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Alcoholism: the story on HearLore | HearLore
Alcoholism
In 1852, Swedish physician Magnus Huss published a groundbreaking work that coined the term alcoholism to describe the systemic adverse effects of chronic drinking, yet the story of human struggle with alcohol stretches back thousands of years before that medical definition existed. Ancient civilizations from Egypt to Babylon recorded both the worship of fermented beverages and the condemnation of their misuse, recognizing early on that excessive consumption caused social chaos and physical harm. By 1647, Greek monk Agapios documented that chronic alcohol misuse was associated with toxicity to the nervous system, leading to seizures, paralysis, and internal bleeding, though the medical community did not fully define habitual drunkenness until the 18th century. The term dipsomania was coined by German physician C. W. Hufeland in 1819 before it was superseded by alcoholism, reflecting the evolving understanding of the condition from a moral failing to a medical disease. The World Health Organization now estimates that 380 million people worldwide suffer from alcohol use disorders, representing 5.1% of the population over 15 years of age, with the highest rates found in Eastern Europe at 11% and the lowest in Africa at 1.1%.
The Biological Trap
The development of alcoholism is attributed to environment and genetics equally, creating a complex biological trap that ensnares millions of people globally. Someone with a parent or sibling with an alcohol use disorder is 3-4 times more likely to develop the condition, yet only a minority of those with a family history actually become dependent. Genetic variations play a critical role, with alleles like ADH1B2 causing more rapid metabolism of alcohol to acetaldehyde and reducing risk for alcoholism, while other variants like ALDH22 greatly reduce the rate at which acetaldehyde is removed, increasing the risk of dependence. These genetic factors are found at different frequencies in people from different parts of the world, with the ADH1B2 allele being most common in individuals from East Asia and the Middle East, and the ADH1B3 allele found in some individuals of African descent and certain Native American tribes. Despite these protective genetic factors, Native Americans have a significantly higher rate of alcoholism than average, suggesting that cultural environmental effects and trauma play a major role in the disease's expression. The evolutionary perspective suggests that humans originated from a primarily frugivorous lineage where the consumption of fermented fruits provided a caloric advantage, leading to an ancestral preference for ethanol that persists in modern humans.
The Silent Killer
Heavy long-term use of alcohol results in many negative health and social consequences that can reduce life expectancy by 10 years, making it the third leading cause of early death in the United States. Alcohol can damage all organ systems, but especially affects the brain, heart, liver, pancreas, and immune system, with long-term misuse causing cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, nutritional deficiencies, peptic ulcers, and sexual dysfunction. In 2023, the World Health Organization stated that no level of alcohol consumption is safe, and even low or moderate consumption may cause harms to someone's health, including an increased risk of many cancers. Women develop long-term complications of alcohol dependence more rapidly than do men, with higher mortality rates from alcoholism and increased risks of breast cancer, brain damage, heart disease, and liver disease. The risk of alcohol dependence begins at low levels of drinking and increases directly with both the volume of alcohol consumed and a pattern of drinking larger amounts on an occasion, to the point of intoxication, which is sometimes called binge drinking. Globally, about 3.3 million deaths, representing 5.9% of all deaths, are believed to be due to alcohol each year, with alcoholism directly resulting in 139,000 deaths worldwide in 2013.
When was the term alcoholism first coined by a physician?
Swedish physician Magnus Huss published a groundbreaking work in 1852 that coined the term alcoholism to describe the systemic adverse effects of chronic drinking.
What percentage of the global population over 15 years of age suffers from alcohol use disorders?
The World Health Organization estimates that 380 million people worldwide suffer from alcohol use disorders, representing 5.1% of the population over 15 years of age.
How does genetics influence the risk of developing alcoholism?
Someone with a parent or sibling with an alcohol use disorder is 3-4 times more likely to develop the condition, yet only a minority of those with a family history actually become dependent.
What are the leading causes of early death associated with heavy long-term alcohol use?
Heavy long-term use of alcohol results in many negative health and social consequences that can reduce life expectancy by 10 years, making it the third leading cause of early death in the United States.
How does alcohol misuse affect mental health and dementia rates?
Long-term misuse of alcohol can cause a wide range of mental health problems, with severe cognitive problems being common and approximately 10% of all dementia cases related to alcohol consumption.
What is the most stable form of remission for recovering alcoholics?
The most stable form of remission for recovering alcoholics is abstinence from alcohol, with a long-term 60-year follow-up of two groups of alcoholic men indicating that return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence.
Long-term misuse of alcohol can cause a wide range of mental health problems, with severe cognitive problems being common and approximately 10% of all dementia cases related to alcohol consumption, making it the second leading cause of dementia. Excessive alcohol use causes damage to brain function, and psychological health can be increasingly affected over time, with social skills significantly impaired due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area. The social skills that are impaired by alcohol use disorder include impairments in perceiving facial emotions, prosody, perception problems, and theory of mind deficits, while the ability to understand humor is also impaired in people who misuse alcohol. Psychiatric disorders are common in people with alcohol use disorders, with as many as 25% also having severe psychiatric disturbances, and the most prevalent psychiatric symptoms are anxiety and depression disorders. The co-occurrence of major depressive disorder and alcoholism is well documented, with a distinction commonly made between depressive episodes that remit with alcohol abstinence and those that are primary and do not remit with abstinence. Women who have alcohol-use disorders often have a co-occurring psychiatric diagnosis such as major depression, anxiety, panic disorder, bulimia, post-traumatic stress disorder, or borderline personality disorder, while men with alcohol-use disorders more often have a co-occurring diagnosis of narcissistic or antisocial personality disorder, bipolar disorder, schizophrenia, impulse disorders, or attention deficit-hyperactivity disorder.
The Withdrawal Danger
Withdrawal from alcohol dependence can be fatal if it is not properly managed, with severe acute withdrawal symptoms such as delirium tremens and seizures rarely occurring after one week post cessation of alcohol. Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression, and with repeated heavy consumption, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. When alcohol consumption is stopped too abruptly, the person's nervous system experiences uncontrolled synapse firing, which can result in symptoms that include anxiety, upset stomach or nausea, life-threatening seizures, delirium tremens, hallucinations, shakes, and possible heart failure. A kindling effect also occurs in people with alcohol use disorders whereby each subsequent withdrawal syndrome is more severe than the previous withdrawal episode, due to neuroadaptations which occur as a result of periods of abstinence followed by re-exposure to alcohol. Individuals who have had multiple withdrawal episodes are more likely to develop seizures and experience more severe anxiety during withdrawal from alcohol than alcohol-dependent individuals without a history of past alcohol withdrawal episodes. The acute withdrawal phase can be defined as lasting between one and three weeks, and in the period of 3-6 weeks following cessation, anxiety, depression, fatigue, and sleep disturbance are common.
The Treatment Paradox
Treatment takes several forms, with medical treatment for alcohol detoxification usually involving administration of a benzodiazepine to ameliorate alcohol withdrawal syndrome's adverse impact, while medications like acamprosate, naltrexone, and disulfiram may also be used to help prevent further drinking. A 2020 scientific review found clinical interventions encouraging increased participation in Alcoholics Anonymous resulted in higher abstinence rates over other clinical interventions, and most studies found AA/TSF led to lower health costs, though the effectiveness of Alcoholics Anonymous remains disputed. Moderate drinking amongst people with alcohol dependence has been subject to significant controversy, with a 2021 meta-analysis and systematic review of interventions designed to promote moderate drinking finding that this treatment model demonstrated a non-inferior outcome compared to an abstinence-oriented approach for many people with alcohol problems. A 2002 US study by the National Institute on Alcohol Abuse and Alcoholism showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking, though a 1982 follow-up showed that 95% of subjects were not able to maintain drinking in moderation over the long term. The most stable form of remission for recovering alcoholics is abstinence from alcohol, with a long-term 60-year follow-up of two groups of alcoholic men indicating that return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence.
The Social Cost
Serious social problems arise from alcohol use disorder due to the pathological changes in the brain and the intoxicating effects of alcohol, with alcohol misuse associated with an increased risk of committing criminal offences, including child abuse, domestic violence, rape, burglary, and assault. Alcoholism is associated with loss of employment, which can lead to financial problems, and drinking at inappropriate times and behavior caused by reduced judgment can lead to legal consequences, such as criminal charges for drunk driving or public disorder. An alcoholic's behavior and mental impairment while drunk can profoundly affect those surrounding the user and lead to isolation from family and friends, which can lead to marital conflict and divorce, or contribute to domestic violence. Alcoholism can also lead to child neglect, with subsequent lasting damage to the emotional development of children of people with alcohol use disorders, who can become afraid of their parents because of their unstable mood behaviors and may develop shame over their inadequacy to liberate their parents from alcoholism. Estimates of the economic costs of alcohol misuse, collected by the World Health Organization, vary from 1-6% of a country's GDP, with one study quantifying the cost to the UK of all forms of alcohol misuse in 2001 as £18.5-20 billion and all economic costs in the United States in 2006 estimated at $223.5 billion.
The Evolutionary Paradox
The evolutionary perspective is often overlooked but is a key perspective in understanding this disease, with the evolution of alcoholism thought to originate at the consumption of fermented fruits that provided an additional source of nutrients and high caloric value. Early humans regularly ingested ethanol which was made from yeast-based fermentation of naturally occurring fruit sugars, and the development of ethanol in fruits occurs during the ripening process which leaves fruits more available for consumption by dispersers. The caloric value of ethanol is 7.1 kcal/g, which is nearly twice that of carbohydrates, and natural selection favoring primates attracted to alcohol, even if the benefits were not direct, is one hypothesis for why some people are more susceptible to alcoholism than others. Humans originate from a primarily frugivorous lineage of primates, with a large part of primate evolution occurring in warm equatorial climates where fruit fermentation occurred quickly and regularly, leading to corresponding adaptation and preference for ethanol that has been preserved in modern humans. In prehistoric human ancestry, there were advantages to human consumption of ethanol in fermenting fruits, but as the world changed and living conditions turned to resemble current modern industrial society, human access to ethanol changed as well, making both obesity and alcoholism diseases of nutritional excess in a society where sugar, fats, and ethanol are readily available.