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Alcoholism and Alcohol  Use Disorder (AUD)


Alcohol Use Disorder Defined 

Alcohol use disorder (AUD) is a relatively new term for the medical condition characterized by an impaired ability to stop or control alcohol use despite the problems it causes with job performance, social relationships or health. It encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism.  The term was first delineated in the DSM–5, which integrated alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD) with mild, moderate, and severe sub-classifications. A.U.D. is a chronic relapsing brain disease typified by the heavy use of alcohol, and typically results in changes to the brain's structure and function. With treatment, the brain dysfunction caused by alcohol can often be reversed. 

The National Institute on Alcohol Abuse and Alcoholism, (NIAAA), recommends the following Maximum Drinking Limits. Safe levels of drinking, with exceptions noted below, are defined as follows:

For healthy men up to age 65

•    No more than 4 drinks a day AND
•    No more than 14 drinks in a week

For healthy women (and healthy men over age 65)

•    No more than 3 drinks in a day AND
•    No more than 7 drinks in a week

Abstinence is advised for anyone who:

•    Takes medications that may interact with alcohol
•    Has a health condition that may be exacerbated by alcohol
•    Is pregnant 
•    Is younger than age 21
•    Is considering becoming pregnant

How much drinking is too much?

The effect of alcohol on each person is unique, but according to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), “low-risk” alcohol use is defined as up to two drinks daily for healthy adult men and one drink daily for healthy adult women. (One drink equals one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits). Any drinking while pregnant is defined as “excessive drinking.”

Signs of Alcohol Use Disorder (AUD)

The Diagnostic and Statistical Manual (DSM) is a classification system published by the American Psychiatric Association. The most recent version, DSM 5, refers to Alcohol Use Disorders (AUD) rather than “Alcohol Abuse” and “Alcohol Dependence”.  The DSM-5 sets the criteria for having AUD as having at least two of the following symptoms:

  1. Alcohol is often taken in larger amounts or over a longer period than was intended.

  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

  4. Craving, or a strong desire or urge to use alcohol.

  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

  8. Recurrent alcohol use in situations in which it is physically hazardous.

  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

  10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.

  11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Alcohol Detoxification 

With proper medical treatment, people with AUD typically reduce their consumption of alcohol gradually over many weeks.  This gradually process avoids the symptoms of withdrawal and the need for expensive and uncomfortable detoxification.  Alcohol is one of the most dangerous drugs from which to withdraw. In some cases, a heavy drinker who stops drinking suddenly will experience confusion and other withdrawal symptoms including shaking, shivering, sweating, seizures, and hallucinations, a potentially fatal condition known as delirium tremens.  This is a true medical emergency - call 911 in this situation. Heavy drinkers, particularly those at risk for a seizure, are typically advised to withdraw from alcohol in a hospital setting.  The telemedicine service we offer is not designed to help alcoholics in withdrawal, or any other emergencies, but can help after withdrawal is over.  The telemedicine practice of Dr. Umhau is not designed to manage crises, and we are not a crisis facility.

What Causes Alcohol Use Disorder (AUD)?

Alcohol Use Disorder (AUD) is an abnormal way to think about alcohol created by changes in the brain. That’s why people with A.U.D. continue to drink despite the adverse consequences.

The development of AUD is based on both the biological condition of our brain as well as conscious control over our behavior. Although we are unaware of the process, our thoughts work through nerve cells and chemical signals: dopamine, a brain chemical which drives motivation; endorphins which are natural pleasure producing brain opiates; serotonin, a brain chemical which gives a signal of “that’s enough”; and norepinephrine, a brain chemical which alerts us to what’s important. A complex pattern of chemicals and nerves form a physical structure of memories and allows us to create, to plan, and to make good choices.

Craving for alcohol may occur as repeated thoughts create well-worn paths in the brain.  Both endorphins and dopamine are released along this path, making a signal that we want something. Once we get what we want, we feel a burst of pleasure, signaled as a release of brain endorphin that is rewarding. The important desires of our existence create oft-traveled thought paths in our brains; the nerve pathways that accompany these thoughts become very important.  Often these desires are subconscious, which is why we don't always recognize our craving for alcohol.  When alcohol cravings become overwhelming, the increase in thoughts that travel well-worn paths in our brains become like a flame which may start small but grows into a fire that can be overwhelming. This process, known as kindling, is similar to the brain activity that occurs with seizures. More information on this process is available here

It’s hard to know where the tipping point lies when alcohol stops being a friend and becomes an all-consuming obsession.  This point is different depending on one’s genetics and other biological factors which determine our predisposition for brain disease. In addition, an individual experiencing emotional distress, physical discomfort or sickness may attempt to temporarily alleviate his symptoms with alcohol consumption. The relief from symptoms that alcohol can give is accompanied by the release of natural opiates in the brain that, over time, create well-worn thought paths which lead to alcohol use disorder. 

The amount any of us can drink without risk of harm is variable, but we know that alcoholism is much more likely to develop when the recommended maximum levels are exceeded. However, for someone with a genetic tendency to develop Alcoholism, even this amount of drinking can lead to well-worn paths of craving for alcohol, and the neuro-chemical driven process leading to alcohol use disorder.

Scientists have noted that when an individual describes his very first experience with alcohol as positive, with few negative symptoms (e.g. sleepiness, nausea, lack of coordination, loss of balance, etc.), those individuals are much more likely to develop alcohol use disorder.  If someone can "Hold his liquor" when he first drinks, this is a red flag that he is at a much greater risk of alcoholism.

Our biological sex can also play an important role in this process; women develop negative effects of alcohol more rapidly than men, as I learned early in my research career.

I remember a delightful young woman I treated on the alcohol detoxification unit at NIH. She was in her late 20s, and like me, she had started her college career as a premed student. In fact, her academic abilities were so promising that she had been given a full scholarship to a prestigious university. Unfortunately, she enjoyed drinking to excess, and made a point to drink as much as her male college friends. After several years of drinking, she dropped out.  When I first treated her at NIH, she was working as a barmaid and had postponed her medical career. She sounded intelligent when we first talked, but there was a spark missing - later her MRI scan showed a remarkable degree of brain atrophy, that is, a shrunken brain. Her IQ, which at one time was above average, was now so low that it she was considered disabled. Although she had the superficial characteristics of an educated young woman, she would never make it to medical school; I hope she’s still alive.  No one is immune from the harm that alcohol can do, but data show it affects women much more rapidly than men.

For more scientific information on alcoholism and nutrition, and related issues, you can find links to published articles on Dr. Umhau’s Research Gate site. 

Medications are available which can help overcome the unnatural reward of alcohol, which is why a knowledgeable physician can be very helpful to someone with AUD.

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