Dr. Khalid is a physician, a researcher, a health writer, and holds a Ph.D. in clinical research.
What is Alcohol Use Disorder?
DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) defines alcohol dependence/AUD (alcohol use disorder) based on the affirmation of any 3 of the following target conditions/dependence symptoms (Wackernah, Minnick, & Clapp, 2014).
- Craving (necessary condition).
- Tolerance to alcohol consumption.
- Withdrawal symptoms develop after every attempt to quit alcoholism.
- Prolonged and increased alcohol consumption.
- Inappropriate/unsuccessful efforts to minimize alcohol consumption.
- Interference of alcoholism in professional/personal life.
- Extended/prolonged alcohol consumption duration.
- Uninterrupted alcohol consumption despite the occurrence of deleterious sequelae.
Alcohol use disorder develops in an individual when he/she loses control of alcohol consumption patterns/behaviors. The affected person increasingly consumes alcohol and any attempt to get rid of alcoholism leads to the development of withdrawal symptoms. The binge drinking pattern reciprocates with the consumption of 5 or more drinks by a male and 4 or more drinks by a female in every 2 hours (Mayo Clinic, 2020). Binge drinking pattern elevates BAC (blood alcohol concentration) of an individual up-to or above 0.08gm (CDC, 2018).
What is the Pathophysiology of Alcohol Use Disorder?
The regular or prolonged consumption of alcohol induces the accumulation of neurotransmitter dopamine inside the ventral tegmental region of the brain (Wackernah, Minnick, & Clapp, 2014). This eventually leads to the enhancement of the mesolimbic dopamine system/neuronal circuits associated with behavioral reward and motivation. The consistent alcohol consumption induces the accumulation of dopamine into the prefrontal cortex and nucleus accumbens of the brain that eventually leads to the reinforcement of drinking behaviors. The alcohol addiction reciprocates with a marked increase in the mesolimbic system’s metaplasticity and neuronal plasticity associated with the reward-based learning processes. Alcohol variably interacts with enkephalins, endorphins, 5-HT, corticotropin-releasing factor, and GABA that resultantly facilitates the release of dopamine. Alcohol promotes the physiology of GABA receptor channels and potentially obstructs the passage of ions to NMDA (N-methyl-D-aspartate) type glutamate receptors (Wackernah, Minnick, & Clapp, 2014). This activity constricts the neuronal activity, thereby disrupting the equilibrium between inhibitory and excitatory neurotransmitters. The chronic alcoholism upregulates NMDA receptors that eventually elevates the neuronal activity through the enhancement of neuroadaptive responses. The prolonged alcohol consumption also impacts glutamate signaling pathways that further increases drinking desire to an unprecedented level. The alcohol addiction vulnerability of individuals reciprocates with the regulation of pathophysiological episodes governed by dopamine neurons and their glutamatergic synapses’ plasticity level. The alcohol withdrawal symptoms develop under the impact of drinking cessation attempts that potentially disrupt the equilibrium between GABA signaling and glutamate pathways, thereby elevating the hyperexcitability state in addicted individuals. Eventually, addicted people crave more for alcohol consumption after every attempt to expedite their alcohol consumption habits (Wackernah, Minnick, & Clapp, 2014). The deleterious, aversive, and anxiogenic alcohol withdrawal outcomes governed by GABA system alterations continue to exist for an extended duration in those addicted individuals who persistently refrain from alcohol consumption through behavioral modifications (Wackernah, Minnick, & Clapp, 2014). Such individuals strongly feel the urge to consume alcohol for relieving their negative sensations, anxiety, and panic state. Eventually, many of them resume their drinking habits under the impact of compulsive behaviors based on withdrawal manifestations.
What are the Adverse Effects of Alcohol Consumption?
Some of the deleterious effects (symptoms and conditions) that variably impact the health and wellness of addicted individuals based on their short-term, prolonged or chronic alcohol use are mentioned below (Wackernah, Minnick, & Clapp, 2014).
- Gastrointestinal bleeding.
- Inflammation of the esophagus and stomach.
- Acute pancreatitis.
- Pancreatic cancer.
- Fatty liver disease.
- Alcohol-induced hepatitis.
- Peripheral vasodilatation.
- Cardiac contractility reduction.
- Abnormal blood pressure.
- High-density lipoprotein elevation.
- Defective clotting mechanism.
- Coronary artery disease.
- Ventricular/atrial arrhythmias.
- Left ventricular impairment.
- Heart failure.
- Holiday heart syndrome.
- Peripheral neuropathy manifests with numbness or tingling in extremities.
- Gait disturbance.
- Cerebellar atrophy.
- Wernicke’s syndrome manifests with eye muscle weakness, uncoordinated muscle movement, and encephalopathy.
- Amnesia-based Korsakoff’s syndrome.
What is the Global Impact of Alcohol Use?
The majority of young adults increasingly consume alcoholic beverages across European Nations and the United States. Approximately 13.7% of young adults remain affected by heavy use of alcohol and associated health risk factors. Some of the potential implications of alcohol addiction are mentioned below (Wackernah, Minnick, & Clapp, 2014).
- 20% health risk in men.
- 10%-15% health risk in women.
- Productivity issues.
- $185 billion annual expenditure incurs in treating health conditions that emanate from alcohol addiction among individuals of various age groups in the United States.
- 2.1/100,000 deaths reportedly occur from alcohol addiction in European nations and the United States.
- Binge drinking pattern badly impacts patient care and medical management systems based on the reported interaction of alcohol with various pharmacotherapeutic regimens.
What is the Standard Treatment for Alcohol Use Disorder (AUD)?
Some of the FDA approved drugs for AUD treatment are mentioned below.
- Naltrexone is an opioid receptor antagonist that assists in reducing alcohol consumption by reducing the level or sense of reward experienced by addicted people after alcohol use (Mason, 2013). The regular administration of naltrexone helps in reducing the frequency of hefty drinking among addicted people. However, naltrexone is associated with compliance issues that restrict its long-term use among alcoholics. Accordingly, physicians recommend the once-monthly administration of extended-release naltrexone through intramuscular injection. The patients affected with illicit opiate use must not consume naltrexone based on the risk of acute opioid withdrawal symptoms. Furthermore, patients with liver disease or related complications should also not utilize naltrexone due to its hepatotoxic potential. Naltrexone is available in tablet form requiring administration in a dose of 50mg or 100mg based on the treatment demand (Singh & Saadabadi, 2020). Naltrexone (380mg) is also available as a depot injection based on its elevated first-pass effect. Naltrexone effectively blocks the functioning of mu-opioid receptors in the context of enhancing euphoria in treated patients. Naltrexone potentially challenges the physiologic dependence of individuals (on opioids) and opioid intoxication. The suppression of alcohol consumption patterns after Naltrexone administration is based on its activity on the hypothalamic-pituitary-adrenal axis.
- Acamprosate helps in managing the addiction pattern of alcoholics affected with withdrawal and heavy drinking patterns that potentially disrupt equilibrium between GABAergic inhibition and glutaminergic neuronal excitation (Mason, 2013). Acamprosate administration helps to systematically restore this equilibrium, thereby elevating the alcohol abstinence tendency of addicted individuals. Acamprosate encounters renal excretion and recommended for alcoholics with a liver impairment since it’s not metabolized through hepatic processes. Acamprosate’s safety profile substantially validates its recommendation for alcohol abstinence. This is because the patients do not develop dependence or tolerance following its long-term utilization. This indicates that acamprosate does not exhibit addiction potential for the treated patients (i.e. alcoholics). The routine dosage of acamprosate is 2grams per day. Acamprosate is not associated with the risk of overdose since the administration of 56gm of the drug does not produce any type of dependency pattern. Acamprosate’s adverse effects remain transient and disappear after 10-15 weeks of its utilization. Diarrhea is the only side effect of acamprosate that persists for a longer duration following its consumption for reducing alcohol addiction (CFSAT, 2009). Acamprosate does not interact with other drugs during the course of its administration. Eventually, addicted people have the option to consume acamprosate despite the occurrence of comorbidities. Acamprosate appears to be a safe drug of choice for the patients affected with the severe liver disease since it does not encounter hepatic metabolism. The administration of acamprosate is recommended for the patients receiving opioid maintenance therapy. This is because acamprosate does not alter the concentration of exogenous or endogenous opioids. Acamprosate proves to be a safe and effective drug for the candidates of medical detoxification since it does not alter the concentration of benzodiazepines. Accordingly, the physicians prefer to administer acamprosate to the patients requiring medical detoxification after resuming their drinking pattern or alcohol consumption habit.
- Disulfiram potentially challenges alcohol metabolism and facilitates the reconfiguration of acetaldehyde (Mason, 2013). This drug works as a psychological disincentive for alcoholism since its consumption leads to palpitations, nausea, and flushing. Eventually, its regular consumption helps alcoholics to exit their alcohol consumption habits. However, alcohol addicts usually refrain to comply with disulfiram for an extended duration. Therefore, medical supervision is necessarily required to optimize the use of disulfiram among alcohol addicts. The administration of disulfiram is not recommended for the individuals affected with alcohol intoxication. Some of the potential adverse effects of disulfiram include drowsiness and hepatotoxicity. Disulfiram potentially competes with NAD (nicotinamide adenine dinucleotide) and ceases the hepatic enzyme ALDH1A1 (aldehyde dehydrogenase) across its active cysteine residue. Eventually, the liver of the treated individuals fails to actively metabolize ethanol to acetaldehyde following alcohol consumption (Stokes & Abdijadid, 2020). The consistent administration of disulfiram to alcoholics leads to the elevated production of serum acetaldehyde and development of symptoms including tachycardia, hypotension, vertigo, nausea, facial flushing, palpitations and diaphoresis. The disulfiram-alcohol interaction in this manner potentially reduces the alcohol consumption desire among alcoholics to an unprecedented level. Disulfiram oral tablets (250mg-500mg) require administration only when the concerned patients refrain from consuming alcohol at least for a duration of half-day or more (Stokes & Abdijadid, 2020). The treated patients must refrain from alcohol consumption for a duration of two weeks after discontinuing the use of disulfiram. The caretakers have the option to administer uniformly crushed disulfiram to the alcoholics with fruit juice, milk coffee, or water.
Note: The dosage decision and administration of the above-mentioned drugs necessarily require medical prescription/supervision of the qualified health care professional.
What are the Robust/Powerful Treatment Interventions for Alcohol Addiction?
Motivational interviewing is a patient-centered and goal-oriented approach warranted to resolve problematic behaviors of individuals (Carter, Sharon, & Stern, 2014). The initial step of motivational interviewing reciprocates with the configuration of trust with addicted people to enhance their engagement in the rehabilitation process. Secondly, the interventionist requires recognizing the bunch of behaviors that need modification. Thirdly, the interventionist needs to enhance the addicted peoples’ change motivation, readiness, and confidence while inviting them to share their perspectives regarding the change process. Subsequently, the interventionist requires configuring practical strategies for their systematic implementation in the context of establishing the required change (Carter, Sharon, & Stern, 2014). The utilization of non-judgmental open-ended questions during motivational interviewing helps the clients to effectively share their alcohol addiction perspectives and withdrawal challenges. Motivational interviewing incorporates summary statements and empathetic listening that substantially increases the trust and compliance of addicted patients with the recommended therapeutic or supportive interventions.
The self-help sessions prove to be the powerful remedies that effectively facilitate character enhancement and the spiritual development of alcoholics (Carter, Sharon, & Stern, 2014). The initial three phases of the self-help sessions allow the alcoholics to earnestly admit their binge drinking habits and submit themselves faithfully to the will of God. The fourth until the ninth steps of the self-help interventions are based on the reconciliation of the clients and mitigation of their resentments. These stages deal with character purification in the context of enhancing their desire to quit the alcohol addiction habit. The tenth till twelfth steps of the process includes spiritual awakening, embracement, meditation, praying, and honesty development. These interventions strongly inspire the alcoholics to purify their inner selves while improving their self-esteem to an unprecedented level.
Cognitive-Behavioral Therapy (CBT)
CBT is a robust evidence-based, time-framed, and structured approach that helps to minimize the alcohol dependence pattern of the addicted individuals (Carter, Sharon, & Stern, 2014). CBT focuses on the systematic modification of behaviors, feelings, and thinking patterns of alcoholics for reducing their inclination towards alcohol consumption. CBT helps alcoholics to overcome the self-defeating and unrealistic thoughts that force them to continue their excessive drinking habits. The interventionists attempt to enhance the alcoholics’ self-empowering thinking patterns while improving their coping skills against drinking triggers. This helps alcoholics to overcome their environmental cues, anxiety, and stress level to a considerable extent. These interventions potentially assist in reducing the alcohol consumption desire of addicted individuals. CBT helps the alcoholics to enhance their daily interactions with circumstantial determinants and risk factors for their gradual and systematic mitigation. Furthermore, the role-play exercises assist alcoholics to improve their overall personality and self-efficacy level. These focussed efforts help the alcoholics to exit their drinking habits while reducing the risk of relapse.
Dialectical Behavioral Therapy (DBT)
DBT is a robust intervention warranted to help the comorbid/psychiatrically complicated alcoholics to reduce their addiction relapses and length of binge drinking patterns (Carter, Sharon, & Stern, 2014). DBT focuses on improving the worth and health-related quality of life of addicted individuals. DBT promotes logical discussion sessions between therapists and alcoholics to establish a sense of acceptance and change related to the need for alcohol abstinence. DBT assists in accomplishing the following significant objectives.
- Reduction in the urge for alcohol consumption.
- Reduction in alcohol temptation and craving.
- Reduction in the utilization of alcohol-related cues.
- Promotion of healthy behaviors through community-based interventions.
- Enhancement in alcohol abstinence negotiation.
- Promoting the clients’ responses circumstances based on elevated risk of alcohol addiction.
- Educating clients regarding the adverse health effects of alcohol consumption.
Mindfulness techniques help in preventing alcohol addiction relapse based on the accomplishment of the following goals (Carter, Sharon, & Stern, 2014).
- Enhanced awareness of alcohol consumption triggers among high-risk patients.
- Reduction in automatic reactions and habitual alcohol addiction patterns.
- Enhancement of awareness of alcoholics regarding their personal experiences through the systematic use of compassionate and non-judgmental strategies.
- Explanation of alternative options to alcohol consumption.
- Improvement in the overall coping skills of alcoholics in the context of mitigating physical, psychosocial, and emotional challenges that consistently force them to adopt a binge drinking pattern.
Community Reinforcement Strategies
Community reinforcement interventions potentially assist the recovery of alcoholics through the systematic implementation of the following interventions (Carter, Sharon, & Stern, 2014).
- Enhanced mutual interaction of alcoholics with their friends, couples, and families not only to improve their socialization pattern but also to minimize their alcohol consumption habit.
- Educational enhancement of alcoholics regarding enabling patterns and recovery processes warranted to improve their wellness outcomes.
- The provision of community-based support helps addicted people to attain alcohol abstinence for an extended duration.
- The provision of sobriety-oriented positive reinforcement sessions through the support of community members helps the alcoholics to overcome their drinking reinforcement cues.
What are the Barriers to AUD Treatment?
The above-listed AUD treatments potentially assist in overcoming the following barriers.
- Treatment denial by the alcoholics.
- The motivation for positive alcohol reinforcement by friends and peers.
- Limited family support.
- Restricted community support.
- Limited insight into alcoholism prevention methods.
- Limited awareness of AUD.
What are the Risk Factors for Alcohol Addiction?
The risk factors potentially elevate the individuals’ predisposition towards the harmful consumption of alcohol. These factors also elevate the likelihood of behavioral health complications. Some of the commonly reported risk factors associated with the risk of alcoholism include the following (Substance Abuse and Mental Health Services Administration, 2016).
- Engagement in alcohol consumption at an early age.
- Consistent problem behavior leading to temperament deterioration, aggressiveness, and distress.
- Rebelliousness based on elevated tolerance for abnormal social behavior.
- Positive feelings and attitude towards alcoholism and substance use behavior
- Reduced perceptions of the deleterious effects of alcoholism.
- Extended association with peers and friends engaging in substance abuse and alcohol consumption activities.
- Genetic susceptibility/predisposition to the utilization of alcohol and drugs.
- Family management issues based on rewards and monitoring.
- Child developmental issues including inconsistent punishment, harsh upbringing, ineffective supervision, inappropriate behavioral expectations, and poor management interventions.
- Potential conflicts between children and parents including neglect or abuse.
- Favorable parental attitude towards drug addiction and alcoholism.
- Family history of substance use disorders and alcoholism.
- Academic failure based on poor school grades.
- The inappropriate academic commitment that not only lacks investment but also remains devoid of rewards and meaningful strategies for the developing child.
- Alcohol cost reduction based on discounting and alcohol tax reduction.
- Increased availability of alcohol beverages and related outlets.
- Religious and community reinforcement for drinking alcohol.
- Organization of beer tasting episodes and a substantial reduction in taxes on tobacco and alcohol.
- Media portrayal and promotion of drinking activities elevate the frequency of alcohol consumption, particularly among adolescents and adults. The display of alcohol consumption by cinema/television actors and artists motivates youngsters to develop binge drinking habits.
- Reduced level of attachment with the neighborhood.
- Community disorganization based on elevated crime rate, physical deterioration, limited natural surveillance of public locations, and elevated population density.
- Socioeconomic status reduction based on occupation, income, and education.
- Elevated mobility pattern and transition between various communities.
What are the Protective Factors for Alcohol Addiction?
The protective factors potentially reduce the risk of behavioral health issues, substance abuse patterns, and alcohol use disorder. Some of these protective factors are listed below (Substance Abuse and Mental Health Services Administration, 2016).
- Moral, cognitive, emotional, and social competence include some of the protective factors that help individuals to reduce their alcohol consumption risk to a considerable extent. For example, the establishment of interpersonal goals and psychosocial targets motivates individuals to improve their interpersonal skills. This eventually helps them to integrate thinking patterns and feelings in a manner to create a strong urge for alcohol consumption.
- Positive behavior recognition is a robust measure to challenge the desire for alcohol consumption among youngsters. Accordingly, the community members, peers, teachers, and parents require motivating youngsters while recognizing their accomplishments and efforts for improving their overall quality of life and wellness outcomes.
- The development of positive interpersonal bonding between individuals is paramount to their healthy behavioral enhancement. Accordingly, communities, schools, and family members require promoting positive communication, commitment, and attachment with the core objective of reducing the frequency of alcohol addiction.
- The promotion of a marriage-based committed relationship is highly required to reduce the risk of drug addiction and alcoholism. This is because marital commitment helps individuals to reduce their alcohol misuse desire to a considerable extent. Similarly, a reduction in extramarital relationships helps to reduce the frequency of alcohol use disorder. These findings reveal the high requirement of relationship commitment to facilitate the development of healthy behaviors.
- Consistent compliance with behavior standards and healthy beliefs potentially helps to discourage the consumption of alcohol among various communities. Accordingly, schools, communities, and families should establish standard norms and expectations to reduce the frequency of drugs/alcohol consumption among individuals of various age groups.
Carter, J., Sharon, E., & Stern, T. A. (2014). The Management of Alcohol Use Disorders: The Impact of Pharmacologic, Affective, Behavioral, and Cognitive Approaches. The Primary Care Companion for CNS DIisorders, 16(4). doi:10.4088/PCC.14f01683
CDC. (2018, 10 24). Fact Sheets - Binge Drinking. Retrieved from Alcohol and Public Health: https://www.cdc.gov/alcohol/fact-sheets/binge-drinking.htm
CFSAT. (2009). Chapter 2—Acamprosate. Rockville (MD): Substance Abuse and Mental Health Services Administration . Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64035/
Mason, B. J. (2013). What Medications Are Used to Treat Alcohol Use Disorder? Retrieved from https://www.niaaa.nih.gov/sites/default/files/publications/video-RSA2017/Mason_508.pdf
Mayo Clinic. (2020). Alcohol use disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243
Singh, D., & Saadabadi, A. (2020). Naltrexone. In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534811/
Stokes, M., & Abdijadid, S. (2020). Disulfiram. In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459340/
Substance Abuse and Mental Health Services_Administration. (2016). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. In Prevention Programs and Policies . Washington (DC): US Department of Health and Human Services. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK424850/
Wackernah, R. C., Minnick, M. J., & Clapp, P. (2014). Alcohol use disorder: pathophysiology, effects, and pharmacologic options for treatment. Substance Abuse and Rehabilitation, 1-12. doi:10.2147/SAR.S37907
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2020 Dr Khalid Rahman
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