dependence: The occurrence of withdrawal symptoms (nausea, sweating, shakiness, and anxiety) when alcohol use is stopped after a period of heavy drinking. These symptoms are usually relieved by drinking alcohol or by taking another sedative drug.
Tolerance: The need for increasing amounts of alcohol in order to feel the same effect..
Alcoholism has little to do with what kind of alcohol one drinks, how long one has been drinking, or even exactly how much alcohol one consumes. But it has a great deal to do with a person's uncontrollable need for alcohol.
This description of alcoholism helps us understand why most alcoholics can't just "use a little willpower" to stop drinking. He or she is frequently in the grip of a powerful craving for alcohol, a need that can feel as strong as the need for food or water. While some people are able to recover without help, the majority of alcoholic individuals need outside assistance to recover from their disease. With support and treatment, many individuals are able to stop drinking and rebuild their lives.
Alcohol abuse differs from alcoholism in that it does not include craving for alcohol, loss of control, or physical dependence. In addition, alcohol abuse is less likely than alcoholism to include tolerance (the need for increasing amounts of alcohol to get "high").
Alcohol abuse is defined as a pattern of drinking that is accompanied by one or more of the following situations within a 12-month period:
Failure to fulfill major work, school, or home responsibilities;
Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
Recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk;
Continued drinking despite having ongoing relationship problems that are caused or worsened by the effects of alcohol.
While alcohol abuse is basically different from alcoholism, it is important to note that many effects of alcohol abuse are also experienced by alcoholics.
Is alcoholism a disease?
Yes. Alcoholism is a chronic, often progressive disease with symptoms that include a strong need to drink despite negative consequences (job or health problems). Like many other diseases, it has a generally predictable course, has recognized symptoms, and is influenced by both genetic and environmental factors that are becoming increasingly well defined.
Can alcoholism be cured?
Not yet. It is a treatable disease, and medications are available to help prevent relapse, but a cure has not yet been found. This means that even if an alcoholic has been sober for a long time and has regained health, he or she may relapse and must continue to avoid all alcoholic beverages.
Are there any medications for alcoholism?
Yes. Two different types of medications are commonly used to treat alcoholism. The first are tranquilizers called benzodiazepines (e.g., Valium®, Librium®), which are used only during the first few days of treatment to help patients safely withdraw from alcohol.
A second type of medication is used to help people remain sober. A recently approved medicine for this purpose is naltrexone (ReVia®). When used together with counseling, this medication lessens the craving for alcohol in many people and helps prevent a return to heavy drinking. Another older medication is disulfiram (Antabuse®), which discourages drinking by causing nausea, vomiting, and other unpleasant physical reactions when alcohol is used.
Does alcoholism treatment work?
Alcoholism treatment is effective in some cases. Studies show that a minority of alcoholics remain sober 1 year after treatment, while others have periods of sobriety alternating with relapses. Still others are unable to stop drinking for any length of time. Treatment outcomes for alcoholism compare favorably with outcomes for many other chronic medical conditions. The longer one abstains from alcohol, the more likely one is to remain sober.
It is important to remember that many people relapse once or several times before achieving long-term sobriety. Relapses are common and do not mean that a person has failed or cannot eventually recover from alcoholism. If a relapse occurs, it is important to try to stop drinking again and to get whatever help is needed to abstain from alcohol. Ongoing support from family members and others can be important in recovery.
Is it safe to drink during pregnancy?
No. Drinking during pregnancy can have a number of harmful effects on the newborn, and can cause fetal alcohol syndrome, fetal alcohol effects, or alcohol-related birth defects. This can cause serious problems ranging from mental retardation, organ abnormalities, and hyperactivity to learning and behavioral problems. Moreover, many of these disorders last into adulthood. While it isn't yet known exactly how much alcohol is required to cause these problems, it is known that they are 100-percent preventable if a woman does not drink at all during pregnancy. Therefore, for women who are pregnant or are trying to become pregnant, the safest course is to abstain from alcohol.
As people get older, does alcohol affect their bodies differently?
Yes. As a person ages, certain mental and physical functions tend to decline, including vision, hearing, and reaction time. Moreover, other physical changes associated with aging can make older people feel "high" after drinking fairly small amounts of alcohol. These combined factors make older people more likely to have alcohol-related falls, automobile crashes, and other kinds of accidents.
In addition, older people tend to take more medicines than younger persons, and mixing alcohol with many over-the-counter and prescription drugs can be dangerous, even fatal. Further, many medical conditions common to older people, including high blood pressure and ulcers, can be worsened by drinking. Even if there is no medical reason to avoid alcohol, older men and women should limit their intake to one drink per day.
Does alcohol affect a woman's body differently from a man's body?
Yes. Women become more intoxicated than men after drinking the same amount of alcohol, even when differences in body weight are taken into account. This is because women's bodies have proportionately less water than men's bodies. Because alcohol mixes with body water, a given amount of alcohol becomes more highly concentrated in a woman's body than in a man's. That is why the recommended drinking limit for women is lower than for men. In addition, chronic alcohol abuse takes a heavier physical toll on women than on men. Alcohol dependence and related medical problems, such as brain and liver damage, progress more rapidly in women than in men.
Alcohol is a powerful depressant of the central nervous system, and in low doses, it can act to loosen inhibitions and relax a person. However, in high doses, it can cause analgesic effects and reduce anxiety, alertness and judgment.
Of all the body organs, the liver is the most severely affected by alcohol.
Alcohol-induced liver disease (ALD) is a major cause of illness and death in the United States. Three patterns of disease present themselves in an alcohol abuser: fatty liver, alcoholic hepatitis and cirrhosis. All three conditions occur as a direct or indirect result of alcohol consumption. It is still to be determined at what level of alcohol consumption and over what period of time ALD will occur - safe levels differ widely among individuals. Also, only a minority of alcohol abusers develop significant liver disease.
Fatty liver, also called steatosis of the liver, is the most common form of ALD, being present in 90 percent of chronic alcohol abusers. It is one of the earliest manifestations of alcohol abuse and is often followed by alcoholic hepatitis. Fatty liver is rarely associated with death, and is usually reversible in patients who cease their consumption of alcohol. Reduced incidence can be seen as soon as one to four weeks after abstinence.
More serious ALD includes alcoholic hepatitis, characterized by persistent inflammation of the liver. The prognosis for patients with alcoholic hepatitis is not good, and 15 - 50 percent of patients diagnosed with this disease die within 30 days of diagnosis, depending on the severity of the disease. While dental clinicians typically think of hepatitis as a viral-induced disease, foreign substances (such as ethanol) can induce the inflammation of the liver as found in this type of hepatitis.
Cirrhosis, characterized by progressive scarring of liver tissue is an outcome rather than a specific disease. It's an irreversible process whereby damaged or dead liver cells are replaced with fibrous tissue, causing severe effects on liver function. The treatment for cirrhosis is directed at the complications that the patient experiences. Those with end-stage cirrhosis are candidates for liver transplantation, although that procedure is contraindicated in patients actively abusing alcohol.
Normal scar formation is part of the wound-healing process. Alcohol-induced cell death and inflammation can result in scarring that distorts the liver's internal structure and impairs its function. This scarring is the hallmark of cirrhosis. The process by which cirrhosis develops involves specialized liver cells (i.e., stellate cells). In the normal liver, stellate cells function as storage depots for vitamin A. Upon activation, stellate cells proliferate, lose their vitamin A stores, and begin to produce scar tissue. In addition, activated stellate cells constrict blood vessels, impeding the delivery of oxygen to liver cells. Acetaldehyde may activate stellate cells directly, promoting liver scarring in the absence of inflammation. This finding is consistent with the observation that heavy drinkers can develop cirrhosis insidiously, without preexisting hepatitis.
Alcohol Metabolism
Most of the alcohol a person drinks is eventually broken down by the liver. However, some products generated during alcohol metabolism (e.g., acetaldehyde) are more toxic than alcohol itself. In addition, a group of metabolic products called free radicals can damage liver cells and promote inflammation, impairing vital functions such as energy production. The body's natural defenses against free radicals (e.g., antioxidants) can be inhibited by alcohol consumption, leading to increased liver damage.
Alcohol is quickly diffused into all body cells and intercellular fluid, with less than 10 percent being excreted directly through the lungs, skin and kidney (breath, sweat and urine). Within five minutes after consumption, alcohol can be detected in a person's blood, also called their blood alcohol concentration (BAC).
The Inflammatory Response
Inflammation is the body's response to local tissue damage or infection. Inflammation prevents the spread of injury and mobilizes the defense mechanisms of the immune system. One such defense mechanism is the generation of free radicals that can destroy disease-causing microorganisms. Long-term alcohol consumption prolongs the inflammatory process, leading to excessive production of free radicals, which can destroy healthy liver tissue.
Also, alcoholics have a reduced immune response with altered function of their neutrophils (one of the first cells involved in the inflammatory response).
Susceptibility to ALD differs considerably among individuals, so that even among people drinking similar amounts of alcohol, only some develop cirrhosis. Understanding the mechanisms of these differences may help clinicians identify and treat patients at increased risk for advanced liver damage.
Genetic Factors
Structural or functional variability in any of the cell types and biochemical substances discussed previously could influence a person's susceptibility to ALD. Researchers are seeking genetic factors that may underlie this variability. Results of this research may provide the basis for future gene-based therapies.Dietary Factors
Nutritional factors influence the progression of ALD. For example, a high-fat, low-carbohydrate diet promotes liver damage in alcohol-fed rats, and high amounts of polyunsaturated fats may promote the development of cirrhosis in animals.Gender
Women develop ALD after consuming lower levels of alcohol over a shorter period of time compared with men. In addition, women have a higher incidence of alcoholic hepatitis and a higher death rate from cirrhosis than men. The mechanisms that underlie gender-related differences are unknown.Hepatitis C
Many patients with ALD are infected with hepatitis C virus (HCV), which causes a chronic, potentially fatal liver disease. The presence of HCV may increase a person's susceptibility to ALD and influence the severity of alcoholic cirrhosis. For example, alcohol-dependent patients infected with HCV develop liver injury at a younger age and after consuming a lower cumulative dose of alcohol than do those without HCV. Patients with HCV are often treated with an antiviral substance called interferon. However, interferon is less effective in patients with chronic HCV who are heavy drinkers, compared with those who are not.
Heart attacks and other forms of coronary heart disease (CHD) result in approximately 500,000 deaths annually, accounting for 25 percent of the nation's total mortality. Research has revealed an association between moderate alcohol consumption and lower risk for CHD. Data from at least 20 countries demonstrate a 20- to 40-percent lower CHD incidence among drinkers compared with nondrinkers. Moderate drinkers exhibit lower rates of CHD-related mortality than both heavy drinkers and abstainers. However, the risk for cardiomyopathy, hypertension, sudden death and hemorrhagic stroke is greater for chronic alcohol abusers. Also, heavy drinkers have an increased death rate from cardiovascular disease.
Is Alcohol's Role Causal or Incidental for CHD?
An association between moderate drinking and lower risk for CHD does not necessarily mean that alcohol itself is the cause of the lower risk. For example, a review of population studies indicates that the higher mortality risk among abstainers may be attributable to other traits other than to the participants' nonuse of alcohol. Health-related lifestyle factors that correlate consistently with drinking level could account for some of the association between alcohol and lower risk for CHD.
Some studies report that wine (particularly red wine) affords more CHD protection than beer or liquor at equivalent levels of alcohol consumption. This finding suggests that the association between alcohol consumption and CHD risk may result from the effects of beverage ingredients other than alcohol itself. Epidemiologic and laboratory studies investigating this hypothesis have produced conflicting results, however.
A comparison of data from 21 developed countries concluded that wine consumption was more strongly correlated with lower CHD risk than was consumption of other alcoholic beverages. However, large-scale studies have not found any difference in the incidence of CHD associated with beverage type. Red wine has been shown to contain certain non-alcoholic ingredients that could hypothetically interfere with the progression of CHD. However, research has not yet demonstrated a significant role for these chemicals in arresting CHD development in humans. Evidence suggests that a preference for wine over other alcoholic beverages is associated with a lifestyle that includes other favorable health-related practices. For example, drinkers who prefer wine tend to smoke less and drink less and have a more healthful diet than those who prefer beer or liquor.
To function normally, the muscle tissue that constitutes the bulk of the heart requires a constant supply of oxygen-containing blood. Blood is delivered to the heart muscle through the coronary arteries.
Cholesterol and other fatty substances can accumulate within the coronary arteries, partially impeding the flow of blood. The clinical manifestations of CHD may range from episodic chest pain to sudden death. The most common serious manifestation of CHD is the heart attack. Heart attacks are generally triggered by the formation of a blood clot within a constricted coronary artery, obstructing blood flow and depriving a portion of the heart muscle of oxygen. The resulting impairment of the heart's pumping ability may cause permanent disability or death, either immediately or through the progressive development of medical complications.
Researchers have investigated several theories to explain how alcohol itself might lower the risk for CHD. For example, alcohol may protect the heart by preventing the constriction of the coronary arteries, inhibiting clot formation, and enhancing recovery following a heart attack.
Alcohol may help prevent clot formation within already narrowed coronary arteries. Clotting occurs partly in response to chemicals released into the blood from the arterial wall. Exposure of these cells to alcohol may suppress the production of substances that promote clotting and stimulates the production and activity of substances that inhibit clotting. In addition, analyses of blood samples drawn from human volunteers indicate that alcohol consumption increases blood levels of anticlotting factors and decreases the "stickiness" of the specialized blood cells (i.e., platelets) that clump together to form clots
The apparent benefits of moderate drinking on CHD mortality are offset at higher drinking levels by increasing risk of death from other types of heart disease, cancer, liver cirrhosis, and trauma, including trauma from traffic crashes. Moderate drinking is NOT risk free. The trade-offs between risks and benefits can be exemplified by the fact that alcohol's anti-clotting ability, potentially protective against heart attack, may increase the risk of hemorrhagic stroke, or bleeding within the brain.
Research findings continue to confirm an association between moderate drinking and a lower risk for CHD. While there is an association between moderate drinking and lower CHD risk, science has not confirmed that alcohol itself causes the lower risk. It also is plausible that the lower risk might result from some as yet unidentified factor associated both with alcohol use and lower CHD risk, such as lifestyle, diet and exercise, or additives to alcoholic beverages.
Research is now in progress to answer these questions. The distinction between an association and a cause is important, particularly when considering what advice to give to our patients. Further, even if we find that alcohol itself is responsible for the lower risk, still to be considered would be the trade-offs between the benefits and risks, particularly for specific subsets of the population.
For example, moderate drinking by older persons may lower CHD but increase risk for other alcohol-related health conditions, such as adverse alcohol-drug interactions, trauma, including falls and automobile crashes, or hemorrhagic stroke. Until these issues are clarified, the most prudent advice is the following:
Individuals who are not currently drinking should not be encouraged to drink solely for health reasons, because the basis for health improvements has not yet been established as deriving from alcohol itself;
Individuals who choose to drink and are not otherwise at risk for alcohol-related problems should not exceed the one- to two-drink-per-day limit recommended by the U.S. Dietary Guidelines; and
Individuals who currently are drinking beyond the U.S. Dietary Guidelines' recommended limits should be advised to lower their daily alcohol intake to these limits.
The idea that alcoholism runs in families is an ancient one. In recent decades, science has advanced this idea from the status of folk-observation to systematic investigation. In the 1970s, studies documented that alcoholism does run in families. But does alcoholism run in families because a child learns to become an alcoholic from parents and the home environment, or because a child inherits genes that create an underlying predisposition for alcoholism? Or both? Research is on-going.
Findings from studies have demonstrated that genetic determinants play an integral role in a person's increased risk for for developing the disorder. Twin studies of alcoholism have revealed a greater rate for the diseas
e among identical twins, who are genetically identical, than among fraternal twins, who are no more genetically alike than non-twin siblings. Adoption studies have shown that the biological offspring of alcoholics possess a heightened risk for alcohol abuse even when they are adopted away and reared by non-relatives.
Although it is clear that genetic factors influence risk for alcoholism, these factors alone cannot account for individual differences in drinking behavior. Adoption and twin studies indicate that psychological, developmental and environmental determinants also contribute to heightened risk for alcoholism. Research findings suggest that children of alcoholics are at increased risk for developing alcoholism and related behavioral disorders not only because of the influence of genetic factors, but also because they are more likely than children of non-alcoholics to grow up in families that are marked by relatively high levels of marital discord, relatively low levels of parental monitoring and parental warmth, or relatively high levels of parental tolerance of adolescent drinking.
* Acknowledgement is made to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) publication, "Ninth Special Report to the U.S. Congress on Alcohol and Health," for providing the reference material used in the preparation of this topic.
The children of alcoholics also have a greater vulnerability for certain psychopathologies than do children of nonalcoholics. It has been reported that the preadolescent and adolescent offspring of alcoholics were significantly more likely than the offspring of nonalcoholics to be diagnosed with opposition disorder or conduct disorder or as overanxious.
Most people reared in an alcoholic home never develop an alcohol problem or manifest an alcohol-related behavioral disorder. In light of this, researchers have questioned whether there are factors that protect or render some individuals resilient to alcoholism, even though they are at high risk for the disease because of family history. Evidence suggests that family functioning and social support may moderate the negative effect of parental alcoholism. One study observed increased rates of alcohol abuse only for those children who perceived that they had low social support from friends.
Observing abusive drinking in a parent may help to protect against the development of drinking problems in some offspring. One study suggests that children with problem-drinking fathers had developed an aversion to drinking after witnessing the consequences of abusive alcohol use on a loved one.
Progress has been made in understanding genetic vulnerability to alcoholism. It is known that more than one gene is likely to be responsible for this vulnerability. It must now be determined what these genes are and whether they are specific for alcohol or define something more general, such as differences in temperament or personality that increase an individual's vulnerability to alcoholism. It must also be determined how genes and the environment interact to influence vulnerability to alcoholism. Based on current understanding, it is probable that environmental influences will be at least as important, and possibly more important, than genetic influences. Success in uncovering the genes involved in a vulnerability to alcoholism will help practitioners to recognize the potential for alcoholism in high-risk individuals, to intervene at an early stage, and to develop new treatments for alcohol-related problems.
Studies in the general population indicate that fewer women than men drink. It is estimated that of the 15.1 million alcohol-abusing or alcohol-dependent individuals in the United States, approximately 4.6 million (nearly one-third) are women. On the whole, women who drink consume less alcohol and have fewer alcohol-related problems and dependence symptoms than men, yet among the heaviest drinkers, women equal or surpass men in the number of problems that result from their drinking
Women become intoxicated after drinking smaller quantities of alcohol than are needed to produce intoxication in men. Three possible mechanisms may explain this response.
First, women have lower total body water content than men of comparable size. After alcohol is consumed, it diffuses uniformly into all body water, both inside and outside cells. Because of their smaller quantity of body water, women achieve higher concentrations of alcohol in their blood than men after drinking equivalent amounts of alcohol. More simply, blood alcohol concentration in women may be likened to the result of dropping the same quantity of alcohol into a smaller pail of water.
Second, diminished activity of alcohol dehydrogenase (the primary enzyme involved in the metabolism of alcohol) in the stomach also may contribute to the gender-related differences in blood alcohol concentrations and a woman's heightened vulnerability to the physiological consequences of drinking. It has been demonstrated that a substantial amount of alcohol is metabolized by gastric alcohol dehydrogenase in the stomach before it enters the systemic circulation. This "first-pass metabolism" of alcohol decreases the availability of alcohol to the system. It has been reported that because of diminished activity of gastric alcohol dehydrogenase, first-pass metabolism was decreased in women compared with men and was virtually nonexistent in alcoholic women.
Third, fluctuations in gonadal hormone levels during the menstrual cycle may affect the rate of alcohol metabolism, making a woman more susceptible to elevated blood alcohol concentrations at different points in the cycle.
Chronic alcohol abuse exacts a greater physical toll on women than on men. Female alcoholics have death rates 50 to 100 percent higher than those of male alcoholics. Further, a greater percentage of female alcoholics die from suicides, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver.
Increasing evidence suggests that the detrimental effects of alcohol on the liver are more severe for women 
than for men. Women develop alcoholic liver disease, particularly alcoholic cirrhosis and hepatitis, after a comparatively shorter period of heavy drinking and at a lower level of daily drinking than men. Proportionately more alcoholic women die from cirrhosis than do alcoholic men.
The exact mechanisms that underlie women's heightened vulnerability to alcohol-induced liver damage are unclear. Differences in body weight and fluid content between men and women may be contributing factors. In addition, researchers have suggested that the combined effect of estrogens and alcohol may augment liver damage.
Finally, alcoholic women may be more susceptible to liver damage because of the diminished activity of gastric alcohol dehydrogenase in first-pass metabolism, as previously mentioned.
Drinking also may be associated with an increased risk for breast cancer. Reports indicte that risk may increase when a woman consumes 1 ounce or more of absolute alcohol daily. Increased risk appears to be related directly to the effects of alcohol. More research is needed to explore the relationship between drinking and breast cancer, however. Menstrual disorders (e.g., painful menstruation, premenstrual discomfort, and irregular or absent cycles) have been associated with chronic heavy drinking. These disorders can have adverse effects on fertility. Further, continued drinking may lead to early menopause.
Extensive research supports the popular observation that "smokers drink and drinkers smoke." Moreover, the heaviest alcohol consumers are also the heaviest consumers of tobacco. Concurrent use of these drugs poses a significant public health threat.
Between 80 and 95 percent of alcoholics smoke cigarettes, a rate that is three times higher than among the population as a whole. Approximately 70 percent of alcoholics are heavy smokers (i.e., smoke more than one pack of cigarettes per day), compared with 10 percent of the general population.
Drinking influences smoking more than smoking influences drinking. Nevertheless, smokers are 1.32 times as likely to consume alcohol as are nonsmokers. Most adult users of alcohol or tobacco first tried these drugs during their early teens. Among smoking alcoholics, the initiation of regular cigarette smoking typically precedes the onset of alcoholism by many years. Adolescents who begin smoking are 3 times more likely to begin using alcohol, and smokers are 10 times more likely to develop alcoholism than are nonsmokers.
What Is the Risk of Cancer From Alcohol and Tobacco?
Smoking and excessive alcohol use are risk factors for cardiovascular and lung diseases and for some forms of cancer. The risks of cancer of the oral cavity, throat, or esophagus for the smoking drinker are more than the sum of the risks posed by these drugs individually. For example, compared with the risk for non-smoking non-drinkers, the approximate relative risks for developing oral and throat cancer are 7 times greater for those who use tobacco, 6 times greater for those who use alcohol, and 38 times greater for those who use both tobacco and alcohol.
How Do Alcohol and Tobacco Increase Cancer Risk?
Approximately 4,000 chemical substances are generated by the chemical reactions that occur in the intense heat of a burning cigarette. A group of these chemicals, collectively known as tar, is carried into the lungs on inhaled smoke. The bloodstream then distributes the components of tar throughout the body.
Certain enzymes found mainly in the liver (i.e., microsomal enzymes) convert some ingredients of tar into chemicals that can cause cancer. Long-term alcohol consumption can activate some such microsomal enzymes, greatly increasing their activity and contributing to smoking-related cancers. Microsomal enzymes are found not only in the liver but also in the lungs and digestive tract, which are major portals of entry for tobacco smoke.
The esophagus may be particularly susceptible, because it lacks an efficient mechanism for removing toxic substances produced by activated microsomal enzymes. Finally, alcoholics frequently exhibit deficiencies of zinc and vitamin A, substances that confer some protection against cancer.
Alcohol and tobacco are frequently used together, they may share certain brain pathways underlying dependence, and because of their numerous social and health-related consequences, are a continuing source of national public policy debate.
Many alcoholism treatment professionals have not actively pursued smoking cessation among their patients based on the belief that the stress of quitting smoking while undergoing alcoholism treatment might cause relapse. However, current research evidence shows that both can be treated simultaneously without endangering alcoholism recovery. As basic science learns more about how alcohol and nicotine act singly and together within the brain, new treatments for alcohol and nicotine dependence will follow.
Finally, public health agencies have attempted to broadcast the consequences of using both alcohol and tobacco through public policy actions, including health warning labels, restrictions on advertising, and age restrictions on use.
Anyone at any age can have a drinking problem. Great Uncle Dan may have always been a heavy drinker--his family may find that as he gets older, the problem gets worse. Grandma Pat may have been a teetotaler all her life, just taking a drink "to help her get to sleep" after her husband died--now she needs a couple of drinks to get through the day. These are common stories. Drinking problems in older people are often neglected by families, health care professionals, and the public.
Persons age 65 and older constitute the fastest growing segment of the American population. Although the extent of alcoholism among the elderly is debated, the diagnosis and treatment of alcohol problems are likely to become increasingly important as the elderly population grows.
Some examples of potential alcohol-aging interactions include the following:
The incidence of hip fractures in the elderly increases with alcohol consumption. This increase can be explained by falls while intoxicated combined with a more pronounced decrease in bone density in elderly persons with alcoholism compared with elderly nonalcoholics.
Studies of the general population suggest that moderate alcohol consumption (up to two drinks per day for men and one drink per day for women) may confer some protection from heart disease. Although research on this issue is limited, evidence shows that moderate drinking also has a protective effect among those older than 65. Because of age-related body changes in both men and women, it is recommended that persons older than 65 consume no more than one drink per day.
Age may interact with alcoholism to increase driving risk. For example, an elderly driver with alcoholism is more impaired than an elderly driver without alcoholism after consuming an equivalent dose of alcohol, and has a greater risk of a crash.
As previously discussed in this section, long-term alcohol consumption activates enzymes that break down toxic substances, including alcohol. Upon activation, these enzymes may also break down some common prescription medications. The average person older than 65 takes two to seven prescription medications daily. Alcohol-medication interactions are especially common among the elderly, increasing the risk of negative health effects and potentially influencing the effectiveness of the medications.
Depressive disorders are more common among the elderly than among younger people and tend to co-occur with alcohol misuse. Studies demonstrate that, among persons older than 65, those with alcoholism are approximately three times more likely to exhibit a major depressive disorder than are those without alcoholism.
Among persons older than 65, moderate and heavy drinkers are 16 times more likely than nondrinkers to die of suicide, which is commonly associated with depressive disorders.
Limited research suggests that sensitivity to alcohol's health effects may increase with age. One reason is that the elderly achieve a higher blood alcohol concentration (BAC) than younger people after consuming an equal amount of alcohol. The higher BAC results from an age-related decrease in the amount of body water in which to dilute the alcohol. Therefore, although they can metabolize and eliminate alcohol as efficiently as younger persons, the elderly are at increased risk for intoxication and adverse effects.
Aging also interferes with the body's ability to adapt to the presence of alcohol (i.e., tolerance). Through a decreased ability to develop tolerance, elderly subjects persist in exhibiting certain effects of alcohol (e.g., incoordination) at lower doses than younger subjects whose tolerance increases with increased consumption. Thus, an elderly person can experience the onset of alcohol problems even though his or her drinking pattern remains unchanged.
Aging and alcoholism produce similar deficits in intellectual (i.e., cognitive) and behavioral functioning. Alcoholism may accelerate normal aging or cause premature aging of the brain. Studies have found more brain tissue loss in subjects with alcoholism than in those without alcoholism, even after their ages had been taken into account. In addition, older subjects with alcoholism exhibited more brain tissue loss than younger subjects with alcoholism, often despite similar total lifetime alcohol consumption. These results suggest that aging may render a person more susceptible to alcohol's effects.
The frontal lobes of the brain are especially vulnerable to long-term heavy drinking. Research shows that shrinkage of the frontal lobes increases with alcohol consumption and is associated with intellectual impairment in both older and younger subjects with alcoholism. In addition, older persons with alcoholism are less likely to recover from cognitive deficits during abstinence than are younger persons with alcoholism. Age-related changes in volume also occur in the cerebellum, a part of the brain involved in regulating posture and balance. Thus, long-term alcohol misuse could accelerate the development of age-related postural instability, increasing the likelihood of falls.
Because alcohol problems among older persons often are mistaken for other conditions associated with the aging process, alcohol abuse and alcoholism in this population may go undiagnosed and untreated or be treated inappropriately. Health care providers should discuss alcohol use with their older patients as a part of routine care. Advice to older patients should include the medical conditions common to older people, such as high blood pressure and ulcers, that can be worsened by drinking and over-the-counter and prescription drugs that can be dangerous, or fatal, when mixed with alcohol.
Older patients who consume alcohol should be advised to limit their alcohol intake to one drink per day. Finally, health care providers who suspect an alcohol problem in their elderly patients should refer such patients to treatment.
More than 9000 prescription and OTC medications can interact with alcohol, leading to increased risk of illness, injury, or death. For example, it is estimated that alcohol-medication interactions may be a factor in at least 25 percent of all emergency room admissions. An unknown number of less serious interactions may go unrecognized or unrecorded.
To exert its desired effect, a drug generally must travel through the bloodstream to its site of action, where it produces some change in an organ or tissue. The drug's effects then diminish as it is processed (metabolized) by enzymes and eliminated from the body. Alcohol behaves similarly, traveling through the bloodstream, acting upon the brain to cause intoxication, and finally being metabolized and eliminated, principally by the liver.
The extent to which an administered dose of a drug reaches its site of action may be termed its availability. Alcohol can influence the effectiveness of a drug by altering its availability. Typical alcohol-drug interactions include the following:
First, an acute dose of alcohol (a single drink or several drinks over several hours) may inhibit a drug's metabolism by competing with the drug for the same set of metabolizing enzymes. This interaction prolongs and enhances the drug's availability, potentially increasing the patient's risk of experiencing harmful side effects from the drug.
Second, in contrast, chronic (long-term) alcohol ingestion may activate drug-metabolizing enzymes, thus decreasing the drug's availability and diminishing its effects. After these enzymes have been activated, they remain so even in the absence of alcohol, affecting the metabolism of certain drugs for several weeks after cessation of drinking. Thus, a recently abstinent chronic drinker may need higher doses of medications than those required by nondrinkers to achieve therapeutic levels of certain drugs.
Third, enzymes activated by chronic alcohol consumption transform some drugs into toxic chemicals that can damage the liver or other organs.
Fourth, alcohol can magnify the inhibitory effects of sedative and narcotic drugs at their sites of action in the brain. To add to the complexity of these interactions, some drugs affect the metabolism of alcohol, thus altering its potential for intoxication and the adverse effects associated with alcohol consumption.
This concludes the first module in the Chemical Dependence: Alcoholism online course. Return to the Table of Contents to continue and click on Module 2.