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Unformatted text preview: CHAPTER 5 DOWNERS: ALCOHOL CHAPTER OVERVIEW Last month, 109 million Americans had at least one drink. Alcohol is the oldest and most widely used psy- choactive drug. Beer, wine, and distilled liquors are legal in most countries. This chapter surveys the chem- istry of alcohol, its pharmacology, and physiological/psychological effects. For many people, alcohol causes more problems than any other psychoactive drug in terms of health effects, legal problems, domestic/social violence, and crime. Some of the effects include fetal alcohol syndrome, cirrhosis of the liver, and drunk- driving arrests. This chapter also looks at the epidemiology of alcohol abuse, examines its effect on various groups including ethnic minorities, and provides a self-assessment test. SHORT CHAPTER OUTLINE I. O VER VIE W A. INTRODUCTION B. HISTORY (ALSO SEE CHAPTER 1) C. THE LEGAL DRUG II. ALCOHOLIC BEVERAGES A. THE CHEMISTRY OF ALCOHOL B. TYPES OF ALCOHOLIC BEVERAGES 1. Beer 2. Wine 3. Distilled Spirits (liquor) III. ABSORPTION, DISTRIBUTION, & METABOLISM A. ABSORPTION & DISTRIBUTION B. METABOLISM 1. Blood Alcohol Concentration (BAC) IV. DESIRED EFFECTS, SIDE EFFECTS, & HEALTH CONSEQUENCES A. LEVELS OF USE l. Abstention 2. Experimentation 3. Social/Recreational Use 4. Habituation 5. Abuse 6. Addiction B. LOW-TO-MODERATE-DOSE EPISODES l. Low-to-Moderate-Dose Use: Physical Effects 2. Low-to-Moderate-Dose Use: Psychological Effects 3. Neurotransmitters, Inhibition, & Other Effects 4. Low-to-Moderate-Dose Use: Sexual Effects C. HIGH-DOSE EPISODES l. High-Dose Use: Physical Effects of Intoxication 2. High-Dose Use: Alcohol Poisoning (overdose) 3. High-Dose Use: Blackouts 4. High-Dose Use: Hangover 5. High-Dose Use: Sobering Up 6. High-Dose Use: Mental & Emotional Effects D. CHRONIC HIGH-DOSE USE 1. Liver Disease 2. Digestive System 3. Cardiovascular Disease 4. Nervous System 5. Reproductive System 6. Cancer 7. Systemic Problems 8. Chronic High-Dose Use: Mental/Emotional Effects E. MORTALITY V. ADDICTION (ALCOHOL DEPENDENCE, ALCOHOLISM) A. CLASSIFICATION 1. Early Classifications 2. E. M. Jellinek 3. Modern Classifications 4. The Disease Concept of Alcoholism B. HEREDITY, ENVIRONMENT, & PSYCHOACTIVE DRUGS 1. Heredity 2. Environment 3. Alcohol & Other Drugs C. TOLERANCE, TISSUE DEPENDENCE, & WITHDRAWAL 1. Tolerance 2. Withdrawal D. DIRECTIONS IN RESEARCH VI. OTHER PROBLEMS WITH ALCOHOL A. POLYDRUG ABUSE B. ALCOHOL & MENTAL PROBLEMS C. ALCOHOL & PREGNANCY l. Maternal Drinking 2. Fetal Alcohol Syndrome (FAS), Alcohol-Related Neurodevelopmental Disorder (ARND), & Alcohol—Related Birth Defects (ARBD) 3. Paternal Drinking D. AGGRESSION & VIOLENCE E. DRIVING UNDER THE INFLUENCE 1. Injuries & Suicide VII. EPIDEMIOLOGY A. PATTERNS OF ALCOHOL CONSUMPTION B. POPULATION SUBGROUPS 1. Men 37 2. Women C. UNDERREPRESENTED 3. Asian & Pacific Islanders 3. Alcohol, Students, & Learning POPULATIONS (APIs) 4. Older Americans 1. Afiican Americans 4. Native Americans & Alaskan 5. Homeless 2. Hispanics Natives EXTENDED CHAPTER OUTLINE hol, methyl alcohol (wood alcohol), isopropyl al- cohol, butyl alcohol. Ethyl alcohol is beverage I. OVER VIEW A. Introduction. The majority of people in most countries, except mainly Islamic countries, drink alcoholic beverages. In the United States last month 48% of the population had at least one drink; yesterday 25—30% of hospital admissions were due to direct or indirect medical complica- tions from alcohol; and last year more than one- half of American adults had a close family mem- ber who has or has had alcoholism. Worldwide, last year 2 million people died due to alcohol and approximately 10% of all diseases and injuries were a direct result of alcohol abuse. (p. 179) . History (also see Chapter 1). Alcohol is the oldest known and most widely used psychoactive drug in the world. Some historians believe the first civilized settlements were created to ensure a regular supply of grapes for wine, grain for beer and food, and poppies for opium. (p. 180) . The legal drug. Historically alcohol has been used as a food (grain-rich beer) for peasants, as a solvent for opium, as a sacrament for religious ceremonies, as a water substitute, as a social lu— bricant, as a tranquilizer, and as a source of taxes. Almost every country has had periods in their history where alcohol use was restricted or banned completely. In England, in the 17005, the unrestricted sale of gin (the Gin Epidemic) led to great abuse and much addiction. In colonial America alcohol was an everyday part of life. In the 18005 attempts at temperance and treatment were tried by various groups, and in the 19305 in America Alcoholics Anonymous (AA) was founded. AA believed in the concept of solving alcohol abuse and addiction through personal spiritual change. Prohibition was mandated by law in America for 13 years but was repealed in 1933. One reason that many restrictions and even Prohibition have been overturned is alcohol’s value as a major source of revenue for corpora- tions and excise taxes for governments. (p. 181) II. ALCOHOLIC BEVERAGES A. The chemistry of alcohol. There are hundreds of different alcohols, examples being ethyl alco- alcohol and is the least toxic of the alcohols. Any beverage with more than 2% grain alcohol con- tent is considered an alcoholic beverage although alcoholic beverages also contain trace amounts of other alcohols. They also contain congeners that are nonalcoholic components produced during fermentation. Alcohol occurs naturally as a result of airborne yeast feeding on the sugars in honey, fruits, berries, vegetables, or grains. This process, called “fermentation,” produces alcohol and car- bon dioxide. (p. 181) . Types of alcoholic beverages are wine (pro- duced from fermenting fruits), beer (from fer- menting grain), and distilled spirits (from dis- tilled whiskey, wine, or other alcoholic bever- ages). (p. 182) 1. Beer includes ale, stout, porter, malt liquor, lager, and book beer. Beer is made (i.e., brewed, fermented) by roasting malt and ce- real grains (usually barley) and then combin- ing the result with a mixture of water, grain, hops, and yeast. The alcohol content of most lager beers is 4—5%, ales 5—6%, and malt liq- uors 6—9%. (p. 182) 2. Wine. In some early cultures beer was the al- coholic beverage of the common people and wine was the drink of the priests and nobles. Wines are usually made (i.e., fermented) from grapes though some are made from berries, other fruits (e. g., peach wine), and even starchy grains (e.g., sake rice wine). They contain from 8—14% alcohol. Wines with more than 14% alcohol content (the natural limit of fermentation) are fortified wines with pure alcohol or brandy added after fermenta- tion. (p. 183) 3. Distilled spirits (liquors). Distillation was discovered by Arabs about AD. 800. Distilled spirits are the result of boiling wine or other alcoholic beverages and collecting the con— densate. Brandy is distilled from wine, rum from sugar cane or molasses, vodka from po- tatoes, whisky and gin from grains. Distilled beverages have much higher alcohol content than wine or beer. Alcoholism eventually ex- ploded in Europe and other countries due to the increased manufacturing of distilled spirits and the desire for excise tax revenues. In co- lonial America, Rum was so popular that the second publicly funded building in New Am- sterdam (i.e., New York City) was a rum dis- tillery on Staten Island. (p. 184) III. ABSORPTION, DISTRIBUTION, & METABOLISM A. Absorption of alcohol into the bloodstream takes place at various sites along the gastrointestinal tract, including the stomach, the small intestines, and the colon. In men, about 10— 20% of the al- cohol is absorbed by the stomach while in women there is very little absorption there. In both men and women most of the alcohol enters the capillaries in the walls of the small intestines. Given the same body weight, women and men differ in their processing of alcohol. Women have higher blood alcohol concentrations than men do from the same amount of alcohol. Furthermore chronic alcohol use causes greater physical dam- age to women than to men. Alcohol is absorbed into the bloodstream, partially metabolized by the liver (first past metabolism), and then quickly distributed throughout the body. The alcohol en- ters into every organ and tissue and crosses all barriers including the placental barrier. The high- est levels of blood alcohol concentration occur 30—90 minutes after alcohol is drunk. (p. 184) . Metabolism. The body treats alcohol as a poison and begins to eliminate it as soon as it is in— gested. About 2—10% is eliminated directly with— out being metabolized, through exhalation, sweat, saliva, and urine. The remaining 90—98% is neu- tralized through metabolism (mainly oxidation) by the liver and then excreted through the kid- neys and lungs. The varying availability and effi- ciency of the enzymes needed to metabolize al— cohol is partly the result of heredity. This ac- counts for some of the variation in people’s reac- tions to alcohol. Alcohol is high in calories but has no real food value. Alcoholics get half of their energy from the empty calories in alcohol and consequently are highly susceptible to mal- nutrition. (p. 185) 1. Blood alcohol concentration (BAC). Alco- hol is metabolized at a defined continuous rate, about 1 oz. of pure alcohol (2 drinks) is eliminated from the body every 3 hours. However, each person’s biochemical makeup due to heredity can have a strong effect on metabolism and elimination. Furthermore, the actual reaction and level of impairment can vary widely depending on drinking history, behavioral tolerance, mood, and a dozen other factors. In most states legal intoxication is .08 or .10 BAC whether the driver can function or not. (p. 186) IV. DESIRED EFFECTS, SIDE EFFECTS, & HEAL TH CONSEQUENCES A. Levels of use: As with other drugs, there are es- calating patterns of use of alcohol with escalating consequences. (p. 187) ' 1. Abstention means no use. (p. 187) 2. Experimentation means use for curiosity with no subsequent drug-seeking behavior. (p. 187) 3. Social/recreational use is sporadic infrequent drug seeking with no established pattern. (p. 187) 4. Habituation means an established pattern of use with no major negative consequences. (p. 187) 5. Abuse means continued use despite negative consequences. (p. 187) 6. Addiction is the compulsion to use, the in- ability to stop use, and major life dysfilnction with continued use. (p. 187) . Low-to-moderate-dose episodes are defined as up to 1 drink a day for women and 2 drinks a day for men. Small amounts of alcohol generally do not have negative consequences for men, even over extended periods of time. Infrequent mild intoxication episodes generally do not have last- ing adverse health consequences for most male drinkers. However, low-level alcohol use is gen- erally not safe for women who are pregnant, peo- ple who have preexisting physical or mental health problems that are aggravated by alcohol, those allergic to alcohol, nitrosamines, or other congeners and additives, those who have a his- tory of abuse and addiction problems, and women who are at risk for breast cancer. (p. 187) 1. Low-to-moderate-dose use: physical effects. Therapeutically alcohol is used as a solvent for other medications, as a topical disinfec- tant, as a body rub to reduce fever, and as a pain reliever for certain nerve-related pain. Some people drink for the taste, to quench thirst, to relax muscle tension, and to stimu- late the appetite before meals. Light-to- moderate use of alcohol has been shown to 39 40 reduce the incidence of heart disease and lower the risk of strokes. Alcohol is often used to help get to sleep particularly if anxiety is causing insomnia. However, alcohol inter- feres with REM sleep and dreaming, both es- sential to feeling fully rested. (p. 188) . Low-to-moderate—dose use: psychological effects. In general alcohol affects people psy- chologically by lowering inhibitions, increas- ing self confidence, and promoting sociability. However for someone who is already lonely, depressed, suicidal, or angry, the depressant and disinhibiting effects of alcohol can deepen negative emotions including verbal or physical aggressiveness and even violence. Alcohol’s disinhibiting effect can result in problems such as automobile crashes and le- gal problems as well as problems such as pregnancy and sexually transmitted diseases (e.g., HIV/AIDS) resulting from high-risk sexual activity. (p. 188) . Neurotransmitters, inhibition, & other ef- fects. Alcohol’s psychological effects are caused by its alteration of neurochemistry in the higher center of the cortex that controls reasoning and judgment and the lower centers of the limbic system that rule mood and emo- tion. Instead of affecting just a few types of neurotransmitters or receptors like most other psychoactive drugs, alcohol interacts with re— ceptors, neurotransmitters, cell membranes, intracellular signaling enzymes, and even genes. Alcohol initially elevates mood by causing the release of serotonin. Dopamine release gives a serge of pleasure as does nor- epinephrine release. Met-enkephalin release by drinking reduces pain. Glutamate release causes stimulation thus reinforcing drinking. Alcohol induces release of anandamide and endorphins that give a reinforcing effect. Al- cohol reduces excitatory neurotransmission at the NMDA receptors (a subtype of glutamate receptors) inhibiting their reactions an affect- ing memory and movement. Most importantly alcohol causes GABA, the major inhibitory neurotransmitter in the brain, to enhance neu- rotransmission at the GABA-A receptor thus lowering psychological inhibitions and even- tually slowing down all of the brain processes. (p. 188) . Low-to-moderate-dose use: sexual effects. In low doses alcohol usually increases desire in males and females, often heightening the intensity of orgasm in females and slightly decreasing erectile ability and delaying ejaculation in males. (p. 189) C. High-dose episodes 1. High-dose use: physical effects of intoxica— tion. Intoxication is a combination of psy- chological mood, expectation, mental/physical tolerance, and past drinking experience as well as physiological changes caused by ele- vated blood alcohol levels. As consumption increases, the amount of alcohol absorbed in- creases and therefore the effects increase but at different rates depending on the physical and mental makeup of the drinker. Further- more, the effects of intoxication can be masked by experienced drinkers (i.e., behav- ioral tolerance). However after enough drinks are consumed, the depressant effects of alco- hol take over. Binge drinking is defined as consuming 5 or more drinks at one sitting for males and 4 or more for females. Heavy drinking is defined as 5 or more drinks in one sitting at least 5 times a month. (p. 190) . High-dose use: alcohol poisoning (over- dose) occurs with depression of the central nervous system (CNS) possibly leading to respiratory and cardiac failure then to uncon- sciousness (passing out) coma, and death. A blood alcohol concentration of .40 is a thresh- old for alcohol poisoning that can fatally de- press major autonomic functions like respira- tion. However a blood alcohol concentration of .20 or greater can result in severely de- pressed respiration and vomiting while semi- conscious especially in individuals with low tolerance. The vomit can be aspirated or swallowed blocking air passages to the lungs and resulting in asphyxiation and death. (p. 190) . High-dose use: blackouts. During blackouts, a person seems to be acting normally and is awake and conscious but afterwards cannot recall anything that was said or done. Black- outs are early indications of alcoholism. They are different from passing out or loss of con- sciousness. A drinker can have only a partial recall of events that is known as a “brown- out.” A possible indicator of susceptibility to blackouts and brownouts and therefore a marker for alcoholism can be seen on an electroencephalogram (EEG). This is found in alcoholics and their young sons but generally not in individuals without a drinking problem. (p. 190) . High—dose use: hangover. The effects of hangover can be most severe many hours after alcohol has been completely eliminated from the system. Typical effects include nausea, vomiting, headache, thirst, dizziness, mood disturbances, abbreviated sleep, sensitivity to light and noise, dry cottony mouth, inability to concentrate, and general depressed feeling. More severe withdrawal symptoms usually occur with chronic high-dose users. The causes of hangover are not clearly understood. (p. 191) . High-dose use: sobering up. Elimination of alcohol from the system is a constant. There- fore until the alcohol has been eliminated and until hormones, enzymes, body fluids, and body systems come into equilibrium, hango- ver symptoms will persist. Neither coffee, nor exercise, nor a cold shower cures a hangover. Feeling better comes only with rest and suffi- cient recovery time. (p. 191) 6. High-dose use: mental & emotional effects. Alcohol depresses and slows functions of the central and peripheral nervous systems, mov- ing from initial relaxation and lowered inhibi- tions at low doses to mental confusion, mood swings, loss of judgment, and emotional tur- bulence at higher doses. At a BAC of .10 a drinker may demonstrate slurred speech and beyond that level, progressive mental confu- sion and loss of emotional control. Heavy al- cohol consumption may also interfere with REM sleep. Consequently chronic alcoholics may suffer from fatigue during the day and insomnia at night as well as nightmares, bed wetting, and heavy snoring. (p. 191) D. Chronic high-dose use 1. Liver disease. In the United States approxi- mately 10—35% of heavy drinkers develop al- coholic hepatitis and 10—20% develop cirrho- sis. Alcoholic hepatitis causes inflammation of the liver, areas of fibrosis, necrosis (cell death), and damaged membranes. Cirrhosis occurs when alcohol kills many liver cells consequently causing scarring. It is the most advanced form of liver disease caused by drinking and is the leading cause of death among alcoholics. Approximately 10,000 to 24,000 Americans die each year from cirrho— sis due to alcohol consumption. Heavy drink- ing countries such as France and Germany 2. have rates of cirrhosis 2 or 3 times greater than the United States. Fatty liver, the accu- mulation of fatty acids in the liver, can begin to occur after just a few days of heavy drink- ing. Abstention will eliminate much of the ac- cumulated fat. When the liver becomes dam- aged due to cirrhosis, fatty liver, or hepatitis, its ability to metabolize alcohol decreases thus allowing alcohol to travel to other organs in its original toxic form. (p. 191) Digestive system. Alcohol’s other effects on the digestive system are caused by its direct effects on organs and tissues. Moderate-to high doses of alcohol stimulate the production of stomach acid and delay the emptying time of the stomach, causing acid stomach and di- arrhea. Gastritis (stomach inflammation) is common among heavy drinkers as are in- flammation and irritation of the esophagus, small intestine, and the pancreas (i.e., pan- creatitis). Other serious disorders linked to heavy drinking include ulcers, stomach hem- orrhage, and gastrointestinal bleeding. Fur- thermore alcoholics may suffer from primary malnutrition since alcohol has little nutritional value but is high in calories. Alcohol can cause hypoglycemia (too little sugar [glucose] in the bloodstream) in drinkers who are not getting sufficient nutrition. If there is suffi- cient nutrition, alcohol use can cause the op- posite effect, hyperglycemia (too much sugar in the bloodstream). (p. 193) . Cardiovascular disease. Chronic heavy drinking is related to a variety of heart dis- eases including hypertension (high blood pressure) and cardiac arrhythmias (abnormal irregular heart rhythms). Acetylaldehyde (a metabolite created when the liver metabolizes alcohol) damages striated heart muscles di- rectly resulting in cardiomyopathy, an en- larged, flabby, and inefficient heart. Heavy drinking also increases the risk of stroke. (p. 194) . Nervous system. Chronic high-dose alcohol use causes direct damage to nerve cells. Alco- hol-induced malnutrition can also injure brain cell and disrupt brain chemistry. Brain atro- phy (loss of brain tissue) has been docu- mented in 50—100% of alcoholics at autopsy. Dementia (deterioration of intellectual ability, faulty memory, disorientation, and diminished problem-solving ability) is a further conse- quence of prolonged heavy drinking. Wemi- 4l cke’s encephalopathy and Korsakoff’ s psy- chosis are two serious brain diseases due to brain damage caused by chronic alcoholism and thiamin deficiency. (p. 194) 5. Reproductive system. In females, heavy drinking decreases sexual desire and the in- tensity of orgasm. It also raises the chances of infertility and spontaneous abortion. In males, long-term alcohol abuse impairs gonadal functions and causes a decrease in testoster- one levels. About 8% of alcoholics are impo— tent and only half can recover sexual function during sobriety. (p. 195) 6. Cancer. There is an association between heavier drinking (3 or more drinks a day) and breast cancer. The risk of mouth, throat, lar- ynx, and esophageal cancer are 6 times greater for heavy alcohol users, 7 times greater for smokers, and an astonishing 38 times greater for those who smoke and drink alcohol. (p. 195) 7. Systemic problems. Alcohol leeches minerals from the body causing a much greater risk of fracture of the femur, the wrist, vertebrae, and the ribs. The unbalancing of electrolytes by chronic or acute use, along with direct toxic effects, can cause myopathy (painful swollen muscles). The reddish complexion of chronic alcoholics is caused by acne rosacea, psoria- sis, eczema, and facial edema. Heavy drinking has been linked to infectious diseases such as respiratory infections, tuberculosis, pneumo- nia, and cancer. Heavy drinking may disrupt white blood cells and weaken the immune system. Alcohol can contribute to a host of other problems including atrophied muscle fi- ber resulting in flabby muscles and weight loss (more so for women than men). (p. 195) 8. Chronic high-dose use: mental/emotional effects. With chronic high-dose use, almost any mental, emotional or psychiatric symptom is a possibility. Furthermore alcohol and memory problems go hand—in-hand. (p. 195) E. Mortality. Heavy drinking increases the chances of dying from disease or trauma. If people con- tinue heavy drinking, they are likely to die 15 years earlier than the general population. (p. 196) V. ADDICTION (alcohol dependence, alcoholism) About 10—12% of the 140 million adult drinkers in the United States have developed addiction. The in- cidence of alcoholism in men is approximately 2 to 3 42 time greater than in women. About 20% of the drinkers consume 80% of all alcohol. (p. 196) A. Classification 1. Early classifications. The purpose of classifi— cation is to develop a framework by which an illness or condition can be studied systemati- cally. The first American treatise on alcohol- ism was published in 1804 by Dr. Benjamin Rush, the first U.S. Surgeon General. It was a compendium of current attitudes towards abuse of alcohol. Around the same time Dr. Thomas Trotter published his thesis that drunkenness was a disease produced by a re- mote cause that disrupts health. In the nine- teenth and early twentieth centuries research- ers developed dozens of classifications of al- coholics. It wasn’t until the 1930s that scien- tific progress on the study of alcoholism really accelerated with the experiences of the newly created Alcoholics Anonymous (AA) and the founding of Yale University’s Laboratory of Applied Psychology. Out of this developed the Quarterly Journal of Studies of A [cohol- ism and the Yale Center of Alcohol Studies. (p. 196) . E.M. Jellinek (Yale University) classified al- coholics into four types: a) primary: immedi- ate liking for alcohol, rapid progression into alcoholism; b) steady endogenous sympto— matic drinkers whose alcoholism is secondary to a psychiatric disorder; c) intermittent en— dogenous symptomatic drinkers, periodic binge drinking; d) stammtisch drinkers in whom alcoholism is precipitated by outside causes or by social drinking. Later he pro— posed an alpha, beta, gamma, delta, and epsi- lon classification with gamma and delta alco— holics as those most likely to be addicts. (p. 196) . Modern classifications rest on knowledge of the pleasure center of the brain, the role of neurotransmitters, genetic research, and tech- niques for imaging the brain. These develop- ments resulted in the following classification: Type I alcoholism (also called “milieu- limited”) is later onset and can affect both men and women. It requires the presence of a genetic and environmental predisposition; it can be moderate or severe and takes years of drinking to trigger it. Type II, also called “male-limited,” mostly affects sons of alco- holics, is moderately severe, is primarily ge- netic, and is only mildly influenced by envi- ronmental factors. Dr. T.F. Babor (University of Connecticut School of Medicine) intro— duced the A/B typologies in 1992. Type A is later-onset alcoholism, less family history of alcoholism, and less severe dependence. Type B refers to a more severe alcoholism with earlier onset, more impulsive behavior and conduct problems or disorders, more co- occurring mental disorders, and more severe dependence. (p. 197) 4. The disease concept of alcoholism. Much of the current research in the treatment of alco- holism is based on the disease concept. It is defined as follows: “Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its de- velopment and manifestation. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccu- pation with the drug (alcohol), use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.” (p. 197) B. Heredity, environment, & psychoactive drugs all play a part in predisposing and influencing al- cohol addiction though some people are more at risk from just one of these influences. 1. Heredity. Family studies, twin studies, ani- mal studies, and adoption studies show strong genetic influences particularly in severe alco- holism. It is theorized that several genes have an influence on one’s susceptibility to alco- holism and other drug addictions. A person could have one, several, or all of the genes that make one susceptible to addiction. Other markers for a strong genetic influence are a tendency to have blackouts, a greater initial tolerance to alcohol, an impaired decision- making area of the brain, a major shift in per— sonality while drinking, an impaired ability to learn from mistakes, and retrograde amnesia. There also seems to be a hereditary link to the physical consequences of alcoholism espe- cially cirrhosis and alcoholic psychosis. (p. 198) 2. Environment. For some people the environ- mental factors are the overwhelming influ- ences, e.g., child abuse, poor nutrition, alco- hol/other drug-abusing friends and relations, and extreme stress. (p. 199) 3. Alcohol & other drugs. For some the toxic effects of alcohol and other drugs that change neurochemistry are most important. (p. 199) C. Tolerance, tissue dependence, & withdrawal. “Exposure of the brain to alcohol initiates a proc- ess of adaptation that works to counteract the al- tered brain function resulting from initial expo- sure to alcohol. This adaptation or change in brain function is responsible for the process called “alcohol tolerance,” “alcohol dependence,’ and “alcohol withdrawal syndrome.” (p. 199) 1. Tolerance. Tolerance is a process through which the brain defends itself against the ef- fects of alcohol. Dispositional (metabolic) tol- erance means the body changes so that it me- tabolizes alcohol more efficiently. In heavy drinkers, over time the liver eventually be- comes less able to metabolize the alcohol, a process called “reverse tolerance.” Pharmaco- dynamic tolerance means brain neurons and other cells become more resistant to the ef- fects of alcohol by increasing the number of receptor sites needed to produce an effect or by creating other cellular changes that make tissues less responsive to alcohol. Behavioral tolerance means drinkers learn how to “handle their liquor” by modifying their behavior or trying to act in such a way that they hope oth- ers won’t notice they are inebriated. Acute tolerance, which starts with the first drink, also develops from high-dose alcohol use. Select tolerance means that tolerance does not develop equally to all the effects of alcohol. (p. 199) 2. Withdrawal. About 85% of those experienc- ing withdrawal will only have minor symp- toms. These include rapid pulse, sweating, in- creased body temperature, hand tremors, anxiety and/or depression, insomnia, nausea or vomiting. Minor withdrawal symptoms will develop for people who drink heavily for 7— 34 days while major withdrawal symptoms will probably develop after 48—87 consecutive days of heavy drinking. Major withdrawal symptoms include tachycardia; transient vis- ual, tactile, or auditory hallucinations and illu- sions; psychomotor agitation; grand mal sei- zures; and delirium tremens (DTs). The DTs is a serious condition requiring hospitaliza- tion. Alcohol at first increases the effective- ness of GABA. Over time the brain compen- sates by creating an excess of energy chemi- cals and decreasing (down regulating) the a 43 number of GABA receptors, resulting in hy- perarousal during withdrawal. Also, with many long-term heavy drinkers, repeated bouts of drinking and withdrawal actually in- tensify subsequent withdrawal symptoms and can cause seizures. This process is called “kindling.” (p. 200) D. Directions in research. Research into heredity has focused on identifying the genes that make a user more susceptible to addiction. Research into environmental causes of alcoholism has focused on identifying which changes in the addict’s sur- roundings will decrease the use of alcohol and other drugs. Research into the physiological and psychological changes that occur with chronic and high-dose drinking involve studying the im- mune system, the development of dispositional and pharmacodynamic tolerance, the beneficial cardiovascular effects, and the learning disabili- ties in drug-affected infants. (p. 201). VI. OTHER PROBLEMS WI TH ALCOHOL A. Polydrug abuse. Most illicit drug users also drink alcohol and most alcohol abusers use other drugs; consequently treatment centers have had to learn how to treat simultaneous addictions. There is a strong association between smoking and drinking. Approximately 70% of alcoholics smoke more than one pack a day. (p. 201) B. Alcohol & mental problems. Individuals who use alcohol or other drugs to try to control the symptoms of their mental state or to avoid ask- ing for psychiatric help are “self-medicating.” On the other hand, if alcohol is used to excess, drinking or withdrawal from drinking can induce symptoms of mental illness. Consequently any psychiatric diagnosis must always take into ac- count the possibility of drug-induced symptoms. Many (if not the majority of) alcoholics who present for treatment are depressed. Heavy drinking raises the levels of chemicals that cause tension and depression. Only after a period of abstinence will it become apparent whether the depression was caused by drinking or by a sepa- rate psychiatric disorder. If there is a dual diag- nosis (i.e., co—occurring disorders), both condi- tions must be treated in order to achieve an ef- fective recovery. The symptoms of borderline personality disorder (BPD) and antisocial per- sonality disorder (ASPD) are very common in individuals who present for alcohol and other drug abuse treatment. About 80% of those with antisocial personality disorder develop substance dependence. As for BPD, there is much debate as to the actual incidence of this disorder since its symptoms shift from moment to moment and can be drug induced. However, individuals with BPD symptoms are difficult to treat and take up a disproportionate amount of clinical staff’s time. (p. 202) C. Alcohol & pregnancy 1. Maternal drinking. Alcohol use during pregnancy is the leading cause of mental re- tardation in the United States. A survey of pregnant women in the America found that 12.4% drank some alcohol during several months of pregnancy, 3.9% used in a binge pattern, while 0.7% were heavy drinkers. In addition 5.5% had used illicit drugs at least once. In a study of the mothers of infants born with fetal alcohol syndrome (FAS), it was found that during their pregnancy about 89% of the women were using alcohol with at least 2 other drugs and 49% were using just 2 drugs, usually cocaine and alcohol. (p. 203) 2. Fetal alcohol syndrome (FAS), alcohol- related neurodevelopmental disorder (ARND), & alcohol-related birth defects (ARBD). We know that alcohol kills cells and changes the wiring of the fetus’s brain causing cognitive/behavioral deficits. The toxic effects of alcohol on the developing fetus are known as “fetal alcohol syndrome” (FAS). ARND and ARBD used to be referred to as “fetal alcohol effects” (FAE). Not all women who drink heavily during pregnancy bear children with FAS. The minimal stan- dards for the diagnosis of FAS are 0 retarded growth before and after birth including height, weight, head circum- ference, brain growth, and brain size; 0 facial deformities including shortened eye openings, thin upper lip, flattened midface, missing groove (filtrum) in the upper lip; <> occasional problems with heart and limbs; 0 central nervous system involvement such as delayed intellectual develop- ment, neurological abnormalities, be— havioral problems, visual problems, hearing loss, and balance or gait prob- lems. In tests of 178 individuals with FAS, IQ scores ranged from 20 to 120 with a mean of 79 (mental retardation is defined as an IQ of less than 70). It is estimated that worldwide FAS births occur anywhere from 0.33 to 2.9 cases per 1,000 live births. Children with FAS are liable for increased risks of other common birth defects including heart dis- ease, cleft lip and palate, and spina bifida. The critical period during pregnancy for al- cohol’s effect on brain development is weeks 3 through 8, at the onset of embryo- genesis (formation of the embryo). Blood alcohol concentration rather than the total amount of alcohol drunk determines the level above which effects are seen. Even though one study concluded that 7 standard drinks per week by pregnant mothers are a threshold level below which most neurobe- havioral effects are not seen, the recommen- dation is that pregnant women should not drink any alcohol during pregnancy. There simply is no way to determine which babies might be at risk from even very low levels of alcohol exposure. (p. 204) 3. Paternal drinking. There is some new evi- dence that the detrimental effects of alcohol on the fetus may also be transmitted by pa- temal alcohol consumption. Alcohol may mutate genes in sperm, kill off certain kinds of sperm, or biochemically and nutritionally alter semen and influence sperm. (p. 206) D. Aggression & violence. Most research suggests that a tendency to violence already resides in some people. Alcohol has been shown to in- crease aggression by interfering with GABA in ways that provoke intoxicated people with pre- existing aggressive tendencies. In addition alco- hol decreases the action and levels of serotonin thus lowering impulse control. About one-fourth of the 11.1 million victims of violent crime re- port that the offender had been drinking alcohol prior to committing the crime. Depending on the study, 34—74% of sexual assault perpetrators had been drinking as had 30—79% of the victims. Al- cohol encourages the release of pent-up anger, hatred, and desires forbidden by society espe- cially in people prone to violence. There are three kinds of interpersonal violence and one can escalate into another, e. g., emo- tional violence, physical violence, and sexual violence. Any type of violence can cause per- manent biochemical changes in the victim that then can make them more susceptible to drug abuse and other emotional problems. (p. 206) . Driving under the influence. Approximately 40% of motor vehicle fatalities in 2001 involved alcohol use. More than 1 in 4 drivers gets behind the wheel within 2 hours of drinking. Of those convicted of DUI, 61% only drank beer, 2% only drank wine, 18% only drank liquor, while 20% drank more than one type of alcoholic bev- erage. Alcohol-related crashes cost an estimated $148 dollars in the United States every year. Legally driving impairment is linked to BAC. When the BAC is over the legal limit (.08 or .10), the ar— resting officer does not have to prove the person is impaired; the driver is guilty per se. But few are caught. Only 1 driver is arrested for every 300 to 1,000 drunk-driving trips. Even though there are prevention strategies like lowering the BAC limit from .01 to .08 and having zero tolerance laws for those under 21, there is no single prevention strategy that is most effective. (208) 1. Injuries & suicide. From 15—25% of emer- gency room patients test positive for alcohol or report alcohol use with relatively high rates among those involved in fights, as- saults, and falls. Alcoholics are 16 times more likely to die in falls and 10 times more likely to become burn or fire victims. About 31% of boating fatalities had a BAC of .10 or more. Among adult alcoholics, suicide rates are twice as high as for the general population. VII. EPIDEMIOLOGY A. Patterns of alcohol consumption. Culture is one of the main determinants of how a person drinks. Wet drinking cultures (e. g., France, Italy) sanction daily or almost daily use and integrate social drinking into everyday life. Dry drinking cultures (e. g., Denmark, Norway) restrict the availability of alcohol and tax it more heavily. Dry cultures consume more distilled spirits than wet cultures and are characterized by binge-style drinking particularly by males on weekends. Mixed drinking cultures (e. g., Canada, England, Ireland, the United States, Wales, and Germany) exhibit combinations of wet and dry where binge drinking in social situations is common. A rela- tively higher incidence of violence against 45 women is found in mixed drinking cultures. Chinese families generally don’t drink much. In Japan most of the men and half of the women drink. In Russia vodka is traditionally drunk between meals in large quantities. Approxi- mately 70% of Britons drink regularly. In the United States much drinking is done in social settings away from lunch and dinner tables. (p. 211) B. Population subgroups 46 1. Men. In all age groups men drink more per drinking episode than women do, regardless of the country. Also men have more adverse social and legal consequences and develop problems with alcohol abuse or dependence at a higher rate than women. (p. 211) 2. Women generally develop problems with al— cohol in their 30s (vs. 208 for men). Even low levels of drinking in women with certain ge- netic susceptibilities can result in major health consequences such as an increased risk of breast cancer. Proportionally more women than men die from cirrhosis of the liver, cir- culatory disorders, suicide, and accidents. Since society more readily accepts the alco- holic male but disdains the alcoholic female, women are less likely to seek treatment for al- coholism than men. (p. 212) 3. Alcohol, students, & learning. Drinking can negatively affect learning and maturation. About 44% of college students admit to binge drinking once every 2 weeks. There is a direct correlation between the number of drinks per week and grade average—the more drinks, the lower the grades. Furthermore secondhand drinking (e.g., being unable to study due to noise in the dorms) is a large problem on col- lege campuses. (p. 212). 4. Older Americans. 2.5 million older adults have alcohol-related problems. Patterns of drinking persist into old age and are the result of general trends in society rather than the aging process. Hip fractures increase with al- cohol consumption mainly due to decreases in bone density caused by the deleterious effects of alcohol. Alcohol and prescription drug in- teractions are quite common. Because of the coexistence of other physical and/or mental problems, isolation, and relaxed attitudes about drinking, it is difficult to diagnose drug or alcohol problems in the elderly and get them help. (p. 214) 5. Homeless. From 500,000 to 2 million Ameri- cans are homeless with the average length of homelessness being 6 months. About 56% are African American, 23% could be considered mentally ill, and 45% have serious substance abuse problems. One major problem is the lack of affiliation with any kind of a support system for these individuals. The services that identify and treat mental illness and substance abuse are hard to come by or, if available, are shunned by the homeless person. (p. 214) . Underrepresented populations. Even though biological and neurochemical differences be- tween ethnic groups account for some of the dif- ferent patterns of alcohol and drug use, diverse cultural traditions seem to make a greater contri- bution to alcohol use and abuse patterns as does the degree of assimilation into the dominant cul- ture. (p. 215) ' 1. African Americans. A 2001 survey found that heavy use of alcohol was lower among African Americans (4.1%) than among Cau- casians (6.4%) or Hispanics (4.4%). More Black women abstain from drinking than White women, but there is greater heavy drinking among those Black women who do drink. Peak drinking for Blacks occurred after the age of 30 whereas drinking among Whites peaked at a younger age. Medical problems brought on by heavy drinking among African Americans are more severe. (p. 215) 2. Hispanics. In 2002, Hispanics comprised about 12.5% of the population in the United States. About 60% of all Hispanics are of Mexican origin. Unlike in the general popula- tion, drinking in the Hispanic community in- creases with both sexes as education and in- come increases. The rate of alcohol use among female Hispanics has grown over the past 20 years. However in general, Hispanic women still drink considerably less than His- panic men. There is unfortunately a lack of culturally relevant treatment facilities and per- sonnel for the Hispanic community. (p. 215) 3. Asian Americans & Pacific Islanders (APIs) are the fastest growing ethnic group in the United States. Currently they make up about 4% of the total population. The have the lowest rate of drinking and drug problems. In one study in Los Angeles, Filipino Americans and Japanese Americans were twice as likely to be heavy drinkers as Chinese Americans but Chinese Americans were less likely to be abstainers. In general, Asian American males under 45 who are educated and in the middle class are most likely to drink but there is rela- tively little problem drinking even among this group. Because there is a stigma involved in admitting problems with alcohol, entry into treatment is difficult and unless the treatment is culturally sensitive, it is unlikely to be ef- fective. (p. 216) 4. American Indians & Alaskan Natives. Na- tive Americans are divided into 300 tribal or language groups that make up about 1% of the population of the United States. In general, drinking patterns vary widely among these tribes—some are nearly abstinent, some drink moderately, and some have high rates of heavy drinking and alcoholism. Contrary to a longstanding American myth, Native Ameri- cans are not more sensitive to the effects of alcohol. Rather they are less sensitive and have to drink more to get drunk. Generally the abuse of alcohol accounts for 5 of the 10 leading causes of death in most Native American tribes. (p. 216) DISCUSSION TOPICS . What kinds of provisions have societies made to control the problems of excess alcohol use? . How could someone use the BAC table to plan an evening of drinking? Using the BAC table, give some specific examples. . Ask students to summarize their perception of the various stages of alcohol use. Include frequency, amount, effects, and thought processes at each of these stages a. experimental; b. social/recreational; c. habituation; d. abuse; e. addiction. . Have students discuss whether safe drinking should be taught in the home and at school even though it is illegal for underage people to drink. . What kinds of programs have been or could be effective in reducing binge and heavy drinking on campus? . What are the effects of secondhand drinking, i.e., effects felt by those who come in contact with drinkers? . What are some specifically male expectations when they drink? What are some specifically fe— male expectations when they drink? 1. Discuss how culturally relevant alcohol and other drug treatment might work for several underrep- resented populations (e. g., Native American, Hispanic). What would be different than in tradi- tional treatment? What aspects of traditional, non-culturally relevant treatment would be diffi- cult for the client? CRITICAL THINKING AND CLASS EXERCISES Have students write arguments for and against prohibition of alcohol as if they had to argue it in a court of law, discussing such aspects as legal- ity, enforcement, cost, and effectiveness. Have students collect at least 10—20 alcohol and cigarette ads and discuss what attitudes and val- ues those ads are selling in relation to their prod- uct. . Ask students to develop 10 rules for responsible ' alcohol consumption (a “drinking etiquette”) that will both prevent harm to and respect the rights of the drinker, others around the drinker, and so- ciety at large. . Have groups of students devise an informative and entertaining advertisement that stresses mod- erate and safe drinking and then share their ads with the class. . Ask students to describe their first drinking expe- riences noting especially a. whether alcohol was the focus of or inciden- tal to the experience, b. how they felt during the experience and im- mediately after it, and c. how they feel about it now. . In the context of a discussion of alcohol binge drinking and abuse, ask students to give exam— ples of typical denial or excuse statements such as a. rationalization (“In college everyone drinks”); b. denial (“I can stop anytime I want”); c. projection (“I don’t have a problem with my drinking, you do.”); d. excuse (“I drink only when I’ve had a hard day-”); e. misinformation (“I’m not an alcoholic, I only get bombed on the weekends”). 47 ...
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This note was uploaded on 04/13/2008 for the course BIO 1033 taught by Professor Joel.martinez,jr.,ph.d. during the Fall '04 term at Texas San Antonio.

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